Philosophical divide evident at Medicaid oversight meeting; Bevin officials say revised plan will be sent to feds ‘shortly’

By Melissa Patrick
Kentucky Health News

As Gov. Matt Bevin prepared to ask federal officials to let him change the state’s Medicaid program, a discussion at a legislative committee meeting offered a glimpse of the philosophical differences between the political parties, through a window that showed the two mindsets at work.

Most of the Medicaid Oversight Committee meeting involved an overview of Bevin’s draft proposal, which is designed to assure that “able bodied adults” have a higher level of involvement in their health care, through things like premiums and “community engagement” requirements.

Most who would be affected by the proposal have gained health insurance under then-Gov. Steve Beshear’s expansion of Medicaid to those who earn up to 138 percent of the federal poverty level. The changes would not affect pregnant women, children or those who are deemed medically frail.

“We will be making some changes” in the draft request for a waiver of some Medicaid rules, Health Secretary Vickie Yates Brown Glisson told the committee. “We anticipate that shortly we will be getting a revised waiver to” the U.S. Department of Health and Human Services.

Comments after the presentation offered some insight into the deep philosophical divide between the political parties about how to provide health insurance to the state’s poorest citizens.

Rep. Benvenuti

Rep. Robert Benvenuti, a Lexington Republican, shared a story that supports his belief that many able bodied Kentucky adults are taking advantage of the system. He said employers have called him and said they were having difficulty filling jobs because people didn’t want to work full time because then they would lose the “free health care” they get from Medicaid.

“Have you all looked at that?” he asked. “The whole issue of people who voluntarily — in other words, they are not vulnerable — they voluntarily decided that it is simply not worth the effort to go work because the benefits of not working have outstripped the benefits of work?”

Adam Meier, the governor’s deputy chief of staff, sympathized with Benvenuti and said the issue was of “serious concern.” He said the fact that four of 10 Kentuckians are not working suggests “We have in some instances created a culture, or an environment where it is sometimes easier to not work and the benefits will be able to sustain you.”

Meier said the work and community-engagement requirements in the draft Medicaid plan would help able-bodied Kentuckians have the tools and incentives they need “to go out and be engaged in their communities, be engaged with their employer.”

Sen. McGarvey

Sen. Morgan McGarvey, a Louisville Democrat, asked the Republicans, “Do you guys have any evidence or numbers of people who have quit work to get Medicaid?

“I think that would be pretty anecdotal, it would be pretty hard to capture that,” Meier said.

To which McGarvey said, “I think it would be too, especially with the roughly 5 percent unemployment rate right now.”

Earlier in the meeting, Medicaid Commissioner Stephen Miller said Bevin’s plan would save approximately $2.2 billion over five years, of which the state portion would be $331 million. The federal government is paying the full cost of Medicaid expansion through this year; next year the state will start paying 5 percent, rising in annual steps to the law’s limit of 10 percent in 2020.

McGarvey asked the administration officials why they thought giving up nearly $2 billion in federal spending on Kentucky health care was a good idea, especially if their shared goal was to “get the best health care for the most number of Kentuckians in the cheapest way possible.”

“We are going to save $331.3 million, but we are essentially giving up $1.9 billion coming into the state to get that savings,” he said. “I am just wondering whether that is a good trade-off.”

Meier said the administration didn’t look at this as giving up money, but rather that it was a savings of taxpayer’s money.

“Our administration’s position is that a taxpayer dollar is a taxpayer dollar,” he said.

McGarvey replied, “Under what you said, that is not necessarily true, because for every dollar we give the federal government, we get a dollar-fifty back. . . . It just looks like we are giving that up.”

Meier responded, “I think from a philosophical standpoint, maybe we are going to have to disagree on that, that’s the best way to use taxpayer dollars and if we can do it in a way that is more efficient and increase outcomes, then that is the approach that our administration is going to take.”

McGarvey countered, “I don’t disagree with that. I think we should do something in the most efficient (way), that gets the best outcomes in the state, I completely agree. I am just wondering when you look at these numbers which one actually gives us that best return. That’s the question that I don’t think I have enough data under the plans being proposed from the governor right now to differentiate, or to make that case.”

Moving the needle

McGarvey said money spent on health care in Kentucky is money well spent, especially because this “is the first thing that has moved that needle effectively in 25 years.”

Glisson disagreed: “The more we’ve spent, we have not moved the needle, we have not seen movement in those outcomes. . . . Our figures do not show that that needle has been improved as we have spent more on Medicaid. Those outcomes did not improve.”

McGarvey asked for data supporting Glisson’s claim, saying there is conflicting evidence. A study published last week found that Medicaid-eligible people in Kentucky and Arkansas, which also expanded Medicaid, are reporting that they are in “excellent” health in increasing numbers.

Emily Beauregard, executive director of Kentucky Voices for Health, noted the study in an interview. She said, “It’s been really disappointing to hear the administration continue to say that we haven’t moved the needle on health with Medicaid expansion, because we absolutely have. . . . We see that in the fact that preventive screenings have doubled, that chronic-disease management has increased by 15 percent, and that emergency department visits have decreased. And all of that points to expanded coverage having a real impact.”

Sen. Alvarado

One area that McGarvey and Sen. Ralph Alvarado, a Republican and physician from Winchester, agreed on was the need for a statewide smoking ban, which both said would improve the state’s dismal health outcomes.

“While we are debating dollars and taxpayer money up here, which is incredibly, incredibly important and certainly a large part of this debate, there are certain policies that we can do that cost nothing to improve the health of Kentuckians,” McGarvey said. “We could all advocate for a smoking ban in the next legislative session.” Bevin opposes such a ban, saying it is a local issue.

Agreeing with McGarvey, Alvarado said, “I think that would be a wise choice for our state going forward.” He also urged the Cabinet to allow managed care organizations to pay for all smoking cessation medications, telling them that “the rates on that are tremendous.”

Glisson noted that every health department in the state has a smoking cessation program, but said they would have to work with the actuaries to determine if MCOs could include all cessation medications. Meier noted that smoking cessation is one of the reward incentives in the new Medicaid plan.

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