Director, Commonwealth Policy Center

A New Approach to a Healthy Kentucky

Kentucky became the first state in the nation to receive a federal waiver to require able-bodied Medicaid recipients to work, go to school, or engage in community service at least 20-hours per week. Gov. Bevin said "This marks the first significant change to a federal entitlement program in more than 20 years." It's a move he believes will provide a model for other states to follow.

Interestingly, the motivation behind the new model which applies to recipients between the ages of 19-64 isn't primarily financial savings.  Seema Verma, administrator for the Centers for Medicare and Medicaid said "This is about helping those individuals rise out of poverty. Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries." Verma worked closely with the Bevin administration to craft the new policy. Nine other states are also seeking the 1115 federal waiver.

The waiver is part of a larger initiative called Kentucky HEALTH (Helping to Engage in Long Term Health). Secretary for the Cabinet for Health and Family Services Vicki Glisson called it a "personalized path to better health… and allows individuals to better engage their communities, improve employability, and is a motivation to long-term success." She announced at Friday's press conference in the Capitol that "its not a one-size fits all solution."

Since 2014, nearly a half-million Kentuckians joined the Medicaid rolls since the Affordable Care Act lowered the participation threshold. Today, one out of every three Kentuckians are on Medicaid, which begs the question: is it a policy achievement to have more Kentuckians dependent upon a government program that was originally designed for children and the disabled? Do more people on Medicaid actually achieve comprehensive and overall health?

Even though more Kentuckians have health care coverage now than four years ago, Kentucky ranks near the bottom in far too many health categories. According to the United Health Foundation's 2017 report, Kentucky nationally ranked 42nd in overall health. Obesity (44th), inactivity (46th), diabetes (46th), smoking (49th), illicit drug use (49th) reveal that there's more to personal health than just having access to a doctor and insurance.

Traditional health entitlements for the needy may have covered insurance but when provided without regard to the contribution that able-bodied recipients can make to achieve their own well being such programs neglect a human dynamic necessary for true health.  It's one thing to provide somebody medical care. It's another thing altogether for individuals to take ownership of their own health. Kentucky HEALTH is simply incentivizing the latter in order for individuals to make better life decisions. 

Medicaid participants under the Obamacare expansion must earn dental and vision benefits through activities like getting a GED or taking financial literacy classes. They are rewarded with Health Spending Accounts of up to $1000 for simply having annual preventive care checkups, avoiding inappropriate emergency room visits and completing chronic disease management courses.

Yet, defender of the status quo, Con. John Yarmuth (D-Louisville) called the move to require the able-bodied to work or go to school in order to stay on Medicaid "dangerous and irresponsible." When a reporter asked Gov. Bevin to comment he said, "How is it dangerous to give somebody an opportunity to make their life better? How is it irresponsible to expect somebody to engage in their own outcomes and create an environment for people to get healthier?"

Facebook Live comments were filled with both supportive and harsh comments. One woman accused Bevin of "literally signing her death certificate." Another said "Thanks for dooming my husband to an early death."

The hysteria resulted in failure to fully understand the proposal which outlined exemptions including the medically frail, full-time students, primary caretakers of dependents, pregnant women, and the homeless. On the other hand, it expands Medicaid to include foster care children until age 26.

According to a Kaiser Family Foundation report 60 percent of Medicaid recipients are working, which fulfills the requirement. An additional one-third of recipients are too ill or disabled to work, so the overhaul will affect a minority of enrollees.

It is estimated that the plan will save $2.4 billion and result in nearly 100,000 fewer Medicaid recipients after five years. The monetary savings is good but it's more valuable to affirm human dignity and to enable and encourage people to take ownership of their own lives.

Bevin said the goal is to help people “not to be put into a dead-end entitlement trap but rather to be given a path forward and upward so they can do for themselves.” And this is something he knows from his own experience of growing up in conditions below the poverty line. 

This column appeared in the January 17, 2018 edition of Kentucky Today.