Susan Zepeda is the president and CEO of the Foundation for a Healthy Kentucky. In early May, the foundation convened a variety of stakeholders in Kentucky’s Medicaid program: physical, behavioral, and oral health providers; consumers and consumer advocates; public health professionals; academic researchers; health systems; and payers. The aim was to gather feedback on Kentucky’s plan to apply for a federal waiver that allows states to test and evaluate new ways to provide Medicaid. Tom Martin talked with Zepeda about that feedback and what was learned.
Q: Let’s begin with that conference. What prompted it?
A: What prompted the May 12 convening was a sense that Kentuckians have things to say about a Medicaid waiver. There’s a lot of expertise and a lot of experience across the Commonwealth, not just from the payers and providers, but from the consumers who use Medicaid to access needed healthcare services. And we thought it would be helpful to give all of those players a place at the table in discussing what might go into a Medicaid waiver.
Q: What is your assessment of how the Affordable Care Act has performed in Kentucky?
A: Well, it’s not just our assessment. We work with a group called the State Health Access Data Assistance Center, also known as SHADAC. And they are doing a 34-month study for us of the experience of Kentucky with the Affordable Care Act, specifically with the state-operated exchange that was called Kynect and also with the former governor’s decision to expand Medicaid as was permitted under the Affordable Care Act to anyone earning up to 138 percent of the federal poverty level. That brought a lot of adults who had no children into eligibility for Medicaid. And what we’ve learned from the SHADAC study so far is that there’s been a significant drop in the number of Kentuckians who are uninsured as folks have come online and utilized the exchange either to purchase insurance or to be eligible for insurance under Medicaid. SHADAC tells us we’ve seen people using preventative health services more than they did before. We’ve seen people accessing dental services and substance abuse services. And one of the things we know about getting care early, not surprisingly, is that it costs less than getting care later in a disease. When you don’t have health insurance, it’s not unusual to wait as long as you can and then maybe seek help in an emergency room in a crisis. But if we’re doing those early screenings and preventative health visits, we spot diseases early on. The outcomes are better and the costs are typically less.
Q: Arguing that Medicaid recipients should have some “skin in the game,” Gov. Bevin has cited Indiana, which received a federal waiver that allows it to charge premiums based on income levels to people who want benefits beyond the basic Medicaid program. How was this idea received among the people who attended the May conference?
A: The folks who were with us on May 12 were loud and clear that they don’t want to see someone dropped off the Medicaid roles because they’ve been unable to pay a premium. But they were more favorably inclined toward premiums than they were toward co-pays. And the understanding behind that is that a premium is a known, fixed amount that you can budget for. When you walk in to get care at different settings, the co-pays may vary from one visit to the next. And if you should happen to have a serious illness and substantial co-pay, we would never want that to deter people from getting the care that they need. Another opportunity is “banking” financial benefit to participants who avail themselves of preventative health services - who engage in a smoking cessation program or an exercise program. Not clear exactly how that could happen. It could be a health savings account where resources are put in that account if you engage in your own self-care in a positive healthy way. That’s another way to have skin in the game.
Q: What is the cost of having so many people without access to health care?
A: The short answer is that when people don’t get timely care and they defer their care, it ultimately costs more for them personally and it costs more for the Commonwealth of Kentucky. We know that chronic diseases are a challenge in our state. And late-stage care of chronic diseases is both financially costly and the outcomes are less promising. The folks who met on May 12 didn’t just look at what happens within the care delivery from the patient perspective. They also looked at it from the provider perspective and had a number of suggestions for ways to streamline the administrative costs of engaging with Medicaid. So, there are cost savings that would be available. Everything from having a single formulary that’s a list of allowed prescriptions for all the managed care organizations, to having the same pre-approval processes for procedures across all the managed care organizations. And some suggested having fewer managed care organizations to deal with because fragmentation and those differences have been driving up administrative costs for the caregivers who want to participate in Medicaid.
Q: It’s no secret that we have a terrible oral health record in Kentucky.
A: What folks don’t seem to realize is the head really is connected to the body. And when you have abscesses and infections in your mouth, yes, that’s oral health, but it can also put your pregnancy at risk if you’re pregnant. It can lead to systemic infections with all kinds of adverse consequences. Not sure how in the dusty history of health we separated the head from the body, but we at the Foundation have certainly been funding pilot projects and arguing for reconnecting them. Behavioral health is another area. A few years back, we invited Steve Malik, a health economist, to speak at our annual health policy forum. And he had the data clearly demonstrating that if you ignore a behavioral health problem, you wind up spending an awful lot on treating other medical problems that have a behavioral component. Whereas if you face it head on and address the behavioral health issues, the overall costs go down.
Q: You mentioned the uninsured rate in Kentucky. That rate has dropped to roughly one-third of where it stood as the Affordable Care Act went into effect. Was Kynect, the state-based health benefit exchange, responsible for that?
A: It’s clear that Kentucky did a great job of getting the word out about the availability of Medicaid and also of more affordable approved health plans that could be purchased. I think a lot of people went on the exchange to see if they could afford to pay the premiums. And when they learned about the tax credits that were available, I think folks were pleasantly surprised. But the vast majority who enrolled through that exchange turned out to be eligible for Medicaid. And frankly, that speaks to the level of poverty in the state.
Q: Gov. Bevin is dismantling Kynect. He’s calling it redundant relative to the Federal Exchange. What’s the foundation’s position on Kynect?
A: The foundation doesn’t have a position specifically on Kynect. We have a position on access to affordable quality care and Kynect seemed to be working. It’s clear that we need to give this next iteration an opportunity to see how well it works. With the study that SHADAC is doing for us, we’ll be able to track and see if this results in people falling off the insurance roles. If it doesn’t, then we would say we’ve made a smooth transition to Benefind and the Federal Exchange.
Q: Many people in Kentucky may be under the impression that Kynect is now dark. Is it still functioning at the moment?
A: We’re still in a transition phase. I think November is the changeover date when the new enrollment period starts. That’s when Kentuckians will be working with this two-pronged system, going to the Federal Health website first to see if they qualify to purchase insurance there. And then if they don’t, the fallback here in Kentucky will be Benefind. And Benefind’s strength is that it permits people not just to apply for Medicaid, but to also be screened to see if they qualify for SNAP (what we used to call food stamps), for WIC (which is a nutrition program for pregnant women and women with small infants). So, it’s a better integration of all the possible programs that folks would be entitled to in a single process there. What’s being broken apart from that is the private purchased insurance. One of the things that we’re certainly aware of is that people move back and forth between eligibility for Medicaid and ability to purchase private insurance. And so, a concern that we’ll all be watching for is how smooth is that transition back and forth when there are two portals.
Q: What do you hope to see emerge from these discussions about Medicaid?
A: Several things. One, it’s hugely exciting to see the way providers, consumers, and payers are willing to come to the table and talk about this opportunity in the Medicaid waiver to do care more effectively, to do care with a more streamlined administration. People want Kentucky to succeed. We want to be “Kentucky proud.” And to their credit, the administration is listening to those voices as well as listening of course to the experience of other states around the nation.
Tom Martin’s Q&A appears every two weeks in the Herald-Leader’s Business Monday section. This is an edited version of the interview. To listen to the interview, find the podcast on Kentucky.com. The interview also will air on WEKU-88.9 FM on Mondays at 7:35 a.m. during Morning Edition and at 5:45 p.m. during All Things Considered.