While Controversial, Kentucky's Medicaid Overhaul is Worthy of Debate

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Gov. Matt Bevin is trying something new in Kentucky, and as we know brash ideas have a way of stirring up controversy, especially in this hyper-partisan political climate. And as it pertains to establishing new requirements for poorer citizens to receive Medicaid benefits, this is what we're seeing right now.

As you may have heard, the Republican governor is upending the status quo by moving forward with a plan, set to take place in July, requiring able-bodied recipients between the ages of 19 and 64 to either obtain employment, enroll in job training or engage in 20 hours of volunteer service per week, as a condition of receiving their medical benefits. 

Exemptions are in place for pregnant women, the elderly, full-time students, primary caregivers to children and those too "medically frail" to participate, a group that includes those facing mental illness, alcohol and drug addiction, and cancer treatment. And current Medicaid recipients already employed would, of course, be unaffected.

Gov. Bevin (photo, left) maintains that with the recent expansion of Medicaid, which his state and 31 others requested before he took office, Kentucky would be facing an ever-increasing portion of the overall cost, and that over time it would be harder and harder to finance. And that's despite the federal government paying nearly the entire tab.

The plan's expected savings – derived mostly from those whose new work income would make them ineligible for Medicaid, as well as others leaving the rolls by failing to comply with the new requirement – would be roughly $300 million over the next five years. 

Kentucky's Medicaid expansion added between 400,000 and 480,000 people to its program, far more than expected. The state's total number of Medicaid recipients rose to 1.4 million people, which is more than 25 percent of its total population.

While the proposal, which received approval from the Trump Administration on Friday, has unnerved patient advocates and other defenders of the poor as appearing unduly harsh, Gov. Bevin's does make a number of valid points that deserve consideration. (On the other hand, his ugly and newly-disclosed threat, to toss all of those added in the expansion off the program if the courts rule against his plan, comes off as rather unseemly and cruel.) But setting his political tantrum aside, let's look at the governor's rationale.

First and foremost, Gov. Bevin's plan allows for many exemptions, so in large measure those who cannot work or make time for community service don't have to. As a result, the true focus of the plan is an individual's untapped ability to contribute to society or self-improve, as well as the goal of instilling a sense of "dignity," as the governor has stated, to those returning effort for the state's aid. In short, creating some accountability and encouraging a moral obligation to contribute to the community.

That accountability is baked into the plan's "rewards program," which induces recipients to engage in healthier practices – having checkups, enrolling in smoking cessation programs, etc. – as a requirement of receiving benefits. (What's controversial is that the some of the benefits are initially taken away, and then used as motivational carrots to be earned back. This approach could stand some improvement.)

Gov. Bevin's plan doesn't appear to be overly Draconian, in that those healthy people initially failing to comply would lose their benefits – but only up to 6 months – and not kicked off Medicaid entirely, an approach that can serve as encouragement to return. 

The governor campaigned to reverse Medicaid expansion, so it's no surprise to voters that he's doing what he said he'd do. And finally, since Medicaid's central mission as stated in the federal statute is to improve public health, Gov. Bevin contends that his plan would work towards that goal if the incentives, in the long run, ended up improving the health of the individual beneficiary.

But the proposal, coming from a Republican, has attracted understandable criticism from the start based on the country's rightward shift over the last year, one that has produced many initiatives on the federal level that have made life increasingly difficult for immigrants and Americans of lesser means. All of which is to say that Gov. Bevin shouldn't lose sight of this polarized, rich-poor environment in the coming months as he engages his critics in productive conversations.

That's also not to say that there's plenty wrong with his executive order filed last Friday, which will summarily end benefits to the hundreds of thousands in the expansion if any court action prevents his plan from being implemented. But there's actually a decent case to be made for what he's proposing, which makes a reasonable observer conclude that Gov. Bevin's threats are unwarranted. 

Kentucky is the first state to venture down this road, and eight others are reportedly preparing similar requests. And while legal challenges are strongly being considered, none yet have been filed. Therefore it would seem that continuing a spirited debate on the merits of the governor's plan – one that's open to alterations, but shelves his heavy-handed threats – makes the most sense right now.