Beshear, Republicans debate the record of Obamacare in Ky.

Kentucky’s roles in implementing and changing federal health-care law were on national display Tuesday night, as former Gov. Steve Beshear gave the televised Democratic response to President Trump’s first address to Congress and Kentucky Republicans criticized Beshear’s embrace of “Obamacare.”

Trump set the table in his speech, using Kentucky as an example of why the Patient Protection and Affordable Care Act should be repealed and replaced: “Governor Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing.” Trump has yet to endorse a replacement plan, but he said five principles should guide Congress:

  • Americans with pre-existing conditions should “have access to coverage.” Republicans talk about doing that through insurance pools for higher-risk people, which require government subsidies to work. Critics say many people still couldn’t afford insurance from high-risk pools, which Kentucky once had.
  • Regular coverage should be subsidized through tax credits and expanded use of health savings accounts, which are exempt from taxes, and people must get “the plan they want, not the plan forced on them by the government.” The ACA set minimum requirements for coverage, making it more expensive, especially for people who had bought low-cost policies.
  • “We should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.” Republicans talk about giving states block grants for Medicaid, with few strings attached but limiting federal funding of the program. There is debate about how to equitably fund states that expanded Medicaid under the ACA and those that didn’t.
  • “We should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance. and work to bring down the artificially high price of drugs and bring them down immediately.”
  • “The time has come to give Americans the freedom to purchase health insurance across state lines, creating a truly competitive national marketplace that will bring cost way down and provide far better care.”
Beshear, speaking from the downtown Lexington Diner, said “So far, every Republican idea to replace the Affordable Care Act would reduce the number of Americans covered, despite your promises to the contrary.”

Trump said in January that he wanted “insurance for everybody,” and presidential adviser Kellyanne Conway promised that no one would lose their insurance. “However, an analysis of the current Republican plan to replace the health-care law shows that millions who have coverage today would lose it,” NPR health correspondent Alison Kodjak reported, citing a presentation made to the National Governors Association last weekend.

Beshear continued, “Mister President, folks here in in Kentucky expect you to keep your word, because this isn’t a game, it’s life and death for people. These ideas promise access to care, but deny the importance of making care affordable and effective. They would charge families more for fewer benefits and put the insurance companies back in control.”

Kodjak says the Republican approach “could help reduce premiums for those who would like to buy a more stripped-down insurance policy,” but the draft plan of House Republicans is “likely less generous, so people could pay more for health care even if they have lower premiums.”

Beshear accused Republicans of thinking “that folks at the lower end of the economic ladder just don’t deserve health care. That it is somehow their fault that their employer doesn’t offer insurance or that they can’t afford to buy expensive health plans.” He added later, “Before the Affordable Care Act, they woke up every morning and went to work, just hoping and praying they wouldn’t get sick because they knew that they were just one bad diagnosis away from bankruptcy.”

When he was governor, Beshear expanded Medicaid to people earning up to 138 percent of the federal poverty level, now $16,394 for an individual or $33,534 for a family of four. As a result, the share of Kentuckians without health insurance dropped to 6 percent from 14 percent, the largest reduction of any state.

Bevin says the state can’t afford to pay its 5 to 10 percent share of the expansion cost, and has asked federal officials to waive rules and let the state charge Medicaid enrollees small, income-based premiums and require able-bodied adults who are not primary caregivers to work or perform work-related activities. The Trump administration is expected to approve the waiver.

Speaking to reporters in Washington Monday, Bevin said of Beshear, “Because he unilaterally chose to expand Medicaid in Kentucky, enrolled hundreds of thousands of people, the net result of it has been a
remarkable decline in access to health-care coverage: more people covered, but covered by what? Fewer people able
actually to even see a doctor.” Then he immediately started talking about private insurance, noting that half of Kentucky’s counties have only one Obamacare provider. “There are only three now in the entire state, only one that covers the entire state.”

Asked how the expansion could have reduced access to coverage when it added 440,000 Kentuckians to Medicaid, Bevin communications director Amanda Stamper said in an email that the governor was “referring to more than simply Medicaid expansion,” and “the loss of quality health
care coverage and shrinking networks. Medicaid coverage is not quality health coverage. Network adequacy is an issue, as fewer and fewer doctors want to deal with [the] administrative burden of accepting Medicaid for reimbursements that do not cover their cost.”

Stamper added that the current version of Medicaid coverage “does nothing to engage the beneficiary or incentivize behaviors that will lead to better health outcomes. A study that looked at the expansion population found that only 10 percent of Kentucky expansion beneficiaries received an annual wellness or physical exam. That is not the kind of utilization that will drive better health outcomes.”

State Senate Floor Leader Damon Thayer, R-Georgetown, delivered a response to Beshear’s response. It can be viewed on the state Republican Party’s Facebook page.

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