Kentucky Submitted A Medicaid Waiver With A Work Requirement And Mandatory Premiums

Modern Healthcare: Kentucky Sent A “Medicaid Waiver With Controversial Work Requirements” To HHS. Modern Healthcare reported on Kentucky Gov. Matt Bevin’s waiver request to the Department of Health and Human Services (HHS), noting that the waiver included “requirements for most beneficiaries to participate in job training or community service.” In particular, the waiver “outlines a five-year program that would require monthly premiums ranging from $1 to $15,” includes “a rewards account that could be used for dental and vision services,” and a work requirement for “able-bodied adults.” From the August 24 article:

Kentucky Gov. Matt Bevin on Wednesday submitted a waiver request to the CMS outlining a conservative vision of Medicaid expansion that includes requirements for most beneficiaries to participate in job training or community service.

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Kentucky Health would require able-bodied adults without dependents to participate in job training and community engagement such as volunteer work to remain eligible. The hours required would increase with the months of eligibility, reaching 20 hours per week after one year.

The waiver request outlines a five-year program that would require monthly premiums ranging from $1 to $15 and includes two health savings accounts. One is for the $1,000 deductible, and the other is a rewards account that could be used for dental and vision services as well as some over-the-counter medicines and gym memberships.

Money for the rewards account is earned through community engagement, job training, wellness activities and proper emergency room usage. In public hearings on the proposal, optometrists and dentists in particular opposed the plan and argued it would limit access and increase costs.

Those who are above the poverty level and miss two months of payments would be disenrolled from the program and required to sit out for six months. Those below the poverty level will be required to pay copays and will have their rewards accounts suspended after 60 days of nonpayment. There are options for early re-entry if the debt is paid and the beneficiary takes a financial or health literacy course. [Modern Healthcare, 8/24/16]

Experts Criticize Kentucky’s Medicaid Waiver As Cruel And Counterproductive

KCEP: Bevin’s Waiver “Would Reduce Coverage And Move Kentucky Backward On Health Progress.” Kentucky Center for Economic Policy’s Dustin Pugel explained in a brief that the proposed waiver “will result in fewer Kentuckians covered and decrease health care access, which will ultimately harm the health status of Kentuckians and move the state backwards in its recent health care gains.” He noted the success of the Medicaid expansion in Kentucky, as “Kentucky is a national leader in its substantial reduction in the uninsured rate under the Affordable Care Act,” and emphasized that the Medicaid waiver “is designed to reduce coverage.” In particular, the provisions that would deny “benefits to people who don’t pay premiums or fail to re-enroll in time and locking them out for a period of time as well as work requirements for maintaining coverage” enact “barriers [that] will reduce the number of people who can participate.” From the July 20 brief (citations removed):

Kentucky is applying to modify its Medicaid program through a waiver under Section 1115 of the Social Security Act. The proposed changes will result in fewer Kentuckians covered and decrease health care access, which will ultimately harm the health status of Kentuckians and move the state backwards in its recent health care gains. And while the proposal is framed in terms of increased financial sustainability and reduced costs, it can end up costing the state more overall as it introduces new, expensive and complex administrative burdens, and limits access to the preventative care that improves health. In the end, rolling back Kentucky’s historic gains in healthcare coverage would be antithetical to the goals of the Medicaid program and the 1115 waiver process and hurt the many Kentuckians who benefit from the Medicaid program in its current form.

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The waiver is projected to result in fewer people enrolled because it includes a number of measures shown to reduce coverage, including denying benefits to people who don’t pay premiums or fail to re-enroll in time and locking them out for a period of time as well as work requirements for maintaining coverage. Ample past research shows such barriers will reduce the number of people who can participate. But the purpose of 1115 Medicaid waivers is to test ways to expand coverage or otherwise improve care, not move backwards on health care access.

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In spite of a rejection of work requirements in every other state that has proposed them (including Indiana and Pennsylvania), this waiver seeks to require work or community engagement activities as both an expectation for coverage and an incentive for added benefits. However, it has been long demonstrated that work requirements in other safety net programs are not only ineffective in promoting long-term employment and wage growth, but have led to a greater likelihood of being stuck in deep poverty – at or below 50 percent of the federal poverty level.

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According to an extensive body of research, premiums create a barrier for health coverage for many low-income individuals. For instance, Oregon received approval in 2003 to increase the premiums it charged participants in its Medicaid waiver program and also impose a six month lock-out period for non-payment of premiums; a study found that following these changes, enrollment in the program dropped by almost half. Similar effects occurred with programs in Utah, Washington and Wisconsin. All five states that have instituted premiums for their expansion populations have seen either an increase in collectable debt among enrollees, a decrease in enrollment or at the very least an increase in churn in and out of the Medicaid program. Finally, since many employers don’t offer coverage, escalating premiums are an ineffective incentive for moving people off of Medicaid on to employer-sponsored health insurance. They become, in effect, a penalty for being poor – especially as they increase over time while wages in low-income jobs remain flat. Escalating premiums are also harmful for entrepreneurs whose businesses often struggle in the early years after start-up; this proposal would introduce a graduating cost to those individuals just as their businesses are getting off the ground. [Kentucky Center for Economic Policy, 7/20/16]

Families USA: Kentucky Medicaid Waiver “Adds Significant Barriers To Care.” Families USA explained that “evidence from other states” that implemented policies similar to Bevin’s Medicaid proposal illustrates that policies like work requirements “make it harder for beneficiaries to afford their coverage and access the care they need.” Families USA emphasized that “the Kentucky HEALTH plan could undo the tremendous progress the state has made over the past two years,” highlighting that the state’s “improved insurance rate is associated with people in the Medicaid program getting more preventive health care” but that Bevin’s proposal makes it “nearly impossible for the state to maintain these gains.” From the June 24 article (boldface original):

Since he was elected in November, Kentucky Governor Matt Bevin has been threatening to recast a successful health care program to fit his political ideology. This week his administration released their proposal for a section 1115 waiver to make changes to its Medicaid expansion program.

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Waiver proposal adds significant barriers to care

The proposal, called Kentucky HEALTH, would put in place harsh new barriers to both coverage and care. Key pieces of the plan include work requirements, premiums, health savings accounts, benefit reductions, and the elimination of retroactive coverage. Bevin’s administration claims that these changes would improve health, build personal responsibility, and promote financial sustainability.

However, evidence from other states suggests that all of these elements could make it harder for beneficiaries to afford their coverage and access the care they need. Many of these changes are also difficult and expensive for states to administer. Our interactive map of state Section 1115 waivers has more information about common waiver elements. 

Proposal elements could destroy gains in coverage, limit access to health care

The Kentucky HEALTH plan could undo the tremendous progress the state has made over the past two years. Since 2014, the state has experienced the second largest decrease in its uninsured rate in the entire country. As a result, enrollees’ have been able to get the health care they need.

Data show that this improved insurance rate is associated with people in the Medicaid program getting more preventive health care. Despite this success, Bevin’s administration claims that the state will only continue Medicaid expansion coverage if it is allowed to implement this new waiver program.

It will be nearly impossible for the state to maintain these gains if it makes coverage and health care services more expensive and difficult to obtain. [Families USA, 6/24/16]

Kentucky Newspapers Consistently Reported On The Specific Policies And Negative Impacts Of The Medicaid Waiver

The Courier-Journal Dedicated The Most Coverage To The Medicaid Waiver. A Media Matters analysis of the top two Kentucky newspapers from June 22, 2016, through April 11, 2017, found that The Courier-Journal devoted substantially more space to covering Bevin’s Medicaid proposal than the Lexington Herald-Leader. The Courier published 17 articles while the Herald-Leader printed seven.

Both Of Kentucky’s Top Two Newspapers Consistently Reported On The Specific Policy Proposals Within The Medicaid Waiver. The majority of articles in the top two Kentucky newspapers discussed specific policies in Kentucky HEALTH. The Courier discussed the work requirement in 15 articles and the monthly premiums in 16 of its 17 total articles. The Herald-Leader discussed the work requirement in four articles, and the monthly premiums in all of the paper’s seven total articles.

The Majority Of Coverage Included Reporting On The Potential Negative Impacts Of The Medicaid Waiver. The top two Kentucky newspapers consistently reported on the negative impacts of the Medicaid waiver and contextualized its possible effect on Kentucky. The Courier reported on the negative impacts of the work requirement in nine articles and the detrimental consequences of monthly premiums in 11 articles of 17 total. The Herald-Leader included information on the potentially deleterious effects of a work requirement in only one article but reported on the negative impacts of monthly premiums in four articles out of seven total articles.

Kentucky Newspapers Properly Reported On The Waiver In The Context Of The Success Of Kentucky’s Medicaid Expansion. Both newspapers consistently grounded their reporting on Bevin’s waiver proposal in the context of the major public health improvements resulting from Kentucky’s Medicaid expansion. The Courier included information on the success of the Medicaid expansion in 16 out of 17 total articles. The Herald-Leader contextualized the waiver to Kentucky’s Medicaid expansion in four out of seven total articles.

Methodology

Media Matters reviewed the Nexis database for articles published from June 22, 2016 (the day Bevin released the Kentucky HEALTH proposal), to April 11, 2017, in The Courier-Journal and the Lexington Herald-Leader for any mention of “Medicaid” and “waiver” and either “kentucky health” or “work” or “job training” or “community service.” Articles that primarily focused on the Kentucky HEALTH Medicaid waiver were included for analysis. Mentions of the waiver’s work requirement, health savings account provision, premiums provision, negative impacts of those provisions, the impact of the Medicaid expansion in Kentucky, and studies or statistics about the percentage of Medicaid beneficiaries who are employed were tallied in their own categories. Editorials, op-eds, opinion columns, and wire reprints were excluded from analysis.