PBS高端访谈：Kentucky’s Medicaid expansion under ACA could soon change
MELONIE OCHSNER: We’re used to it now.
CHRIS BURY: For Steve and Melonie Ochsner, the Affordable Care Act has meant life-saving health care without going broke. Steve, who is 60, has throat cancer.
MELONIE OCHSNER: Everyday look like we seem to be getting a little bit better.
CHRIS BURY: His treatments, including chemotherapy and radiation, are covered by Medicaid, the federal government health program for low income and disabled Americans. The Ochsners qualified after the act, known as “Obamacare,” took effect. But the cancer, chemo and radiation have taken their toll, leaving burns on Steve’s neck and costing him his voice.
DOCTOR: Are they giving you a topical steroid for that?
MELONIE OCHSNER: No, I’ve been using cocoa butter.
CHRIS BURY: Melonie speaks for both of them. What has having this insurance meant for Steve’s health?
MELONIE OCHSNER: With the Medicaid, we’ve paid nothing. It has covered every ounce of it. So, I mean, peace of mind has just been just absolutely tremendous.
CHRIS BURY: The Ochsners, who take care of their three-year-old granddaughter, now get health insurance because Kentucky — like 31 other states — agreed to expand Medicaid under “Obamacare.”
Before qualifying for Medicaid, Steve relied on private insurance from the company that owned the gas station where he worked, which Melonie says paid a maximum of only two thousand dollars a year in benefits.
RECEPTIONIST: I’m going to put a note in for the billing department.
CHRIS BURY: After Steve was diagnosed with cancer in 2009, his treatments ran up bills of more than $100 thousand before the couple qualified for Medicaid in 2014. Would you be deeply in debt if you didn’t have this insurance?
MELONIE OCHSNER: We are deeply in debt from not having it before, yeah. And we would be even more deeply in debt. Selling this house wouldn’t get us out from under it.
CHRIS BURY: Under the Affordable Care Act, Kentucky — like 17 other states and Washington D.C.– set up its own health insurance exchange. Kentucky called theirs “Kynect.” Residents could sign up for private insurance, often with government subsidies.
Yet for every Kentucky resident who obtained private insurance this way, another four residents obtained coverage through Medicaid expansion. The expansion raised the income eligibility to 138% of the federal poverty line — that’s about $16 thousand a year for an individual and $33 thousand for a family of four.
Here in Kentucky the rollout of the Affordable Care Act in 2013 was considered such a success, it became a model for other states. In the first few months, more than 300,000 people qualified for Medicaid coverage under the new law, and Kentucky saw a dramatic decrease in the percentage of uninsured residents. One of the biggest drops of its kind in the country.
In 2013, nearly 19% of Kentucky’s non-elderly population had no health insurance. By 2015, the uninsured rate had fallen to less than 7%. That’s better the national rate of the uninsured, which has dropped to 10.5%.
Former Kentucky Governor Steve Beshear — a Democrat — pushed for both a state exchange and Medicaid expansion under the Affordable Care Act.
STEVE BESHEAR, FORMER GOVERNOR KENTUCKY (D): I didn’t care who passed it, I didn’t care it was a Democrat or a Republican, in terms of politics. I mean, it was the one opportunity that I felt like we had to make a big difference in Kentucky in the next generation or so in our health.
CHRIS BURY: That difference is seen in a study published by the Journal of the American Medical Association last October. It found Kentuckians newly insured in the first two years of Medicaid expansion received more primary and preventive care, made fewer emergency room visits, and reported better health.
But in Kentucky, like many states that usually vote Republican for president, “Obamacare” became a political punching bag. And in 2015, Republican Matt Bevin successfully ran for governor promising to roll back parts of the law if elected.
Last year, Kentucky eliminated its state exchange, saying it was redundant given the federal exchange. To help control costs, Governor Bevin also asked the federal government for permission — known as a waiver — to overhaul the state’s Medicaid program, which now covers 1.3 million people, almost one in three residents.
GOVERNOR MATT BEVIN, KENTUCKY (R): I want to see us to become a healthier state. I don’t want us to simply to provide people with a Medicaid card and feel like we’ve done our part. We owe people better than that.
CHRIS BURY: The governor declined our interview request, but Republican State Representative Addia Wuchner, who chairs the State Committee on Health and Family Services, supports his plan.
ADDIA WUCHNER, KENTUCKY STATE REP. (R): The goal is to help every individual that is being served by traditional Medicaid, or expanded Medicaid, or moving into the exchange to learn to utilize the tools of having insurance and coverage.
CHRIS BURY: Are you saying it provides an incentive?
ADDIA WUCHNER: It allows them to have that skin in the game, to be consumers, but also taking that responsibility.
CHRIS BURY: Under Bevin’s plan, Medicaid would no longer be free. Recipients would be charged monthly premiums up to $15 a month, or $180 a year.
Able-bodied recipients without dependents would be required to work or volunteer up to 20 hours a week or to be enrolled in school. Those eligible for expanded Medicaid who miss a single premium payment could lose coverage for at least six months.
ADDIA WUCHNER: $180 a year to have this — almost the same coverage that you and I would have. And that’s a pretty good deal. So, the governor’s not asking, nor are we asking too much of them. But we’re asking them to be collaborators in– their coverage of care.
CHRIS BURY: The consequence is you can lose your insurance if you don’t meet these obligations?
ADDIA WUCHNER: If you don’t step up and be responsible. We want to–but we’re going to put all the tools in place to help citizens be responsible Just giving them health insurance, just giving– people, often, coverage doesn’t mean that they’re really engaged in the care that they have.
CHRIS BURY: Wuchner says Kentucky needs the waiver, because the Affordable Care Act requires states to pay a growing share of Medicaid expansion costs: five percent this year, rising to ten percent by 2020, costing the state an estimated $1.2 billion between 2017 and 2021, and making Medicaid the largest piece of the state budget pie after education.
ADDIA WUCHNER: 5 percent doesn’t sound like a lot, but it adds up to be a lot of money. So, I think the governor’s approach to look at is still wanting to assure people have care; but, actually, we have a shared responsibility in that care.
CHRIS BURY: Former Governor Beshear sees another motive at work.
STEVE BESHEAR: My biggest concern is that the efforts to get a waiver are really just disguise for, “we’d like to kick as many people off this program as we can.”
CHRIS BURY: The current government says that Kentucky cannot afford this expansion of Medicaid.
STEVE BESHEAR: Yes. And it’s simply not true.
CHRIS BURY: Beshear argues that healthcare spending due to the Medicaid expansion provides an economic boost and thousands of health care jobs for the state.
STEVE BESHEAR: It is sustainable and it’s affordable. But, you know, when you get into ideology, which this current administration is in, and they’re not the only ones. I mean, this is rampant around the country, it’s sort of, “don’t let the facts get in your way.”
CHRIS BURY: At the Shawnee Christian Healthcare Center in Louisville, which serves one of the city’s poorer neighborhoods, outreach director Anne Peak fears a return to the days when nearly one-in-five Kentuckians were uninsured.
ANNE PEAK: We will lose hundreds of thousands of folks’ coverage, people will not be able to get the care that they need and people will be going back to the emergency rooms in droves.
ROBIN DUNCAN: I’ve been coughing a whole lot,
CHRIS BURY: Robin Duncan now gets regular checkups at the Shawnee clinic, because she is covered by Medicaid. But last April, before she had Medicaid, Robin showed up at the ER uninsured and had to undergo gallbladder surgery.
Before you had insurance, how much did you rely on the emergency room?
ROBIN DUNCAN: I was probably having to go there for a little while. I was probably having to go, like, two or three times, like, a month.
CHRIS BURY: For your basic health care.
ROBIN DUNCAN: Correct, yes.
CHRIS BURY: After the Medicaid expansion, Kentucky hospitals saved more than a billion dollars in uncompensated or charity care from 2013 to 2014 according to a state-commissioned study.
Kentucky’s waiver — if approved by the Trump Administration — could provide a glimpse of what a Republican replacement for “Obamacare” might look like.
Brian Blase, a former staffer for Congressional Republicans, now works as a health policy analyst.
BRIAN BLASE, SENIOR RESEARCH FELLOW, MERCATUS CENTER AT GEORGE MASON UNIVERSITY: We have 50 states. They’re often referred to as laboratories of democracy. Let them figure out some of these problems, and learn from each other.
CHRIS BURY: Blase favors a repeal of the Medicaid expansion and says that in states like Kentucky, the investment has not paid off.
BRIAN BLASE: Right now, when states spend an extra dollar, the federal government is reimbursing the state for most of that dollar. I wanna see– a change where states get a set amount of money with a lot more freedom with how to manage the dollars, and who to gear the program to. I think we have probably way too many people on the Medicaid program, and that it’s not able to serve sort of the truly needy, who need the public assistance.
CHRIS BURY: About 20 million Americans have health insurance that didn’t have health insurance before. Isn’t that a good thing?
BRIAN BLASE: It’s a good thing, if you don’t look at what the corresponding costs are. Right? You have to think, what’s the value that people are getting on this health insurance? And is the value that people are getting worth the costs?
CHRIS BURY: Blase cites a 2013 study from Oregon that found people who got coverage through a Medicaid expansion did utilize more health services, but showed no significant improvement in physical measures like high blood pressure and cholesterol levels. Though diabetes detection and treatment went up.
But Jonathan Weiner, a professor of public health at Johns Hopkins University, says there are definite health benefits to having coverage.
JONATHAN WEINER, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH: For the individual, unquestionably, people with an insurance card in their pocket are healthier and over the long term have a better and longer life than someone that doesn’t have an insurance card.
CHRIS BURY: One of the reasons Republicans opposed this Medicaid expansion. They say it’s been far too expensive for the health outcomes that have been produced.
JONATHAN WEINER: Well, health care is expensive. People in private insurance plans spend even more than is the case here. But this way they can get preventive care. They can get their diabetes treated. Yes, that’s more expensive– but they will be healthier.
DOCTOR: Say ‘Ahhhhh’
STEVE OCHSNER: Ahhhhh
CHRIS BURY: Steve Ochsner and his wife, Melonie, credit the Affordable Care Act with helping keep Steve alive during his battle with throat cancer. They’re open to changes in the law, including paying a premium or volunteering to keep their Medicaid coverage.
You’d be okay?
MELONIE OCHSNER: We’d be okay with it. And I know that there are a lot of people that wouldn’t. But we’d be okay with it. We just would.
CHRIS BURY: Because the insurance is that important.
MELONIE OCHSNER: Because the insurance is that important. It is.