LEXINGTON — Why did the national Democratic response to President Trump’s first speech to Congress come from former Gov. Steve Beshear, speaking from the downtown Lexington Diner?
Mainly because national Democratic leaders think their best issue right now is health care, and they see Kentucky as an example of why Trump and Congress need to keep much of the Patient Protection and Affordable Care act. The state is a good example in some ways, but Republicans aren’t conceding any of the point.
Even before Beshear spoke, Trump and other Republicans pushed back, arguing that the state is actually an example of how the Patient Protection and Affordable Care Act needs repealing and replacing.
“Gov. Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing,” Trump announced to Congress, roughly paraphrasing what Bevin had told Washington reporters the day before.
But if Obamacare opponents are looking for an anti-Beshear to make their case, Bevin — who clearly relishes the role — hasn’t gotten the drill down.
After calling Obamacare in Kentucky “an unmitigated disaster,” he 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; (in) 50 percent of our counties, there’s only a single health-care provider on the coverage front, there are only three now in the entire state, only one that covers the entire state.”
Bevin conflated and confused Medicaid, the state-federal program that gives the poor free health care, with private insurance that is subsidized by federal tax credits on the government exchanges.
In Kentucky, only three companies are selling such coverage, and only one statewide: Anthem Blue Cross Blue Shield. We once had seven Obamacare insurance companies, but as in other states, insurers have stopped selling on the exchanges because they lose money on them. Not enough young, healthy people are buying the subsidized policies, mainly because the law’s penalty for not having insurance is a lot cheaper than the premiums, which are rising along with deductibles.
That’s probably been most of what you have heard about Obamacare, but fewer than 100,000 Kentuckians have private insurance under it. Medicaid is the most important feature of the law, especially in Kentucky.
In a state with some of the nation’s poorest health, the expansion now covers 440,000 people with incomes up to 138 percent of the federal poverty level: $16,394 for an individual or $33,534 for a family of four. But Republicans, including Senate Majority Leader Mitch McConnell, don’t like to talk about Medicaid; they prefer to decry the private-insurance problems.
In his primary campaign, Bevin said he would abolish the expansion, but wiser heads apparently persuaded him that taking health care away from so many people could be a big political loser. So now he wants to refashion the program to charge small, income-based premiums and require able-bodied recipients who aren’t primary caregivers to work or do work-related activities. His administration estimates that with the changes, Medicaid would have 86,000 fewer enrollees in five years than it would otherwise. Bevin argues, and Trump repeated, that the expansion is “unsustainable” because the state can’t afford to pay its 5 to 10 percent share.
Beshear argued as governor that the expansion would pay for itself by funneling billions of dollars to hospitals and other health-care providers, allowing them to hire more people who would pay more taxes (and greatly reducing their uncompensated care). There have been gains in health-care employment, but not as much as projected.
The expansion’s economic costs are clear, but its economic benefits are not. A study is needed before decisions are made. As Beshear told Trump, “This isn’t a game. It’s life and death for people.”
The more important benefit of the expansion is that a lot of people who weren’t getting care are getting it. From January 2014 through last September, it has paid for 224,720 dental exams, 15,692 screenings for diabetes, 59,529 breast-cancer screenings, 38,190 colorectal cancer screenings, 24,157 hepatitis C screenings and 53,465 substance-abuse treatments.
Bevin told the Washington reporters, “It’s not purely about coverage, it’s about access to, and the receipt of, health care so that folks have better health outcomes.” Asked to explain his remark that the expansion has caused “a remarkable decline in access to health-care coverage,” Bevin’s communications director, Amanda Stamper, wrote in an email:
“The quoted statement has to be looked at in the full context of the governor’s remarks. From that, it’s clear he is referring to more than simply Medicaid expansion but the effect of the ACA as a whole on Kentucky, and he is referring to 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.”
The implication is that fewer doctors are accepting Medicaid, but asked for figures on that, Stamper didn’t reply.
Her email went on, “Medicaid coverage as it exists today 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.”
That much is true. Health should be a shared responsibility. People who get something for nothing may not place proper value on it. As Bevin says, some need “skin in the game.” His proposal is likely to be approved since it’s modeled after an Indiana program fashioned by the woman Trump has appointed to oversee Medicaid and Medicare. Parts of it could be included in a new national model for the program. In that way, and with McConnell’s key role, Kentucky will continue to be part of the national health-care debate. Let’s just hope Bevin gets more coherent and Trump and Congress keep the president’s promise to have “insurance for everybody.”
Al Cross, former C-J political writer, is director of the Institute for Rural Journalism and Community Issues and associate professor in the University of Kentucky School of Journalism and Telecommunications. His opinions are his own, not UK’s. This column previously appeared in the Louisville Courier-Journal.