Impact of Medicaid expansion and Kynect workers are discussed at Friedell Committee for Health’s annual meeting

By Melissa Patrick
Kentucky Health News

Medicaid expansion and Kynect, the state’s health insurance exchange, have transformed health care in Kentucky by providing health insurance to an additional 500,000 Kentuckians, but that hasn’t come without some challenges for both consumers and providers.

The expansion and the exchange for it were parts of a timely panel discussion Oct. 25 at the Friedell Committee for Health‘s annual meeting in Lexington, as Kentuckians prepared to decide between gubernatorial candidates who are deeply divided on both topics.

Democratic gubernatorial nominee Jack Conway and independent candidate Drew Curtis favor keeping the expansion, at least for the near future, as well as the exchange. Republican nominee Matt Bevin says he wants to change the Medicaid expansion, and would abolish Kynect, sending people to the federal exchange.

“We are truly at a juncture in Kentucky where the results of this November’s election could have huge impact on access to care for people throughout the commonwealth,” Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, said in her opening statement.

Impacts of health reform

Since the implementation of the Patient Protection and Affordable Care Act, Kentucky has shown the biggest drop in the uninsured rate in the country, now at 8.5 percent, according to the U.S. Census Bureau.

Medicaid expansion, which allows those up to 138 percent of the poverty line to join the program, covers about 400,000 Kentuckians, many whom have never had insurance before.

It has also helped decrease the uncompensated care of hospitals, which have seen a drop to $83 million in the last quarter of the year from a high of $288 million about a year ago, according to a foundation report.

In addition, it has helped provide health coverage to the poorest regions of the state, with Eastern Kentucky recorded as the the greatest beneficiaries of the expansion, followed by Western Kentucky.

But despite these gains, Zepeda said many people who have never had health insurance don’t know how to use it, having been conditioned to only seek care in emergencies.

“There is a huge health-literacy task ahead of us,” she said, “because people are going to have to learn how to use the system at the right time and the right way so that they get healthy and stay healthy.”

Another problem is that Medicaid recipients often have difficulty finding providers, and this is one of the reasons they tend to still use emergency rooms, Zepeda said. She noted that there is an effort being made with state licensure boards to create an accurate, up-to-date data base about who is really accepting Medicaid patients and to what extent.

Medicaid expansion and hospitals

“We have had a huge impact at the University of Louisville Hospital from the expansion of Medicaid,” Mark Pfeifer, the hospital’s chief medical officer, told the committee.

He said the hospital’s share of uninsured patients has dropped to 5 percent from 25 percent in the last two years, calling it a “profound story and change for a safety-net hospital.” Emergency department use has dropped 5 percent, Pfeifer said, but the patients they do see are sicker.

Pfeifer said the drop in emergency-room use could be a result of the reform law, as those with less urgent needs seek care elsewhere because they now have insurance. He said he expects ER use to decrease further as the newly insured better manage their chronic illnesses and seek care earlier.

One of the best things about more people having insurance is access to medications, Pfeifer said. “I can give you all the care I want out of my pocket, but if you don’t take the medications I prescribe you, I will see you back again in three weeks in the emergency room,” he said.

Medicaid expansion also benefits city and state budgets, which have decreased their funding to the hospital this year to less than $8 million, from $30 million. “And it’s worked out OK,” Pfeifer said. “Financially, it hasn’t really changed our books.”

Pfeifer said it is a fallacy to think Medicaid expansion allows all Kentuckians access to insurance, because many make too much money to qualify for the expansion but can’t afford the monthly premiums for private insurance, even with the subsidies provided by Kynect.

He said that for some people the cost is “easily 15 to 18 percent of their take-home [pay], and that is just not possible for someone making $28,000 a year.”

Even for those who qualify for the expansion, “It has been a bit of an uneasy transition,” Pfeifer said, because of confusion about how it works; difficulties in dealing with the administrative side of it; limited access to providers; poor health literacy; and a general distrust of the system, he said.

Medicaid expansion and clinics

Bill Wagner, executive director of the Family Health Centers of Louisville, seven facilities that take care of under-served populations, shared the many benefits they have seen from the reforms: a drop in their share of uninsured patients to 17 percent, from 51 percent in 2013; a $5 million decrease in uncompensated care between fiscal year 2013 and 2014, with an expectation of a greater drop this year; a $5 million capital grant used to expand and improve several of their facilities; and the ability to sign up 14,000 of their patients with insurance.

He then noted some of the challenges: Many of the newly insured don’t understand the penalties involved if they don’t sign up for insurance, not thinking about a year and a half from now when they will be required to file their taxes and pay the penalty.

The annual fee for not having insurance in 2016 is $695 per person and $347.50 per child, per year, or 2.5 percent of household income, whichever is greater, with a family maximum of $2,085.

“They are making decisions about cost without seeing the big picture,” Pfeifer said.

He also said many of the newly covered struggle with their failure to maintain eligibility. For example, Medicaid clients have a very short window to change their address when they move or they lose Medicaid eligibility, and those on private insurance don’t understand that they have to inform their insurance company if they have a change in income status within the covered year.

The reform law funded “Kynectors” to help people unfamiliar with health insurance navigate Kynect, the official name of which is the Kentucky Health Benefit Exchange. Because patients have created a personal relationship with their Kynectors, they “end up becoming case managers going forward” to help them with these issues, Wagner said.

He said that should be an important consideration when deciding whether to abandon Kynect and adopt the federal exchange, as gubernatorial Matt Bevin has said he would do, because that would cause Kentucky to lose 75 percent of its funding for Kynectors, who are now in every county.

“Having the boots on the ground from the Kynectors, having the close working relationship with the Kentucky Health Benefit Exchange, I think has really helped us provide more ongoing care and coordinated case management around insurance, so I worry about that if that were to change,” Wagner said.

He said providers also face challenges, such as administrative complexities, which he expects to get worse with two more Medicaid managed-care organizations being added to the existing five this year; workforce shortages; challenges with electronic health records and inter-operability; and patient turnover.

Medicaid expansion and oral health

Raynor Mullins, emeritus faculty member of the University of Kentucky College of Dentistry, said he is “a tough grader” but gives the Medicaid expansion in Kentucky an A-.

“What has occurred has been monumental,” he said, noting that Medicaid dental visits have risen 31 percent, mostly in adults.

But claims paid to dentists went up only 28 percent, and only 24 percent of practicing dentists “participate at meaningful levels in Kentucky Medicaid program,” Mullins said, for several reasons: administrative difficulties, poor reimbursement rates for dentists, Medicaid patients not keeping appointments; and the many dental services not paid for by Medicaid.

“We have a very fragile population of participating dentists,” Mullins warned.

Mental-health advocate Sheila Schuster said many people who have never been to a dentist, which includes many of those who are newly insured through the expansion, fear doing so. She suggested that dental care and behavioral health care should be integrated to help these patients.

Medicaid expansion and the consumer

Kentucky Voices for Health’s “Sustaining Health Gains” campaign has been sharing county-by-county enrollment and preventive service data with Kentuckians, as well as sharing videos online of Kentuckians who have benefited from the reform law. (Read more)

For example, one of their tweets said, “Of #McCracken county’s 6,133 folks with new #Medicaid coverage, 637 got preventive dental care. #KeepKyCovered.”

One of the many videos features a homeless man in Eastern Kentucky whose Kynector, Jennifer Gates, not only helps him sign up for health insurance and get care, but also helps him continue to get care and make sure he doesn’t fall through the cracks.

“Kynectors are so much more than just someone who helps you enroll,” KVH Executive Director Emily Beauregard told the committee.

Kentuckians want new governor to focus on health care

Two of the top five priorities that Kentuckians want their next governor and legislature to address involve health, according to a recent poll taken for the Foundation for a Healthy Kentucky.

However, Republicans place less emphasis on health. The poll found 88 percent of Democrats say reducing health-care costs was extremely or very important to them, compared to 78 percent of Republicans. And the partisan gap was even wider on improving Kentuckians’ health, with 91 percent of Democrats and 71 percent of Republicans saying that this was very or extremely important for the state.

“You do the math,” Zepeda said, “and you figure out whose attention we might need to get to really sustain health gains in the commonwealth.”
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