Bevin wants Medicaid plan to deliver dignity, but it may just punish the poor

Published 9:02 am Tuesday, March 6, 2018


Contributing columnist

Two-thirds of Kentucky’s registered voters already oppose Gov. Bevin’s plan to cut Medicaid.  Now comes the news (front page article in the February 17 Courier Journal)  that we can’t afford it. Why spend tons more money to cover tons fewer people? How can we justify that?  

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According to the governor, the justification is moral, not monetary. He believes that the plan can restore the dignity and enhance the health of able-bodied adults without jobs or other community engagement who still get health care through Medicaid. “What price can you put on dignity?” he asks.  They are being delivered from an “entitlement dead-end.” Or in the words of Seema Verma, administrator of the federal Centers for Medicare and Medicaid  Services, from the “soft bigotry of low expectations.” That’s a moral mission, isn’t it? Not according to conscientious objectors on their own moral grounds.    

According to Dustin Pugel, a policy analyst for the Kentucky Center for Economic Policy,  it will cost Kentucky more to provide health coverage to people affected by the Bevin changes than if the state did nothing at all. The target population is the 480,000 adults added to Medicaid under the Affordable Care Act. (In fact, the target is also the Affordable Care Act itself.)  

The Bevin plan assumes that nearly 100,000 people will drop out of Medicaid by the end of the five-year project. Those who remain will mostly be the less healthy, so monthly costs per person will increase faster than if no changes were made, meaning that more money is spent on fewer people.  They will delay or reject getting health care until the care they get is more costly and often too late.

The administration officials say that the changes will bring savings of $11.5 million (80 percent coming from the federal government), but there will be no savings in the next two budget years, according to Medicaid Commissioner Stephen Miller. In years three to five, $2.4 billion would be saved — $300 million from state funds, the rest from federal funds. However, the state also plans to spend close to $374 million over the next two years to get the plan in operation, mostly for the creation of a computer system to track compliance with the new rules, as required by the federal government. These changes would affect fewer than 200,000 people out of the 1.4 million enrolled.     

Because of the complexity of the new rules, for reporting work and volunteer hours, paying monthly premiums, etc., health advocates doubt that recipients who get better jobs (many already work) will leave Medicaid. There are more ways to lose coverage, and it could take six months to be restored. The program creates another layer of bureaucracy with greater risk of paperwork mistakes for people who already may have trouble negotiating the system (perhaps due to mental illness, addiction or chronic illness).  Barbara Cooper, a doctor at a University of Louisville clinic who has been treating low-income patients for two decades, contends that more people will end up uninsured than will find a job. “This whole program is geared toward punishing people for being poor,” she feels.  

Herein lies an opposing moral counter-claim about the whole plan. Critics call it punitive, mean-spirited and even cruel. What presents itself as being driven by an obligation to do something for a vulnerable population’s own good and its improved health is reframed as a deprivation of the very assistance toward health through Medicaid that could enable a person’s move toward greater independence, more community engagement, and a generally better and healthier life.

The conscientious objectors are quick to point out that  we are talking about economically disadvantaged people’s access to health care. We are not talking about provision of an allowance for housing and other living expenses; we are talking about people’s need to be healthy enough to seek, get and hold a job.  

What group exactly is the target? It’s those notorious able-bodied adults who refuse to work.  According to statistics from the Kaiser Family Foundation, of the working-age adult Medicaid recipients who were not receiving disability benefits in 2016, 42 percent worked full-time, 18 percent worked part-time, 14 percent were sick, 12 percent were caring for family members, 6 percent were in school and 7 percent were idle. (Given the goal of Medicaid to provide medical care for low-income people, it is not even clear that a work requirement can be legally introduced for this population. There are lawsuits.)    

Are there any people in that 7 percent who could and should be working or going to school or doing some other form of community engagement? Odds are, there are. But should major  health care needs of the many go unmet in order to discipline a few able-bodied freeloaders?  

The Medicaid work requirement does not guarantee increased income or even finding a job, but for workers in jobs that don’t provide benefits, Medicaid has actually been found to help people to stay employed or to find jobs. In Ohio and Michigan, residents who gained coverage with Medicaid expansion found it easier to look for work (helped by access to primary doctors and prescription medication).

So it appears that we are faced with clashing moral visions, not just cuts to the safety net to finance hundreds of billions of dollars in tax cuts that primarily further advantage wealthy households and corporations. Where do justice and compassion point?