Fewer families report having trouble paying medical bills; near-poor struggle more than poor families

Fewer American families are having problems paying medical bills, but 20 percent of them, particularly those without insurance and those that are "near poor" but not :poor," still struggle with health costs, says a study released Tuesday by the National Center for Health Statistics.

The report says 54.2 million people, or 20.3 percent of families headed by someone under the age of 65, had difficulty covering medical expenses in the first half of 2012. During the first half of 2011, 21.7 percent of families, or 57.8 million people, found it difficult to pay medical bills.

Hispanics (25.2 percent) and blacks (27.9 percent) were more likely than whites (20.1 percent) or Asians (10.3 percent) to report trouble paying their medical bills, says the report. It says families with incomes from 100 to 199 percent of the poverty line were most likely to have difficulty paying medical bills, probably because those below the poverty line qualify for Medicaid. State income limits vary; in Kentucky, income-based Medicaid is available to those with incomes less than 70 percent of the poverty line.

'Poor' are below the poverty line. 'Near poor' had incomes of 100 to 199 percent of the poverty line. 

Among families with insurance, 14 percent of those with private insurance and 25.6 percent  with Medicaid or other public insurance had similar problems paying bills in the first half of 2012, which represents a 1.7 percent and 2.5 percent decrease from 2011, respectively. For a report on the study, click here.

Fewer American families are having problems paying medical bills, but 20 percent of them, particularly those without insurance and those that are "near poor" but not :poor," still struggle with health costs, says a study released Tuesday by the National Center for Health Statistics.

The report says 54.2 million people, or 20.3 percent of families headed by someone under the age of 65, had difficulty covering medical expenses in the first half of 2012. During the first half of 2011, 21.7 percent of families, or 57.8 million people, found it difficult to pay medical bills.

Hispanics (25.2 percent) and blacks (27.9 percent) were more likely than whites (20.1 percent) or Asians (10.3 percent) to report trouble paying their medical bills, says the report. It says families with incomes from 100 to 199 percent of the poverty line were most likely to have difficulty paying medical bills, probably because those below the poverty line qualify for Medicaid. State income limits vary; in Kentucky, income-based Medicaid is available to those with incomes less than 70 percent of the poverty line.

'Poor' are below the poverty line. 'Near poor' had incomes of 100 to 199 percent of the poverty line. 

Among families with insurance, 14 percent of those with private insurance and 25.6 percent  with Medicaid or other public insurance had similar problems paying bills in the first half of 2012, which represents a 1.7 percent and 2.5 percent decrease from 2011, respectively. For a report on the study, click here.

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Medicaid expansion could change Kentucky's course, big time

NEWS ANALYSIS

By Al Cross

Kentucky Health News

"Today we change the course of Kentucky's history."

It is not often that a public official can say such a thing with a large measure of credibility, but Gov. Steve Beshear legitimately raised that hope Thursday, as he announced that he would expand Kentucky's Medicaid program under federal health reform.

Beshear with graph predicting positive impact on budget

If Beshear's vision is fulfilled, Kentucky will no longer have one of the unhealthiest populations of any state, a change that will make it more attractive to employers, and any Kentuckian who wants health insurance will be able to get it.

It is in large measure the realization, in the state where all President Harry Truman's grandparents were born, of his 68-year-old dream of national health insurance. The statue of Truman's vice president, Alben Barkley of Paducah, seemed to shine a little more brightly than usual in the Capitol rotunda as the press-conference crowd dispersed.

But this is a project with many moving parts -- billions of dollars, thousands of health-care providers, hundreds of thousands of Medicaid beneficiaries, and scores of political and bureaucratic decisions -- and much could go wrong.

Skeptics point to the problems with the managed-care Medicaid system that Beshear implemented too hurriedly, apparently to avoid complicating his November 2011 re-election, and argue that the program needs fixing before adding 300,000 new enrollees to the 825,000 already on the rolls. Beshear says he's tackling the problems, the program is "working pretty well" and the managed-care companies can handle the influx.

The skeptics also question whether the state can afford the match for the federal funds. "Broad and vague anxieties," Beshear called them, and he came armed with two studies concluding that expansion would actually gain the state money -- mainly because of the billions it will send to the state's health-care providers, creating more jobs, but also because many of the 300,000 or so newly eligible people are not expected to enroll, based on a Price Waterhouse Coopers study drawing on research by the Congressional Budget Office.

University of Louisville research

Preliminary estimates were that expansion would add 400,000 Kentuckians to the Medicaid rolls. However, the study estimated that only 308,000 will become eligible and that only 188,000 will enroll, thus costing the state much less than some expected when it has to match federal funds beginning in January 2017. The initial match will be 5 percent, rising to 10 percent in 2020. The estimated cost for the newly eligible in fiscal 2020-21 is $151 million, in a state budget that is likely to exceed $10 billion. (The state's current share of Medicaid costs, 29.5 percent, is about $1.5 billion a year.)

Those are just estimates. "I believe reality will dwarf those numbers on the spending side," Tea Party activist David Adams, who says he plans to challenge the plan in court, told reporters. But for the time being at least, Beshear has the numbers on his side, and he said they are "very conservative."

The governor said opponents of the plan "fall back on national politics" and say expansion means that Kentucky, a state that President Obama lost big both times, will be "supporting Obamacare. To them I say, 'Get over it.' . . . I'm going to do what's best for Kentucky's people, period." Asked why so many governors have rejected expansion, he said it was mostly "partisan politics."

Conservative columnist John David Dyche cites an Oregon study saying Medicaid is ineffective, but a Harvard School of Public Health study in three other states showed that expansion of Medicaid improves health and saves lives.

Beshear said the expansion, along with health insurance and subsidies available through a state-run exchange that is also part of health reform, would give the state a healthier workforce because studies show that people with health insurance are less likely to skip exams and let health conditions worsen and become costlier and more difficult to treat. "The lack of early care is one reason that Kentucky's health picture is so horrendous," he said.

Kentucky's workforce is one of the nation's least healthy, and the state has a disproportionate number of working-age people who are not in the workforce because of health problems. The state ranks first in smoking, cancer deaths and preventable hospitalizations; second in heart disease and poor physical-health days; third in heart attacks and poor mental-health days; and in the top 10 in diabetes,  cholesterol and sedentary lifestyles. That hurts the state's image as well as its economy, Beshear said. "There will be a huge economic effect for a healthier Kentucky."

He said most of the newly eligible people are not "freeloaders asking for a handout," but people who are working at jobs without health insurance. He said another 332,000 Kentuckians will get insurance through the state exchange, 276,000 of them with subsidies available to people with incomes up to 400 percent of the poverty level. Without Medicaid expansion, he said, 206,000 would not be eligible for Medicaid or a subsidy, and "We cannot leave those people stranded."

The health-reform law tried to force states into expanding Medicaid, but the U.S. Supreme Court ruled that the states should make the choice without fear of financial penalties. The law calls for expansion to cover people under 65 in households up to 138 percent of the federal poverty level -- currently $15,856 for an individual or $32,499 for a family of four.

Republicans can do little to stop the expansion. They control the state Senate, but Medicaid eligibility and benefit decisions belong to the executive branch, and even if a bipartisan legislative committee were to block the implementing regulations, Beshear could override it.

Or perhaps we should say he would override it. Emotional at times, Beshear called the move "the single most important decision of our lifetime for improving the health of Kentuckians" but said it was easy to make. As a governor who has failed to win his main campaign promise, expanded gambling, and has had relatively little money to spend because of the Great Recession, this is likely to be his largest legacy.

For details and background from the governor's office, click here. For Beshear's YouTube commentary on the issue, click here.

NEWS ANALYSIS

By Al Cross

Kentucky Health News

"Today we change the course of Kentucky's history."

It is not often that a public official can say such a thing with a large measure of credibility, but Gov. Steve Beshear legitimately raised that hope Thursday, as he announced that he would expand Kentucky's Medicaid program under federal health reform.

Beshear with graph predicting positive impact on budget

If Beshear's vision is fulfilled, Kentucky will no longer have one of the unhealthiest populations of any state, a change that will make it more attractive to employers, and any Kentuckian who wants health insurance will be able to get it.

It is in large measure the realization, in the state where all President Harry Truman's grandparents were born, of his 68-year-old dream of national health insurance. The statue of Truman's vice president, Alben Barkley of Paducah, seemed to shine a little more brightly than usual in the Capitol rotunda as the press-conference crowd dispersed.

But this is a project with many moving parts -- billions of dollars, thousands of health-care providers, hundreds of thousands of Medicaid beneficiaries, and scores of political and bureaucratic decisions -- and much could go wrong.

Skeptics point to the problems with the managed-care Medicaid system that Beshear implemented too hurriedly, apparently to avoid complicating his November 2011 re-election, and argue that the program needs fixing before adding 300,000 new enrollees to the 825,000 already on the rolls. Beshear says he's tackling the problems, the program is "working pretty well" and the managed-care companies can handle the influx.

The skeptics also question whether the state can afford the match for the federal funds. "Broad and vague anxieties," Beshear called them, and he came armed with two studies concluding that expansion would actually gain the state money -- mainly because of the billions it will send to the state's health-care providers, creating more jobs, but also because many of the 300,000 or so newly eligible people are not expected to enroll, based on a Price Waterhouse Coopers study drawing on research by the Congressional Budget Office.

University of Louisville research

Preliminary estimates were that expansion would add 400,000 Kentuckians to the Medicaid rolls. However, the study estimated that only 308,000 will become eligible and that only 188,000 will enroll, thus costing the state much less than some expected when it has to match federal funds beginning in January 2017. The initial match will be 5 percent, rising to 10 percent in 2020. The estimated cost for the newly eligible in fiscal 2020-21 is $151 million, in a state budget that is likely to exceed $10 billion. (The state's current share of Medicaid costs, 29.5 percent, is about $1.5 billion a year.)

Those are just estimates. "I believe reality will dwarf those numbers on the spending side," Tea Party activist David Adams, who says he plans to challenge the plan in court, told reporters. But for the time being at least, Beshear has the numbers on his side, and he said they are "very conservative."

The governor said opponents of the plan "fall back on national politics" and say expansion means that Kentucky, a state that President Obama lost big both times, will be "supporting Obamacare. To them I say, 'Get over it.' . . . I'm going to do what's best for Kentucky's people, period." Asked why so many governors have rejected expansion, he said it was mostly "partisan politics."

Conservative columnist John David Dyche cites an Oregon study saying Medicaid is ineffective, but a Harvard School of Public Health study in three other states showed that expansion of Medicaid improves health and saves lives.

Beshear said the expansion, along with health insurance and subsidies available through a state-run exchange that is also part of health reform, would give the state a healthier workforce because studies show that people with health insurance are less likely to skip exams and let health conditions worsen and become costlier and more difficult to treat. "The lack of early care is one reason that Kentucky's health picture is so horrendous," he said.

Kentucky's workforce is one of the nation's least healthy, and the state has a disproportionate number of working-age people who are not in the workforce because of health problems. The state ranks first in smoking, cancer deaths and preventable hospitalizations; second in heart disease and poor physical-health days; third in heart attacks and poor mental-health days; and in the top 10 in diabetes,  cholesterol and sedentary lifestyles. That hurts the state's image as well as its economy, Beshear said. "There will be a huge economic effect for a healthier Kentucky."

He said most of the newly eligible people are not "freeloaders asking for a handout," but people who are working at jobs without health insurance. He said another 332,000 Kentuckians will get insurance through the state exchange, 276,000 of them with subsidies available to people with incomes up to 400 percent of the poverty level. Without Medicaid expansion, he said, 206,000 would not be eligible for Medicaid or a subsidy, and "We cannot leave those people stranded."

The health-reform law tried to force states into expanding Medicaid, but the U.S. Supreme Court ruled that the states should make the choice without fear of financial penalties. The law calls for expansion to cover people under 65 in households up to 138 percent of the federal poverty level -- currently $15,856 for an individual or $32,499 for a family of four.

Republicans can do little to stop the expansion. They control the state Senate, but Medicaid eligibility and benefit decisions belong to the executive branch, and even if a bipartisan legislative committee were to block the implementing regulations, Beshear could override it.

Or perhaps we should say he would override it. Emotional at times, Beshear called the move "the single most important decision of our lifetime for improving the health of Kentuckians" but said it was easy to make. As a governor who has failed to win his main campaign promise, expanded gambling, and has had relatively little money to spend because of the Great Recession, this is likely to be his largest legacy.

For details and background from the governor's office, click here. For Beshear's YouTube commentary on the issue, click here.

Read More

Beshear looks likely to announce that he will expand Medicaid

Gov. Steve Beshear appears likely to announce tomorrow that he will expand Kentucky's Medicaid program to people in households with incomes up to 138 percent of the federal poverty level, under federal health-care reform.

The notice of the governor's news conference about "Decision regarding Medicaid expansion" says it will be held in the ornate State Reception Room on the second floor of the state Capitol, an unlikely venue for an announcement that would disappoint so many of his natural allies in the Democratic Party. And Rep. Tom Burch, D-Louisville, chairman of the House Health and Welfare Committee, reiterated his February prediction that Beshear would expand Medicaid, cn|2 reports.

Under health reform, the federal government would pay all the cost of the estimated 400,000 newly eligible Kentuckians in Medicaid in 2014, 2015 and 2016. The state would pay 3 percent of the added cost in 2017, rising to 10 percent in 2020. Beshear has said the state should expand Medicaid if it can afford it.

Some Republicans have said the state can't afford it, but national research has estimated that the state's cost for Medicaid would increase only 5 to 6 percent over the amount it would pay if the program were not expanded. The federal government now pays more than 70 percent of the program's cost in Kentucky.

More background on Mediaid in Kentucky is available from a PowerPoint presentation that Deputy Medicaid Commissioner Lisa Lee gave yesterday at a meeting sponsored by the Foundation for a Healthy Kentucky and the Kentucky Rural Health Association. It can be downloaded here.

Gov. Steve Beshear appears likely to announce tomorrow that he will expand Kentucky's Medicaid program to people in households with incomes up to 138 percent of the federal poverty level, under federal health-care reform.

The notice of the governor's news conference about "Decision regarding Medicaid expansion" says it will be held in the ornate State Reception Room on the second floor of the state Capitol, an unlikely venue for an announcement that would disappoint so many of his natural allies in the Democratic Party. And Rep. Tom Burch, D-Louisville, chairman of the House Health and Welfare Committee, reiterated his February prediction that Beshear would expand Medicaid, cn|2 reports.

Under health reform, the federal government would pay all the cost of the estimated 400,000 newly eligible Kentuckians in Medicaid in 2014, 2015 and 2016. The state would pay 3 percent of the added cost in 2017, rising to 10 percent in 2020. Beshear has said the state should expand Medicaid if it can afford it.

Some Republicans have said the state can't afford it, but national research has estimated that the state's cost for Medicaid would increase only 5 to 6 percent over the amount it would pay if the program were not expanded. The federal government now pays more than 70 percent of the program's cost in Kentucky.

More background on Mediaid in Kentucky is available from a PowerPoint presentation that Deputy Medicaid Commissioner Lisa Lee gave yesterday at a meeting sponsored by the Foundation for a Healthy Kentucky and the Kentucky Rural Health Association. It can be downloaded here.

Read More

Beshear says he will decide in four to five weeks, or July 1 at the latest, whether or not to expand Medicaid

By Al Cross
Kentucky Health News
This story has been updated.

Gov. Steve Beshear said Monday that he will decide within the next four to five weeks, or maybe by July 1, whether to expand the Medicaid program under federal health-care reform.

Beshear, who has said he would expand Medicaid if the state can afford it, told reporters that he is considering other factors, which he did not name. He said his administration has not calculated the cost of expansion, which the state would not pay immediately.

The federal government pays about 71 percent of Medicaid's cost in Kentucky, and would pay the full cost of covering those newly eligible in 2014-16. The state would have to pay 3 percent in 2017, rising to 10 percent by 2020.

About 830,000 Kentuckians are covered by Medicaid, and at least 400,000 more could be added if Beshear expanded it to include households earning up to 138 percent of the federal poverty level, as required by the reform law.

Another possibility is that Beshear would seek approval from the federal government to use federal money to subsidize purchase of private health insurance by the poor, which has been approved in Arkansas but not in Tennessee.

The governor's office, asked if the administration was considering that option and what other factors Beshear is considering, has not responded had this response: "The governor is considering multiple issues as he determines whether Kentucky will expand Medicaid eligibility.  Along with affordability for the state, he is also looking at potential economic impact through jobs and investment created by possible expansion, as well anticipated changes in health outcomes for newly-eligible Kentuckians."

That is also the case with There has still been no response from Humana Inc., which does much of its business through government-financed health plans. The Louisville-based insurance company was asked if it has had discussions with the Beshear administration about the idea of a Medicaid expansion that would use federal money to buy, or subsidize the purchase of, private health insurance.

"Beshear said Monday that he is getting a lot of pressure from the medical field – particularly hospitals – to green-light the expansion," Beth Musgrave of the Lexington Herald-Leader writes. "Hospitals will lose additional money they receive through Medicaid on Jan. 1 as part of the Affordable Care Act. Hospitals in Ohio and other states have also put pressure on state governments to expand Medicaid rolls."

Beshear said, “I think they look at the expansion as a means to at least replace some of that (money) that they are going to lose.”

Many Republicans have opposed expansion, "saying that the state could not afford it," Musgrave writes. "The Republican-led state Senate passed a bill during the legislative session that would have required that the two-term Democratic governor get legislative approval before expanding the health care program. But the measure died in the Democratic-controlled House. Beshear could expand the program via executive order."

Beshear said today, “We have a very large uninsured population and we have a very unhealthy population. Anything that we can do — that we can afford — to make our population more healthy, I”m certainly in favor of doing.” He added, “We are looking long-term as well as short-term from a financial standpoint to see if it makes sense for us.”

While he said he would act within four to five weeks, Beshear gave himself some wiggle room, saying also that he would make the decision by July 1, the beginning of the state's fiscal year. (Read more)

By Al Cross
Kentucky Health News
This story has been updated.

Gov. Steve Beshear said Monday that he will decide within the next four to five weeks, or maybe by July 1, whether to expand the Medicaid program under federal health-care reform.

Beshear, who has said he would expand Medicaid if the state can afford it, told reporters that he is considering other factors, which he did not name. He said his administration has not calculated the cost of expansion, which the state would not pay immediately.

The federal government pays about 71 percent of Medicaid's cost in Kentucky, and would pay the full cost of covering those newly eligible in 2014-16. The state would have to pay 3 percent in 2017, rising to 10 percent by 2020.

About 830,000 Kentuckians are covered by Medicaid, and at least 400,000 more could be added if Beshear expanded it to include households earning up to 138 percent of the federal poverty level, as required by the reform law.

Another possibility is that Beshear would seek approval from the federal government to use federal money to subsidize purchase of private health insurance by the poor, which has been approved in Arkansas but not in Tennessee.

The governor's office, asked if the administration was considering that option and what other factors Beshear is considering, has not responded had this response: "The governor is considering multiple issues as he determines whether Kentucky will expand Medicaid eligibility.  Along with affordability for the state, he is also looking at potential economic impact through jobs and investment created by possible expansion, as well anticipated changes in health outcomes for newly-eligible Kentuckians."

That is also the case with There has still been no response from Humana Inc., which does much of its business through government-financed health plans. The Louisville-based insurance company was asked if it has had discussions with the Beshear administration about the idea of a Medicaid expansion that would use federal money to buy, or subsidize the purchase of, private health insurance.

"Beshear said Monday that he is getting a lot of pressure from the medical field – particularly hospitals – to green-light the expansion," Beth Musgrave of the Lexington Herald-Leader writes. "Hospitals will lose additional money they receive through Medicaid on Jan. 1 as part of the Affordable Care Act. Hospitals in Ohio and other states have also put pressure on state governments to expand Medicaid rolls."

Beshear said, “I think they look at the expansion as a means to at least replace some of that (money) that they are going to lose.”

Many Republicans have opposed expansion, "saying that the state could not afford it," Musgrave writes. "The Republican-led state Senate passed a bill during the legislative session that would have required that the two-term Democratic governor get legislative approval before expanding the health care program. But the measure died in the Democratic-controlled House. Beshear could expand the program via executive order."

Beshear said today, “We have a very large uninsured population and we have a very unhealthy population. Anything that we can do — that we can afford — to make our population more healthy, I”m certainly in favor of doing.” He added, “We are looking long-term as well as short-term from a financial standpoint to see if it makes sense for us.”

While he said he would act within four to five weeks, Beshear gave himself some wiggle room, saying also that he would make the decision by July 1, the beginning of the state's fiscal year. (Read more)

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Will Kentucky expand Medicaid, and if so, how?

By Molly Burchett
Kentucky Health News

Kentucky is one of the last states to decide whether to expand Medicaid under federal health reform, and now that the General Assembly has gone home, Democratic Gov. Steve Beshear can turn his attention to the many questions that linger. Some Republican legislators think he will expand the program, but they worry about the cost when the state would have to start helping cover the new expenses, beginning in 2017.

Republican Gov. Bill Haslam of Tennessee decided Wednesday that he will not pursue Medicaid expansion, saying that it could put hospitals in financial jeopardy by giving them more patients on which they lose money, reports Michelle Kaske of Bloomberg. If he is right and the same logic applies to Kentucky, Medicaid expansion in the state could harm the rural hospitals and providers -- some of whom are already squeezed by the issues with the new managed-care system.

Along with Kentucky, 10 other states are undecided about Medicaid expansion: Alaska, Indiana, Kansas, Nebraska, New York, Oregon, Utah, Virginia, West Virginia and Wyoming. The map by The Advisory Board Company shows the lay of the land; for an interactive picture that outlines the research behind the map, click here.

Red=Not participating; Pink=Leaning toward not participating;
Gray=Undecided; Blue=Participating; Light Blue=Leaning toward participating

Only three states with Democratic governors are undecided; 18 Republican governors have rejected expansion. Kentucky is shown as leaning for it because Beshear has repeatedly said that he will expand Medicaid if the state can afford it. He has also mentioned that the state can reserve the right to pull out of the deal in 2017, when it must paying 3 percent of the cost of covering the newly insured, reaching 10 percent in 2020. Still, the questions about cost and affordability remain, and Beshear could be considering another option.

Tennessee has joined Ohio and Arkansas in negotiating with the Obama administration over plans to use federal Medicaid money to purchase private insurance for those who can't afford it but don't qualify for Medicaid now. However, Haslam's plan has been held up because the administration placed too many conditions on the money, writes Kaske. Republicans in other states, including Florida, Louisiana, Pennsylvania and Texas, have expressed interest in this option since Gov. Mike Beebe of Arkansas, a Democrat, ignited the wildfire of creating a hybrid of the two alternatives, reports Robert Pear of The New York Times.

The idea of privatizing Medicaid expansion appeals to many doctors and hospitals because they typically receive higher payments from commercial insurance than from Medicaid. However, many Kentucky hospitals and providers are concerned about the managed-care program that is run by three private organizations, and are calling for immediate action. Beshear has not said whether he will sign or veto a bill that would subject the managed-care firms to the prompt-payments and dispute-resolution rules of the state Department of Insurance.

"Action is needed to address the problems that patients and hospitals are experiencing with Medicaid managed care and to make the system work properly," wrote Harold "Bud" Warman, chair of the Kentucky Hospital Association, and Charles Lovell, chair-elect of the association, in a recent Herald-Leader article that laid out the various problems with the system. "And with the possibility that Medicaid will be expanded in Kentucky to include an additional 350,000 people, it is critical that these issues be addressed right away to avoid even greater problems in the future."

Either using federal dollars to buy private insurance in order to cover newly qualified individuals (the hybrid plan) under the health law's expansion  or expanding in the "traditional" way will not change the current managed care structure of Medicaid in Kentucky. Yet, it would mean that 350,000 more Kentuckians would be covered under managed care; Medicaid would cover those earning up to 138 percent of the federal poverty level, currently up to $15,856 a year for an individual.

The money that the federal government offers for expansion is very tempting. The question then may be, how will it be used?

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

By Molly Burchett
Kentucky Health News

Kentucky is one of the last states to decide whether to expand Medicaid under federal health reform, and now that the General Assembly has gone home, Democratic Gov. Steve Beshear can turn his attention to the many questions that linger. Some Republican legislators think he will expand the program, but they worry about the cost when the state would have to start helping cover the new expenses, beginning in 2017.

Republican Gov. Bill Haslam of Tennessee decided Wednesday that he will not pursue Medicaid expansion, saying that it could put hospitals in financial jeopardy by giving them more patients on which they lose money, reports Michelle Kaske of Bloomberg. If he is right and the same logic applies to Kentucky, Medicaid expansion in the state could harm the rural hospitals and providers -- some of whom are already squeezed by the issues with the new managed-care system.

Along with Kentucky, 10 other states are undecided about Medicaid expansion: Alaska, Indiana, Kansas, Nebraska, New York, Oregon, Utah, Virginia, West Virginia and Wyoming. The map by The Advisory Board Company shows the lay of the land; for an interactive picture that outlines the research behind the map, click here.

Red=Not participating; Pink=Leaning toward not participating;
Gray=Undecided; Blue=Participating; Light Blue=Leaning toward participating

Only three states with Democratic governors are undecided; 18 Republican governors have rejected expansion. Kentucky is shown as leaning for it because Beshear has repeatedly said that he will expand Medicaid if the state can afford it. He has also mentioned that the state can reserve the right to pull out of the deal in 2017, when it must paying 3 percent of the cost of covering the newly insured, reaching 10 percent in 2020. Still, the questions about cost and affordability remain, and Beshear could be considering another option.

Tennessee has joined Ohio and Arkansas in negotiating with the Obama administration over plans to use federal Medicaid money to purchase private insurance for those who can't afford it but don't qualify for Medicaid now. However, Haslam's plan has been held up because the administration placed too many conditions on the money, writes Kaske. Republicans in other states, including Florida, Louisiana, Pennsylvania and Texas, have expressed interest in this option since Gov. Mike Beebe of Arkansas, a Democrat, ignited the wildfire of creating a hybrid of the two alternatives, reports Robert Pear of The New York Times.

The idea of privatizing Medicaid expansion appeals to many doctors and hospitals because they typically receive higher payments from commercial insurance than from Medicaid. However, many Kentucky hospitals and providers are concerned about the managed-care program that is run by three private organizations, and are calling for immediate action. Beshear has not said whether he will sign or veto a bill that would subject the managed-care firms to the prompt-payments and dispute-resolution rules of the state Department of Insurance.

"Action is needed to address the problems that patients and hospitals are experiencing with Medicaid managed care and to make the system work properly," wrote Harold "Bud" Warman, chair of the Kentucky Hospital Association, and Charles Lovell, chair-elect of the association, in a recent Herald-Leader article that laid out the various problems with the system. "And with the possibility that Medicaid will be expanded in Kentucky to include an additional 350,000 people, it is critical that these issues be addressed right away to avoid even greater problems in the future."

Either using federal dollars to buy private insurance in order to cover newly qualified individuals (the hybrid plan) under the health law's expansion  or expanding in the "traditional" way will not change the current managed care structure of Medicaid in Kentucky. Yet, it would mean that 350,000 more Kentuckians would be covered under managed care; Medicaid would cover those earning up to 138 percent of the federal poverty level, currently up to $15,856 a year for an individual.

The money that the federal government offers for expansion is very tempting. The question then may be, how will it be used?

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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Study finds only counties in Appalachia, mostly in Kentucky, had increasing rates of death among both sexes as century turned

By Molly Burchett
Kentucky Health News

More than 40 percent of counties saw increases in female death rates as the 21st Century began, while the death rate for men rose in just 3 percent of counties, a study shows. Only Appalachian counties, mostly in Kentucky, had worsening rates for both sexes. (Click on a map for a larger version.)

Change In Male Mortality Rates From 1992–96 To 2002–06

Change In Female Mortality Rates From 1992–96 To 2002–06

On the Health Affairs maps above, blue counties showed substantial improvement, while those in aqua showed minimal improvement and worsening counties are in red.

The study identifies some shared characteristics among the 1,334 counties where more women are dying prematurely, but the main factors weren't medical or behavioral, according to David Kindig and Erika Cheng, authors of the study report.

Although counties with high rates of smoking and obesity had increased mortality rates, the report found socioeconomic factors in the Appalachian states of Kentucky and West Virginia, such as the percentage of a county’s population with a college education and the rate of children living in poverty, had more to do with increased mortality rates.

In Kentucky, Owsley County has been ranked last on health-related measures by the Population Health Institute. Areas like this in Appalachia suffered rising death rates in both sexes because college education is a rarity, child poverty is normal, recreational facilities are scarce, restaurants are mostly fast-food outlets, and adults lack social support, reports Geoffrey Cowley of msnbc.

The chart below shows how Kentucky compares to the national average in premature death and that Owsley County suffers from tremendously high rates.

County Health Rankings by University of Wisconsin's Population Health
Institute and the Robert Wood Johnson Foundation (countyhealthrankings.org)

These findings provide supporting evidence for the ever-increasing need for significant health improvement efforts in Appalachia. According to the report, efforts must extend beyond a focus on health care delivery and include stronger policies affecting health behaviors and the social and environmental determinants of health,with corresponding investments in those areas. (Read more)

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

By Molly Burchett
Kentucky Health News

More than 40 percent of counties saw increases in female death rates as the 21st Century began, while the death rate for men rose in just 3 percent of counties, a study shows. Only Appalachian counties, mostly in Kentucky, had worsening rates for both sexes. (Click on a map for a larger version.)

Change In Male Mortality Rates From 1992–96 To 2002–06

Change In Female Mortality Rates From 1992–96 To 2002–06

On the Health Affairs maps above, blue counties showed substantial improvement, while those in aqua showed minimal improvement and worsening counties are in red.

The study identifies some shared characteristics among the 1,334 counties where more women are dying prematurely, but the main factors weren't medical or behavioral, according to David Kindig and Erika Cheng, authors of the study report.

Although counties with high rates of smoking and obesity had increased mortality rates, the report found socioeconomic factors in the Appalachian states of Kentucky and West Virginia, such as the percentage of a county’s population with a college education and the rate of children living in poverty, had more to do with increased mortality rates.

In Kentucky, Owsley County has been ranked last on health-related measures by the Population Health Institute. Areas like this in Appalachia suffered rising death rates in both sexes because college education is a rarity, child poverty is normal, recreational facilities are scarce, restaurants are mostly fast-food outlets, and adults lack social support, reports Geoffrey Cowley of msnbc.

The chart below shows how Kentucky compares to the national average in premature death and that Owsley County suffers from tremendously high rates.

County Health Rankings by University of Wisconsin's Population Health
Institute and the Robert Wood Johnson Foundation (countyhealthrankings.org)

These findings provide supporting evidence for the ever-increasing need for significant health improvement efforts in Appalachia. According to the report, efforts must extend beyond a focus on health care delivery and include stronger policies affecting health behaviors and the social and environmental determinants of health,with corresponding investments in those areas. (Read more)

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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Survey suggests Great Recession has harmed the health of Kentuckians

A recent poll shows continuation of a trend threatening Kentucky's overall health: as the number of Kentuckians living in poverty goes up, the percentage of adults who report their health as excellent or very good goes down.

Just over four in 10 Kentucky adults in the latest Kentucky Health Issues Poll described their health as excellent or good. In 2008, almost half used those descriptions.

People with higher incomes have consistently reported better health since the poll began tracking the health status of Kentucky adults 2008. Since research has shown a strong link between higher income and better health, the Great Recession and the resulting increases in unemployment, underemployment and poverty appear to be harming the overall health of Kentucky’s population.

In the accompanying graph, showing responses by income categories, FPL stands for federal poverty level, which in 2011 was a yearly household income of $22,350. Among the categories, 58 percent in the highest category said their health is excellent or good, but only 25 percent of those living in poverty used those descriptions.

Although the health status for each income category has remained fairly constant, the poll reflects federal data that show more people living in poverty. More than 33 percent in the latest poll were earning less than the federal poverty level; in 2008, that was only 19 percent. The polls, which used self-reporting of income and survey methods that differ from federal methods, showed much higher poverty rates than federal data.

“We know there is a direct relationship between income and good health, and these data reflect that,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, a sponsor of the poll. “While changes in our health-care delivery system may provide more health-care opportunities for low-income Kentuckians, these results show how vital a strong economy, and jobs that pay well, are to our population’s health.”

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points.

A recent poll shows continuation of a trend threatening Kentucky's overall health: as the number of Kentuckians living in poverty goes up, the percentage of adults who report their health as excellent or very good goes down.

Just over four in 10 Kentucky adults in the latest Kentucky Health Issues Poll described their health as excellent or good. In 2008, almost half used those descriptions.

People with higher incomes have consistently reported better health since the poll began tracking the health status of Kentucky adults 2008. Since research has shown a strong link between higher income and better health, the Great Recession and the resulting increases in unemployment, underemployment and poverty appear to be harming the overall health of Kentucky’s population.

In the accompanying graph, showing responses by income categories, FPL stands for federal poverty level, which in 2011 was a yearly household income of $22,350. Among the categories, 58 percent in the highest category said their health is excellent or good, but only 25 percent of those living in poverty used those descriptions.

Although the health status for each income category has remained fairly constant, the poll reflects federal data that show more people living in poverty. More than 33 percent in the latest poll were earning less than the federal poverty level; in 2008, that was only 19 percent. The polls, which used self-reporting of income and survey methods that differ from federal methods, showed much higher poverty rates than federal data.

“We know there is a direct relationship between income and good health, and these data reflect that,” said Dr. Susan Zepeda, president and CEO of the Foundation for a Healthy Kentucky, a sponsor of the poll. “While changes in our health-care delivery system may provide more health-care opportunities for low-income Kentuckians, these results show how vital a strong economy, and jobs that pay well, are to our population’s health.”

The poll, co-sponsored by the Health Foundation of Greater Cincinnati, was taken Sept. 20 through Oct. 14 by the Institute for Policy Research at the University of Cincinnati. A random sample of 1,680 adults throughout Kentucky was interviewed by landline and cell telephones. The poll's margin of error is plus or minus 2.5 percentage points.

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Kasich of Ohio is fifth Republican governor to accept Medicaid expansion; he and others cite need to protect rural hospitals, poor

Several Republican governors have decided to expand Medicaid under federal health-care reform, saying their conservative principles were outweighed by a need to protect their state's rural hospitals and low-income people. Yesterday, the governor of one of the biggest states got on the bandwagon.

John Kasich of Ohio joined Jan Brewer of Arizona, Brian Sandoval of Nevada, Susana Martinez of New Mexico and Jack Dalrymple of North Dakota in saying they will take heavy federal subsidies to expand the program to households with incomes up to 138 percent of the federal poverty threshold.

Democratic Gov. Steve Beshear of Kentucky has said he wants to expand Medicaid if Kentucky can afford it, and he expects to get cost estimates around the end of March.

While Kasich is not an "Obamacare" supporter, he said expanding Medicaid “makes great sense for Ohio” because it would save $235 million over the next two years and free about $100 million in local funds for mental-health and addiction services, reports The Columbus Dispatch.

Kasich said the decision could extend health coverage to as many as 578,000 uninsured Ohio residents, and could keep everyone else’s health insurance premiums down because there won’t be so many uninsured people going to emergency rooms for their medical care, reports David Nather of Politico.

Kasich emphasized that he would like to see the 2010 law repealed, but the federal money it would pump into the state — about $13 billion over the next seven years — was too much to pass up, reports Stateline. The federal government will pay the full cost of expansion through 2016; then  states will have to pitch in, rising to a limit of 10 percent by 2020.

Brewer likewise said it doesn't make sense for Arizona to pass up federal dollars, reports Howard Fischer of the Arizona Daily Sun. "We will protect rural and safety-net hospitals from being pushed to the brink by growing their cost in caring for the uninsured," Brewer said. She also said the expansion will create enormous economic benefit, inject $2 billion into the Arizona economy, save and create thousands of jobs and provide health care to hundreds of thousands of low-income individuals, reports Fischer.

Brewer said going along with expansion will save Arizona money because the costs of providing care to the uninsured are not simply absorbed by hospitals but passed along through increased insurance premiums. Supporters of the expansion hope the five Republicans' decisions will prompt more GOP governors to follow suit. Twenty governors from both political parties are still undecided. (Read more)

Several Republican governors have decided to expand Medicaid under federal health-care reform, saying their conservative principles were outweighed by a need to protect their state's rural hospitals and low-income people. Yesterday, the governor of one of the biggest states got on the bandwagon.

John Kasich of Ohio joined Jan Brewer of Arizona, Brian Sandoval of Nevada, Susana Martinez of New Mexico and Jack Dalrymple of North Dakota in saying they will take heavy federal subsidies to expand the program to households with incomes up to 138 percent of the federal poverty threshold.

Democratic Gov. Steve Beshear of Kentucky has said he wants to expand Medicaid if Kentucky can afford it, and he expects to get cost estimates around the end of March.

While Kasich is not an "Obamacare" supporter, he said expanding Medicaid “makes great sense for Ohio” because it would save $235 million over the next two years and free about $100 million in local funds for mental-health and addiction services, reports The Columbus Dispatch.

Kasich said the decision could extend health coverage to as many as 578,000 uninsured Ohio residents, and could keep everyone else’s health insurance premiums down because there won’t be so many uninsured people going to emergency rooms for their medical care, reports David Nather of Politico.

Kasich emphasized that he would like to see the 2010 law repealed, but the federal money it would pump into the state — about $13 billion over the next seven years — was too much to pass up, reports Stateline. The federal government will pay the full cost of expansion through 2016; then  states will have to pitch in, rising to a limit of 10 percent by 2020.

Brewer likewise said it doesn't make sense for Arizona to pass up federal dollars, reports Howard Fischer of the Arizona Daily Sun. "We will protect rural and safety-net hospitals from being pushed to the brink by growing their cost in caring for the uninsured," Brewer said. She also said the expansion will create enormous economic benefit, inject $2 billion into the Arizona economy, save and create thousands of jobs and provide health care to hundreds of thousands of low-income individuals, reports Fischer.

Brewer said going along with expansion will save Arizona money because the costs of providing care to the uninsured are not simply absorbed by hospitals but passed along through increased insurance premiums. Supporters of the expansion hope the five Republicans' decisions will prompt more GOP governors to follow suit. Twenty governors from both political parties are still undecided. (Read more)

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Feds plan to let states impose co-payments on Medicaid patients above poverty level to encourage them to expand the program

By Molly Burchett and Al Cross
Kentucky Health News

If Kentucky expands its Medicaid program, it will probably be able to reduce the cost by requiring patients whose incomes are above the federal poverty level to help pay for their care. That could make it more feasible for the state to expand the program to people with incomes up to 138 percent of the poverty line.

A proposed federal policy will let states charge co-payments and increased premiums for doctor visits and some prescription drugs and hospital care. Robert Pear of The New York Times reports that the policy is designed to encourage states to expand Medicaid under the federal health-care reform law, with generous federal help. By shifting costs to patients, the state and federal governments would pay less.

That adds a new perspective to the cost consideration in Kentucky's debate over expansion of Medicaid. It could influence the state's decision, Republican state Sen. Julie Denton of Louisville said Friday during a legislative panel at the Kentucky Press Association convention.

Denton cautioned that the state needs to fix its problems with Medicaid managed care before it expands the program. Democratic Gov. Steve Beshear has said he wants to expand Medicaid if the state can afford it, and since there is no deadline for deciding whether to participate in the expansion, the debate may carry over into 2014.

Some Republicans have said Kentucky can't afford the expansion. If the state expands Medicaid eligibility to 138 percent of poverty from its current threshold of 70 percent, the federal government would pay all the cost of the expansion until 2017, when the state would begin helping out, with its share reaching 10 percent in 2020. The federal share of the state's current program is 72 percent.

This proposed rule could have important implications not just for state finances, but for Medicaid patients. It means that a family of three with an annual income of $30,000 could be required to pay $1,500 in premiums and co-payments, Pear reports in the Times.

As published in the Federal Register last week, the rule proposes to "update and simplify Medicaid premium and cost sharing requirements, to promote the most effective use of services and to assist states in identifying cost-sharing flexibilities." It proposes "new options for states to establish higher cost sharing for nonpreferred drugs and to propose higher cost sharing for non-emergency use" of emergency rooms.

Barbara K. Tomar, director of federal affairs at the American College of Emergency Physicians, told Pear that the administration had not adequately defined the “nonemergency services” for which the poor might have to pay. "In many cases, she said, patients legitimately believe they need emergency care, but the final diagnosis does not bear that out," Pear writes.

The proposed rule has no limit on emergency department charges for "non-emergency use." It says the hospital will have responsibility to assess the individual clinically and ensure access to other sources of care before requiring payment, which could pose problems for hospitals.

The public has until Feb. 13 to comment on the proposed rule, which can be submitted at www.regulations.gov.

By Molly Burchett and Al Cross
Kentucky Health News

If Kentucky expands its Medicaid program, it will probably be able to reduce the cost by requiring patients whose incomes are above the federal poverty level to help pay for their care. That could make it more feasible for the state to expand the program to people with incomes up to 138 percent of the poverty line.

A proposed federal policy will let states charge co-payments and increased premiums for doctor visits and some prescription drugs and hospital care. Robert Pear of The New York Times reports that the policy is designed to encourage states to expand Medicaid under the federal health-care reform law, with generous federal help. By shifting costs to patients, the state and federal governments would pay less.

That adds a new perspective to the cost consideration in Kentucky's debate over expansion of Medicaid. It could influence the state's decision, Republican state Sen. Julie Denton of Louisville said Friday during a legislative panel at the Kentucky Press Association convention.

Denton cautioned that the state needs to fix its problems with Medicaid managed care before it expands the program. Democratic Gov. Steve Beshear has said he wants to expand Medicaid if the state can afford it, and since there is no deadline for deciding whether to participate in the expansion, the debate may carry over into 2014.

Some Republicans have said Kentucky can't afford the expansion. If the state expands Medicaid eligibility to 138 percent of poverty from its current threshold of 70 percent, the federal government would pay all the cost of the expansion until 2017, when the state would begin helping out, with its share reaching 10 percent in 2020. The federal share of the state's current program is 72 percent.

This proposed rule could have important implications not just for state finances, but for Medicaid patients. It means that a family of three with an annual income of $30,000 could be required to pay $1,500 in premiums and co-payments, Pear reports in the Times.

As published in the Federal Register last week, the rule proposes to "update and simplify Medicaid premium and cost sharing requirements, to promote the most effective use of services and to assist states in identifying cost-sharing flexibilities." It proposes "new options for states to establish higher cost sharing for nonpreferred drugs and to propose higher cost sharing for non-emergency use" of emergency rooms.

Barbara K. Tomar, director of federal affairs at the American College of Emergency Physicians, told Pear that the administration had not adequately defined the “nonemergency services” for which the poor might have to pay. "In many cases, she said, patients legitimately believe they need emergency care, but the final diagnosis does not bear that out," Pear writes.

The proposed rule has no limit on emergency department charges for "non-emergency use." It says the hospital will have responsibility to assess the individual clinically and ensure access to other sources of care before requiring payment, which could pose problems for hospitals.

The public has until Feb. 13 to comment on the proposed rule, which can be submitted at www.regulations.gov.

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Feds tell states it's all or nothing on Medicaid expansion; Washington Post map shows Ky. is only state 'leaning' toward it

By Al Cross
Kentucky Health News

When the Supreme Court upheld federal health reform but said states could opt out of the expansion of Medicaid to people with incomes above the poverty line, to be funded with generous federal subsidies, one of the first questions was whether a state had to go all the way: to 133 percent of poverty (138 percent with an official fudge factor). Now the Obama administration has answered "no." And that could make the decision tougher for Kentucky, which is the only state The Washington Post listed this month as leaning toward expansion.

The Post's Sarah Kliff wrote, "The administration’s reasoning goes like this: The federal government was giving states a really, really good deal on the Medicaid expansion. It was footing the entire bill for the newly eligible enrollees for three years," 2014 through 2016, rather than the 72 percent it pays Kentucky for current enrollees. The subsidy for the new eligibles would drop to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019; and 90 percent in 2020.

White House aides told Kliff that in passing the bill, Congress (which is to say the Democrats in Congress) "gave states that really high funding in the service of a very specific goal: Ensuring all Americans have access to insurance options." But "If a state decided to cover, say, everyone up to the federal poverty line, they would be working with a smaller, more manageable population," Kliff explains. "Those living above the poverty line, meanwhile, wouldn’t be left in the lurch. The Affordable Care Act allows them to receive very generous subsidies in the private insurance market."

However, Medicaid Administrator Cindy Mann told Kliff that if states could fall short of the 133 percent level, they wouldn’t be within the spirit of the law. Kliff paraphrases Mann: "They wouldn’t offer all their residents a way to purchase affordable coverage, and if they’re not going to do that, the White House says they don’t deserve the extra funding."

Gov. Steve Beshear said again today that Kentucky should expand Medicaid "if we can afford it" because so many people in the state have no health insurance and are in poor health, and improving their health would be good for the state's economy.

Kentucky now makes Medicaid available to people with household incomes below 70 percent of the poverty line, which varies by household size. The Urban Institute has estimated that expanding the program to 133 percent of poverty would cost the state about 5 percent more than it would otherwise spend through 2022. That would be $1.3 billion extra in 2017-22, and some Republicans in the legislature have said the state can't afford it. The state expects to spend $1.5 billion on Medicaid in the 2013-14 fiscal year.

While the Post lists Kentucky as the only state "leaning yes" to expansion, it seems likely to be joined by several others. "States have stayed mum on whether they will participate in the expansion, seeing first if they could get a better deal — the partial expansion," Kliff writes. "The federal government took a while to show its cards; it wanted to see if states would sign up for the full expansion, without giving them a scaled-back option." Only 17 states have said yes, and as many are undecided, the Post reports.

In setting a firm rule, the White House may think states "will decide the 100 percent match is too good to pass up and that the federal money will pull everyone in," Kliff writes. "Or, it could indicate the Obama administration is okay with not all states participating with the Medicaid expansion on day one. Again, this wouldn’t be unprecedented: Only six states initially signed up for Medicaid when it launched in 1965."

States should realize that expanding Medicaid is a long-term investment in the health of their people that will pay off in the long run, Dr. Wayne Myers, who once ran Kentucky's rural-health office and was the first director of the federal Office of Rural Health Policy, writes in the Daily Yonder. He says that if a state doesn't expand Medicaid, many of its people will remain or become uninsured.

"Medicaid is a rural issue because a higher percentage of low-income people live in rural communities, and rural families are less likely to have private health insurance," Myers writes, adding that the program is also "a major economic driver." According to the National Center for Rural Health Works at Oklahoma State University, Medicaid was responsible for 113,000 jobs and a total of $10.5 billion in economic activity in Oklahoma in 2010.

Myers cites studies showing that patients with insurance who are hospitalized after accidents are 40 percent less likely to die than those without insurance, because uninsured patients got less attention from medical staff. Opting out of the expansion "may get a governor a self-inflicted gunshot wound to the foot, some dead hospitals and a bunch of dead citizens who needn't have died," Myers writes.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

By Al Cross
Kentucky Health News

When the Supreme Court upheld federal health reform but said states could opt out of the expansion of Medicaid to people with incomes above the poverty line, to be funded with generous federal subsidies, one of the first questions was whether a state had to go all the way: to 133 percent of poverty (138 percent with an official fudge factor). Now the Obama administration has answered "no." And that could make the decision tougher for Kentucky, which is the only state The Washington Post listed this month as leaning toward expansion.

The Post's Sarah Kliff wrote, "The administration’s reasoning goes like this: The federal government was giving states a really, really good deal on the Medicaid expansion. It was footing the entire bill for the newly eligible enrollees for three years," 2014 through 2016, rather than the 72 percent it pays Kentucky for current enrollees. The subsidy for the new eligibles would drop to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019; and 90 percent in 2020.

White House aides told Kliff that in passing the bill, Congress (which is to say the Democrats in Congress) "gave states that really high funding in the service of a very specific goal: Ensuring all Americans have access to insurance options." But "If a state decided to cover, say, everyone up to the federal poverty line, they would be working with a smaller, more manageable population," Kliff explains. "Those living above the poverty line, meanwhile, wouldn’t be left in the lurch. The Affordable Care Act allows them to receive very generous subsidies in the private insurance market."

However, Medicaid Administrator Cindy Mann told Kliff that if states could fall short of the 133 percent level, they wouldn’t be within the spirit of the law. Kliff paraphrases Mann: "They wouldn’t offer all their residents a way to purchase affordable coverage, and if they’re not going to do that, the White House says they don’t deserve the extra funding."

Gov. Steve Beshear said again today that Kentucky should expand Medicaid "if we can afford it" because so many people in the state have no health insurance and are in poor health, and improving their health would be good for the state's economy.

Kentucky now makes Medicaid available to people with household incomes below 70 percent of the poverty line, which varies by household size. The Urban Institute has estimated that expanding the program to 133 percent of poverty would cost the state about 5 percent more than it would otherwise spend through 2022. That would be $1.3 billion extra in 2017-22, and some Republicans in the legislature have said the state can't afford it. The state expects to spend $1.5 billion on Medicaid in the 2013-14 fiscal year.

While the Post lists Kentucky as the only state "leaning yes" to expansion, it seems likely to be joined by several others. "States have stayed mum on whether they will participate in the expansion, seeing first if they could get a better deal — the partial expansion," Kliff writes. "The federal government took a while to show its cards; it wanted to see if states would sign up for the full expansion, without giving them a scaled-back option." Only 17 states have said yes, and as many are undecided, the Post reports.

In setting a firm rule, the White House may think states "will decide the 100 percent match is too good to pass up and that the federal money will pull everyone in," Kliff writes. "Or, it could indicate the Obama administration is okay with not all states participating with the Medicaid expansion on day one. Again, this wouldn’t be unprecedented: Only six states initially signed up for Medicaid when it launched in 1965."

States should realize that expanding Medicaid is a long-term investment in the health of their people that will pay off in the long run, Dr. Wayne Myers, who once ran Kentucky's rural-health office and was the first director of the federal Office of Rural Health Policy, writes in the Daily Yonder. He says that if a state doesn't expand Medicaid, many of its people will remain or become uninsured.

"Medicaid is a rural issue because a higher percentage of low-income people live in rural communities, and rural families are less likely to have private health insurance," Myers writes, adding that the program is also "a major economic driver." According to the National Center for Rural Health Works at Oklahoma State University, Medicaid was responsible for 113,000 jobs and a total of $10.5 billion in economic activity in Oklahoma in 2010.

Myers cites studies showing that patients with insurance who are hospitalized after accidents are 40 percent less likely to die than those without insurance, because uninsured patients got less attention from medical staff. Opting out of the expansion "may get a governor a self-inflicted gunshot wound to the foot, some dead hospitals and a bunch of dead citizens who needn't have died," Myers writes.

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

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Four companies will oversee Medicaid coverage in 16-county Louisville region that includes 175,000 Kentuckians

Beginning Jan. 1, four companies will share management of the health care of roughly 175,000 Medicaid patients in the Jefferson County region. This reflects a major, federally mandated change that some say raises concerns about disrupting care. The nonprofit Passport Health Plan has served all Medicaid recipients in the 16-county region for 15 years. On Thursday, the state Cabinet for Health and Family Services said it had signed 18-month contracts with Passport and three other companies -- Humana, Wellcare of Kentucky and Coventry Cares -- to manage Medicaid recipients’ care starting next year. Other details of the contracts were not released.

The federal government has made it clear that the state it could no longer operate with a single managed-care company in the region and that it must give patients a choice among several providers. In addition to Jefferson, the region’s other counties are Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, LaRue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble and Washington.

According to The Courier-Journal's Tom Loftus, "Passport had hoped that, if the state went with multiple companies, it initially would assign all recipients to it and then give them an option of moving to another company. Instead, the cabinet initially will assign recipients to one of the four companies. The cabinet said the state will use 'a high-tech matching system' that assigns a person based on 'available provider networks and any special health care needs.' (Read more)

Andrea Bennett, deputy director of Kentucky Youth Advocates, said the new system raises concerns for child advocates. "While we still have threads of hope, we cannot ignore the ongoing Medicaid managed care issues that have occurred throughout the rest of the state over the past year.  . . . We’ve heard providers threaten to give up on Medicaid altogether because they are frustrated and still not receiving proper payment. We’ve seen lawsuits and fights between the state, the managed care companies, and the providers. And we still haven’t seen hard data showing how managed care is improving quality and access to care for children in the Commonwealth."

Beginning Jan. 1, four companies will share management of the health care of roughly 175,000 Medicaid patients in the Jefferson County region. This reflects a major, federally mandated change that some say raises concerns about disrupting care. The nonprofit Passport Health Plan has served all Medicaid recipients in the 16-county region for 15 years. On Thursday, the state Cabinet for Health and Family Services said it had signed 18-month contracts with Passport and three other companies -- Humana, Wellcare of Kentucky and Coventry Cares -- to manage Medicaid recipients’ care starting next year. Other details of the contracts were not released.

The federal government has made it clear that the state it could no longer operate with a single managed-care company in the region and that it must give patients a choice among several providers. In addition to Jefferson, the region’s other counties are Breckinridge, Bullitt, Carroll, Grayson, Hardin, Henry, LaRue, Marion, Meade, Nelson, Oldham, Shelby, Spencer, Trimble and Washington.

According to The Courier-Journal's Tom Loftus, "Passport had hoped that, if the state went with multiple companies, it initially would assign all recipients to it and then give them an option of moving to another company. Instead, the cabinet initially will assign recipients to one of the four companies. The cabinet said the state will use 'a high-tech matching system' that assigns a person based on 'available provider networks and any special health care needs.' (Read more)

Andrea Bennett, deputy director of Kentucky Youth Advocates, said the new system raises concerns for child advocates. "While we still have threads of hope, we cannot ignore the ongoing Medicaid managed care issues that have occurred throughout the rest of the state over the past year.  . . . We’ve heard providers threaten to give up on Medicaid altogether because they are frustrated and still not receiving proper payment. We’ve seen lawsuits and fights between the state, the managed care companies, and the providers. And we still haven’t seen hard data showing how managed care is improving quality and access to care for children in the Commonwealth."

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Infant mortality, pre-term birth, teenage pregnancy, children living in smokers' homes all drop even as as child poverty goes up

Nationwide, the rates of infants who die, babies who are born prematurely, teens who are having babies, and the percentage of young children who live in a home where someone smokes have all decreased in the last five years. But the percentage of kids who live in poverty has gone up.

These findings are some highlights of the report "America's Children in Brief: Key National Indicators of Well-Being, 2012," compiled by the Federal Interagency Forum on Child and Family Statistics. The report, which does not break down data by state, looks at children's demographic backgrounds, family and social environments, economic circumstances, health care, physical environment and safety, behavior, education and health.

"This year's report contains good news about newborns," said Dr. Alan E. Guttmacher, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. "Fewer infants were born pre-term and fewer died in the first year of life."

Among other findings: In the last five years there has been a five-fold increase in the percentage of teens who have received the vaccine that prevents the most dangerous form of meningitis. Other key findings show:
• A drop in the percentage of children who live in homes that are classified as food insecure.
• A drop in the percentage of teens ages 16 to 19 who don't work and are not enrolled in high school or college.
• A rise in the percentage of children from birth to age 17 who live in counties in which one or more air pollutants were above allowable levels.
• An increase of one statistical point in the average math scores for 4th and 8th graders from 2009 to 2011. For a quick glance at the findings, click here. (Read more)

Nationwide, the rates of infants who die, babies who are born prematurely, teens who are having babies, and the percentage of young children who live in a home where someone smokes have all decreased in the last five years. But the percentage of kids who live in poverty has gone up.

These findings are some highlights of the report "America's Children in Brief: Key National Indicators of Well-Being, 2012," compiled by the Federal Interagency Forum on Child and Family Statistics. The report, which does not break down data by state, looks at children's demographic backgrounds, family and social environments, economic circumstances, health care, physical environment and safety, behavior, education and health.

"This year's report contains good news about newborns," said Dr. Alan E. Guttmacher, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. "Fewer infants were born pre-term and fewer died in the first year of life."

Among other findings: In the last five years there has been a five-fold increase in the percentage of teens who have received the vaccine that prevents the most dangerous form of meningitis. Other key findings show:
• A drop in the percentage of children who live in homes that are classified as food insecure.
• A drop in the percentage of teens ages 16 to 19 who don't work and are not enrolled in high school or college.
• A rise in the percentage of children from birth to age 17 who live in counties in which one or more air pollutants were above allowable levels.
• An increase of one statistical point in the average math scores for 4th and 8th graders from 2009 to 2011. For a quick glance at the findings, click here. (Read more)

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Who is on Medicaid already? Not all poor Kentuckians, foundation president says on op-ed distributed to Kentucky newspapers

By Susan Zepeda
President and CEO, Foundation for a Healthy Kentucky

In the wake of the recent Supreme Court decision upholding much of the Affordable Care Act, states have many factors to weigh. Importantly, SCOTUS affirmed the right of states to opt out of the expansion in Medicaid coverage envisioned under Affordable Care, without penalty. Some state and national leaders have been heard to say that the poor are “already covered under Medicaid.”

Currently, nearly 15 percent of Kentuckians lack health insurance, including approximately 290,000 low-income adults who are uninsured and would be eligible for the Medicaid expansion. It may surprise many to know that about eight out of 10 uninsured Kentuckians are working adults. According to the Kaiser Family Foundation, Kentucky could benefit the most, compared to other states, as a result of the Medicaid expansion — with about 57 percent of our uninsured adults newly eligible for coverage.

While many believe that Medicaid provides coverage for all low-income individuals, Medicaid coverage is actually quite complex, with significant state-to-state variation. In Kentucky:
• Working parents are eligible for Medicaid only if they earn 62 percent or less of the federal poverty level - less than $8,926 per year for a family of two.
• Jobless parents are eligible if their total income is 36 percent or less of the federal poverty level – less than $5,144 per year for a family of two.
• Pregnant women are eligible if their income is up to 185 percent of the poverty level (about $20,665) but lose this eligibility, dropping to the lower income limits above, after the child is born.
• Legal immigrants, child or adult, in the U.S. for less than five years, are not eligible for Medicaid. Undocumented immigrants are not eligible for Medicaid coverage regardless of how long they’ve been in the U.S.

Susan Zepeda

In short, not all Kentuckians living in poverty are covered by Medicaid. If Kentucky does not take the option of expanding Medicaid, many individuals and families living in low-income and poor households will be left without health-insurance access.

The new law also creates health insurance exchanges, and places limits on out-of-pocket expenses on health insurance depending on income level. While these subsidies will allow many low-income parents and individuals to purchase health insurance, they appear only to be available for families above the poverty level.

And other pieces of the law were developed with the assumption that all states would expand Medicaid coverage. Because of this assumption, cuts to other federal health funding are built into the continuing roll-out of the Affordable Care law: For example, nationally Disproportionate Share Hospital (DSH) funding has provided an average of 95 percent of uncompensated care costs for state-owned hospitals; 69 percent of uncompensated care for local public hospitals; and 38 percent of uncompensated care for private hospitals. The law will reduce DSH funding by $14 billion over 10 years, starting in 2014.

This funding decrease to key providers was supposed to be offset by the increase in Medicaid coverage, since the number of uninsured individuals seen at hospitals would drop significantly under the Medicaid expansion. If Kentucky opts out of the Medicaid expansion, however, state, local, and private hospitals could be faced with sharp increases in uncompensated care (care provided but not paid).

The coming months will present opportunities for our state leaders to look at the sometimes difficult health realities of our Commonwealth and make decisions that will best serve the health of all Kentuckians. To quote the late Daniel Patrick Moynihan, “Everyone is entitled to his own opinion, but not to his own facts.”

Susan G. Zepeda is president and CEO of the Foundation for a Healthy Kentucky, a non-profit, non-partisan philanthropic organization that invests in communities and informs health policy through research, education and grant making.

By Susan Zepeda
President and CEO, Foundation for a Healthy Kentucky

In the wake of the recent Supreme Court decision upholding much of the Affordable Care Act, states have many factors to weigh. Importantly, SCOTUS affirmed the right of states to opt out of the expansion in Medicaid coverage envisioned under Affordable Care, without penalty. Some state and national leaders have been heard to say that the poor are “already covered under Medicaid.”

Currently, nearly 15 percent of Kentuckians lack health insurance, including approximately 290,000 low-income adults who are uninsured and would be eligible for the Medicaid expansion. It may surprise many to know that about eight out of 10 uninsured Kentuckians are working adults. According to the Kaiser Family Foundation, Kentucky could benefit the most, compared to other states, as a result of the Medicaid expansion — with about 57 percent of our uninsured adults newly eligible for coverage.

While many believe that Medicaid provides coverage for all low-income individuals, Medicaid coverage is actually quite complex, with significant state-to-state variation. In Kentucky:
• Working parents are eligible for Medicaid only if they earn 62 percent or less of the federal poverty level - less than $8,926 per year for a family of two.
• Jobless parents are eligible if their total income is 36 percent or less of the federal poverty level – less than $5,144 per year for a family of two.
• Pregnant women are eligible if their income is up to 185 percent of the poverty level (about $20,665) but lose this eligibility, dropping to the lower income limits above, after the child is born.
• Legal immigrants, child or adult, in the U.S. for less than five years, are not eligible for Medicaid. Undocumented immigrants are not eligible for Medicaid coverage regardless of how long they’ve been in the U.S.

Susan Zepeda

In short, not all Kentuckians living in poverty are covered by Medicaid. If Kentucky does not take the option of expanding Medicaid, many individuals and families living in low-income and poor households will be left without health-insurance access.

The new law also creates health insurance exchanges, and places limits on out-of-pocket expenses on health insurance depending on income level. While these subsidies will allow many low-income parents and individuals to purchase health insurance, they appear only to be available for families above the poverty level.

And other pieces of the law were developed with the assumption that all states would expand Medicaid coverage. Because of this assumption, cuts to other federal health funding are built into the continuing roll-out of the Affordable Care law: For example, nationally Disproportionate Share Hospital (DSH) funding has provided an average of 95 percent of uncompensated care costs for state-owned hospitals; 69 percent of uncompensated care for local public hospitals; and 38 percent of uncompensated care for private hospitals. The law will reduce DSH funding by $14 billion over 10 years, starting in 2014.

This funding decrease to key providers was supposed to be offset by the increase in Medicaid coverage, since the number of uninsured individuals seen at hospitals would drop significantly under the Medicaid expansion. If Kentucky opts out of the Medicaid expansion, however, state, local, and private hospitals could be faced with sharp increases in uncompensated care (care provided but not paid).

The coming months will present opportunities for our state leaders to look at the sometimes difficult health realities of our Commonwealth and make decisions that will best serve the health of all Kentuckians. To quote the late Daniel Patrick Moynihan, “Everyone is entitled to his own opinion, but not to his own facts.”

Susan G. Zepeda is president and CEO of the Foundation for a Healthy Kentucky, a non-profit, non-partisan philanthropic organization that invests in communities and informs health policy through research, education and grant making.

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