New Baseline Report Shows Kentucky’s Gains Under ACA, Medicaid Expansion

By: Kentucky Voices for Health, Insure Kentucky

The University of Louisville’s Commonwealth Institute of Kentucky today released a report on the Affordable Care Act (ACA)’s impact on Kentucky’s health and economy since 2014.

This report documents Kentucky’s numerous health and economic gains that largely hang in the balance of the federal court case Stewart v. Azar, brought by sixteen Kentuckians against the Centers for Medicare & Medicaid Services (CMS), which re-approved Governor Bevin’s 1115 Medicaid waiver, called Kentucky HEALTH, on November 20, 2018. As Kentucky weathers numerous threats to its healthcare safety net, this report offers a new baseline to measure changes in insurance coverage, access to care, health outcomes, and economic impact.

Baseline Highlights

Insurance coverage for Kentuckians increased dramatically under the ACA, largely due to the state’s decision to implement Medicaid Expansion for those living at or below 138 percent of the Federal Poverty Level. Kentucky’s uninsured rate fell from 20.4 percent in 2013 to 7.8 percent in 2016 – the largest decline in the country. Access to care increased dramatically under the ACA due to expanded Medicaid, protections for pre-existing conditions, new individual plan offerings with more comprehensive coverage, and income-based tax credits. Each Medicaid dollar spent in the healthcare system generates a return of $1.35 to $1.80 to Kentucky’s economy. More than 16,000 jobs have been created in the healthcare and social services sectors since 2014. Expansion states have increased Medicaid budgets; however, benefits such as reduced uncompensated care and job growth in health and social services offset the increase.

"For health advocates who are working to protect these gains, this report reminds us that there’s a lot at stake."

The report found that numerous studies associate expanded coverage with improved overall health, increased access to care, higher rates of preventive care, less reliance on emergency room care, better chronic disease management, and a decrease in self-report of psychological distress and poor mental health days. More affordable access to care has also led to a decrease in healthcare related debt, which used to be the number one cause of personal bankruptcy.

“The positive impact of expanded coverage for Kentucky’s health and economy cannot be overstated,” said Emily Beauregard, executive director of Kentucky Voices for Health. “For health advocates who are working to protect these gains, this report reminds us that there’s a lot at stake.” “The Kentucky HEALTH waiver threatens to reverse much of the progress Kentucky has made under the ACA. While the waiver proposal cites cost savings as members fall off the Medicaid rolls, the cost per member is expected to increase,” said Dr. Sheila Schuster, executive director of the Advocacy Action Network. “In reality, it will shift more burden onto Kentucky’s already strained healthcare safety-net and put the most vulnerable Kentuckians at risk of losing access to mental health and substance use treatment.”

Other states, such as Indiana and Arkansas, have implemented similar waivers with disastrous results. In Indiana, 55 percent of those subject to premium payments failed to meet the requirement, and more than 18,000 in Arkansas lost coverage for failing to meet reporting requirements in 2018. In both states, beneficiaries cited confusion and lack of awareness as reasons for their inability to comply.

"Individuals who lose Medicaid because of Kentucky HEALTH requirements are unlikely to find other sources of coverage, as most are already working in low-wage jobs that do not offer employer-sponsored health insurance."

“Even modest cost-sharing reduces coverage and utilization of necessary services and does not improve health outcomes,” said Susan Buchino, assistant director of the Commonwealth Institute of Kentucky. “Consumers cut back on preventive services such as cancer screenings as a result of financial barriers at the point of care.” For many Medicaid-eligible recipients, computer literacy and connectivity are barriers. According to national level survey data cited in the report, one in three Medicaid members never uses a computer and one in four report that they never use the internet. “For many people experiencing housing insecurity, particularly in rural Kentucky, the widespread lack of internet connectivity may be a serious barrier to health coverage. As we move forward from this baseline, Kentucky should conduct outreach and enrollment with this condition in mind,” stated Adrienne Bush, executive director at the Homeless and Housing Coalition of Kentucky. Health insurance literacy is another challenge that Kentuckians face. “For many Medicaid-eligible recipients, health insurance literacy is a factor,” said Jean Edward, an assistant professor with the University of Kentucky’s College of Nursing. “Many of the low-income adults who qualify under Medicaid and Medicaid Expansion have low confidence in both their understanding of basic health insurance terms and use of health insurance to access appropriate healthcare services.” “ACA implementation – and in particular, Medicaid expansion – has resulted in great improvements in insurance coverage and access to care, as well as a major influx of federal dollars into the state’s healthcare system,” said Dustin Pugel, policy analyst at the Kentucky Center for Economic Policy. “By the state’s own estimates, the implementation of Kentucky HEALTH will increase administrative costs while reducing the number of people covered by Medicaid. Individuals who lose Medicaid because of Kentucky HEALTH requirements are unlikely to find other sources of coverage, as most are already working in low-wage jobs that do not offer employer-sponsored health insurance.”

InsureKY is a statewide coalition of nonprofits formed to promote more affordable health insurance, better care, and stronger consumer protections for all Kentuckians.

“The reporting requirements under the Kentucky HEALTH waiver have caused great concern for farmers, entrepreneurs, and others with seasonal jobs,” said Martin Richards, executive director of Community Farm Alliance. “Any increase in red tape takes precious time away from families and small businesses.”

“For all of these reasons, it will be critically important that we measure the impact of Kentucky HEALTH on the nearly 1.2 million Kentuckians who will be subject to complicated new and penalties,” said Beauregard. “This baseline is the key to understanding whether the waiver will ultimately help or hurt Kentuckians.

Read the executive summary here. Read the full report here.