Deborah Yetter

@d_yetter

Before he got dental coverage, David Thompson, who works at various construction jobs, said he suffered for years with untreated dental pain and decay.

"I'd go to work and the pain would be so excruciating that I would literally at lunch go in the parking lot and pull my own teeth," said Thompson, 49, who lives in South Louisville.

Now, having just gained health coverage through Kentucky's expansion of Medicaid under the Affordable Care Act, Thompson is hurrying to schedule dental and eye exams — care he said he urgently needs but realizes could be eliminated under major changes to Kentucky's Medicaid program proposed by Gov. Matt Bevin.

"I'm trying to do everything I possibly can before these rules change," said Thompson, a patient at Family Health Centers of Louisville. "Had I had insurance before this, I would have more teeth."

Kentucky is moving closer to an overhaul of the state's Medicaid program Bevin has said is aimed at controlling costs and encouraging more personal responsibility in consumers, changes that include elimination of basic dental and vision benefits for most "able-bodied" adults who instead would have to earn them through a "rewards" program.

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Such changes could be enacted by January under a timetable laid out by Bevin's administration. State officials have said the administration expects preliminary approval for its proposal as early as June from the federal government, which provides most of the funding for Medicaid.

While the Bevin administration is still negotiating with the federal government over details, state officials "feel optimistic about the ultimate outcome," said Doug Hogan, a spokesman for the Kentucky Cabinet for Health and Family Services, which is overseeing the plan.

Hogan described the administration's proposal as one "tailored to meet the unique needs of Kentuckians" that mirrors commercial health plans and is meant to "better engage members in their own health, wellness, education and employability." It's also meant to improve health outcomes for Kentuckians, he said.

But advocates and public health officials are increasingly concerned about what they believe will be an adverse effect on Kentuckians they say have benefited enormously under the Medicaid expansion launched in 2014 by Bevin's predecessor, former Gov. Steve Beshear.

"We're all very, very concerned," said Muriel Harris, an associate professor of public health at the University of Louisville and chair of the Family Health Centers board in Louisville. "Those who have made the decisions are not considering the population we serve. It's just undermining any gains we have made in the past."

The proposed loss of dental benefits in a state with poor overall dental health is especially alarming to Bill Wagner, CEO of Family Health Centers. The community health agency just opened a new, full-service dental clinic at its East Broadway site with funds available through the federal health law also known as Obamacare.

"We see a lot of patients with severe dental problems," Wagner said. "This is really not the time to be cutting back on dental benefits for adults."

Thompson, who said he is a Democrat and did not vote for Bevin, a Republican, agrees.

"It is expensive to go to a dentist," he said. "These changes are just ludicrous."

But state officials, anticipating approval of Bevin's proposal from the Trump administration, expect to launch the new plan on Jan. 1, 2018, with changes that will affect many of the 440,000 Kentuckians added through the expansion of Medicaid to anyone at or below 138 percent of the federal poverty level. That's an annual income of up to $16,400 for an individual.

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Advocates worry consumers won't understand the complex changes to the program and, as a result, will lose coverage.

"I think people are going to fall away as the system gets more complicated," said Richard Seckel, director of the Kentucky Equal Justice Center in Lexington. "It's an experiment and there's some peril in it. Ideally, we'd be trying things that help people get coverage and keep coverage."

Details of the Bevin plan are outlined in an April 4 document drafted by Deloitte Consulting, an outside firm under contract to the state.

Proposed changes include monthly premiums, co-payments for services, mandatory work or volunteer activity to maintain Medicaid coverage and "lock-outs" of coverage for up to six months for some who fail to pay premiums. The state proposal also includes a "My Rewards" account where people can accumulate points for activities such as passing a GED exam, completing job training or completing wellness activities such as stop-smoking classes, points that go toward the purchase of services such as dental or vision care.

But Medicaid members also would have points deducted from their rewards account for infractions such as failing to pay premiums or "inappropriate" use of emergency rooms up to a negative balance of $150.

Critics of the requirement to work or volunteer up to 20 hours a week argue that a majority of adults affected by the changes already work, many in jobs such as food service, construction or housekeeping that don't come with health insurance.

"To use this as a stick just doesn't make any sense to me," said Emily Beauregard, executive director of Kentucky Voices for Health.

Collecting premiums and co-payments, tracking work or volunteer activity and managing the rewards accounts all will involve major technology systems changes and likely, hiring of outside vendors to manage such systems, advocates say. That adds to expense and potential complications, they said.

"One scary possibility is that the systems crash like they did with Benefind," said Seckel, referring to the massive failure last year of a new state public benefit system that led to disruption of health coverage, food stamps and other assistance for thousands of Kentuckians. "With any kind of major technical modernization, there's some initial chaos."

Seckel said other states that have attempted to impose modest premiums allowed by Medicaid have found that the cost of collecting monthly payments greatly exceeds any revenue the state takes in.

Kentucky is proposing monthly premiums of $1 to $37.50 per month, based on income and length of time enrolled in Medicaid. The longer people remain in Medicaid, the more it will cost since Bevin's plan is aimed at pushing people to move to the commercial insurance market through employer coverage when available.

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Much of the administrative work would be delegated to five private managed care companies that oversee care for the majority of the more than 1.3 million Kentuckians enrolled in Medicaid. Mark Carter, CEO of the Louisville-based Passport Health Plan, which manages care for about 300,000 Kentuckians, said his organization is working to prepare for the changes.

Carter said the increased work will increase Passport's costs, which likely will mean more costs to the state Medicaid program. And he said it's inevitable some people won't understand the changes or be able to meet new demands and lose coverage.

"It will take some time and there will be some fallout from that," Carter said.

Both the state's dentists and optometrists urged the Bevin administration to consider restoring basic vision and dental services to its proposal. Instead, the administration agreed to offer such coverage only for the first three months for new members.

After that, the benefits are available only through the "My Rewards" system for the adults considered "able-bodied," not including those who are disabled or "medically fragile," according to the state proposal. The changes also do not apply to pregnant women or children.

A 2016 report by Pew Charitable Trusts found oral health to be dismal throughout Kentucky but problems were the most severe among poor residents, especially those in rural areas with less access to dental services.

Kentucky optometrists have argued routine eye exams often uncover other serious health problems including diabetes, high blood pressure and eye disease that can result in blindness.

Family Health's East Broadway clinic, in a renovated former warehouse, opened in 2015, a $6.5 million expansion made possible through the federal health law. The new dental clinic was added with additional federal funds to renovate, equip and operate it.

Medicaid dental benefits will help cover the cost of running the dental clinic because it gives many more patients who previously lacked coverage a way to pay for services, Wagner said.

Before, Family Health, which also operates a dental clinic at its Portland site, charged a sliding scale fee with a minimum $30 per visit. Patients who couldn't afford that generally relied on the emergency room where they might receive a painkiller and antibiotic for infection but no dental treatment, Wagner said.

"They'd be told to follow up with a dentist," he said. "A lot of them have no dentist."

Aaron Cole, a mechanic and Family Health patient covered by Medicaid, said he considers his dental and health benefits to be essential.

"If it ain't broke, don't fix it," he said. "Why don't they just leave it the way it is?"

Cole, 37, who doesn't have full-time work with health benefits, said his Medicaid coverage allowed him to get hernia surgery he needed and to get treatment for a decayed tooth. Both conditions had become extremely painful before he received treatment.

"The dental care, you need that just as much as the health care," he said. "If your teeth are aching, you have to get that fixed."

Contact reporter Deborah Yetter at 502-582-4228 or at dyetter@courier-journal.com.

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