Bevin and Beshear hotly debate governor’s Medicaid work rules, their effect and their cost; and their stands on health insurance
Gov. Bevin and Attorney General Beshear debated Oct. 15. (Photo by Ryan Hermens, Lexington Herald-Leader)
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By Melissa Patrick
Kentucky Health News
A key difference between Kentucky’s gubernatorial candidates is that one wants to require most able-bodied adults on Medicaid to work or participate in other “community engagement activities” in exchange for their health insurance, while the other says he would immediately dismiss such a proposal if elected because it’s designed to kick people off of the Medicaid rolls.
Republican Gov. Matt Bevin and his administration have tried to add such requirements through a waiver of traditional Medicaid rules. It would require, among other things, most of the state’s able-bodied adults who gained coverage through the expansion of Medicaid (to people who earn up to 138 percent of the federal poverty line) to work, go to school or take job training 80 hours a month unless they are medically frail or must care for children.
A federal judge in Washington, D.C., has blocked the waiver. On Oct. 11, an appeal was heard by judges who indicated they are unlikely to revive it. Bevin has said he expects the Supreme Court to decide the issue. He has issued an executive order that would end the Medicaid expansion six months after a final ruling against his plan.
The televised debate at the University of Kentucky Oct. 15 was the first time Bevin and Attorney General Andy Beshear had locked horns over this issue and it was a lively exchange.
Bevin said, “I am a strong proponent of able-bodied, working-aged men and women who do not have dependents and have the capability of going to work, to go to work in exchange for that which is provided for them by people who do go to work.”
The governor said he has empathy for such people, telling his oft-told story of how he was raised poor and no health insurance until he joined the Army.
Beshear disagreed. After calling health care “a basic human right” he declared that if he was elected Nov. 5 he would drop the waiver, which would require those covered by the community-engagement rules to report their hours monthly and be locked out of the program for non-compliance.
“This is red tape. This is paperwork and it is intended to tear healthcare away from people,” Beshear said. “I will always stand up against that, and I’m going to rescind that Medicaid waiver in my first week of office.”
Beshear noted that after Arkansas implemented Medicaid work requirements,where 18,000 people lost their coverage before the same judge who got Kentucky’s case blocked the program, “The vast majority of people who lost their coverage were already working,” he said.
Harvard University researchers have found that most of those affected by the Arkansas work requirements were already working and likely lost coverage because of a “lack of awareness and confusion about the reporting requirements,” Phil Galewitz reports for Kaiser Health News. “They also found that there was no evidence they had either secured jobs or other insurance coverage.”
Studies indicate that if appellate courts allow the Kentucky waiver, most who would be affected by its work rules are already meeting them. One study based on polling found that 97% are already meeting the requirements; another, based on claims data, shows 64% are.
Numbers, oversimplified
Beshear added, “Governor Bevin’s plan will rip 95,000 people off health care that have it for the very first time and I think that’s wrong.”
That line had some over-simplifications. Some people on the Medicaid expansion have had health insurance in the past, and the numbers cannot be individualized because tens of thousands of people go on and off Medicaid each month due to changes in their eligibility.
The 95,000 number comes from Bevin’s original proposal, which estimated that in five years, Kentucky’s Medicaid rolls would have 95,000 fewer people than they would without the waiver. Academic health experts said in a friend-of-the-court brief that a more likely range was 175,000 to 297,500. Medicaid covers 1.4 million Kentuckians, around 450,000 of them under the expansion.
Bevin replied to Beshear, “This isn’t about people being, having anything ripped away from them. What I propose is that people work and or volunteer and or go to school or be in training or take care of someone in exchange.” Further, he said if a person is already meeting the requirements, as was a person Beshear cited as an example, they have nothing to worry about.
Beshear also noted a recently published report by the General Accounting Office, the investigative arm of Congress, which found that Kentucky has budgeted $272 million in fiscal years 2019 and 2020 to pay for the technology and administrative costs of Bevin’s plan, an amount roughly twice the combined expense of four other states that are also working to implement similar requirements.
“And his plan is going to cost $272 million of our taxpayer dollars,” Beshear said. He did not note that 87 percent of the money comes from the federal government.
Talking over each other, Bevin pushed back and suggested that Beshear and “the people who wrote your comments” didn’t bother to read the report, saying it would not cost that much.
The report says the budget is based on 620,000 Kentuckians being affected by the new Medicaid requirements, which is a much larger number than has been previously reported but apparently includes people who would qualify for exemptions because of children, frailty or other reasons.
Asked about access to care, Beshear said he would fight to keep “federal health care reform” — otherwise known as the Affordable Care Act or Obamacare — and its expansion of Medicaid, which he said is “absolutely critical” to the survival of rural health care and rural hospitals.
“With the current lawsuit that threatens the very future of expanded Medicaid, rural health care is on the line,” Beshear said. “Everybody should be able to get the health care coverage they need in their hometowns,” he said.
Answering the question about access, Bevin said it is a “form of bigotry” to assume that people can’t fend for themselves. “It’s easy to say that health care is a right,” he said, “but the reality is it’s one that costs money.”
Requiring insurance for pre-existing conditions
The two candidates also had a noisy discussion about whether Bevin supports taking away protections for pre-existing conditions.
This stems from his support of association health plans (AHPs), a type of insurance that makes it easier for small employers to band together, free of many of the requirements of the ACA.
Bevin says he doesn’t support any plan that denies coverage for pre-existing conditions because the U.S. Department of Labor clearly says AHPs “may not charge higher premiums or deny coverage to people because of pre-existing conditions.”
Beshear says AHPs have loopholes that allow them to deny coverage. For example, AHPs do not have to cover all the essential benefits required by the ACA, such as maternity, mental health or prescription drugs, allowing them to create benefit packages that are of limited use to people with certain health conditions. AHPs are also allowed to vary premiums based on age, gender, industry and geography, which are factors that can be used to predict or anticipate pre-existing conditions.
“You can go to the doctor and learn you have a chronic disease, but it’s not covered,” Beshear said. “Your kids may get the flu . . . but pediatrics isn’t covered. You might get home and find out that you’re expecting a child, but maternity is not covered,” Beshear said. “This governor supports health care that doesn’t cover anybody’s basic needs.”
Pre-existing pool for pre-existing conditions?
Beshear’s campaign said he was referring to Bevin’s comment that he would support going back to high-risk pools for people with pre-existing conditions, which Kentucky used before the ACA.
Problems with the high-risk pool, called Ky Access, were numerous. It never enrolled more than 4,837 people, cost almost $14,000 a year in 2013 and had a $2 million lifetime cap per enrollee, Lisa Gillespie reported in 2017 for Louisville’s WFPL.
“Costs to both the state and individuals rose so much because there weren’t any young, healthy people to balance out all the high medical costs,” Gillespie reported. “That’s according to Advocacy Action Network executive director Sheila Schuster. She helped oversee the rollout of KY Access.”
“It was essentially a conglomeration of people with high-risk, chronic conditions that were going to be very costly,” Schuster told Gillespie. “The premiums were very high, but it was the only game in town.”