The Kentucky Armageddon

The Commonwealth of Kentucky, best known for its weirdly colored grass, fine bourbon and equestrian pageantry, is about to be destroyed by the Trump administration. Many will suffer and perhaps die because Kentucky obtained a Medicaid waiver to impose additional and often insurmountable hardships on poor people receiving their free health care from the State. Since all I need to know, I learned on Twitter, allow me to share with you some illuminating insights from the Twitterati.

The evil Republican Governor of Kentucky, Matt Bevin, is salivating at the prospect off changing Medicaid as we know it, which obviously means that poor people and especially people of color will be suffering greatly under this plan. You really don’t need to know more, since this should be reason enough to mobilize the worried wealthy, who are tossing and turning in their featherbeds night after night, searching for ways to save the poor. For those who are neither worried nor wealthy enough to really care, here are the ominous provisions of the Kentucky racist, homophobic and xenophobic plan to change Medicaid (it is all these things because it was not only approved, but encouraged by the Trump administration, and we all know what that means).

The most egregious transgression in the Kentucky HEALTH plan is the imposition of work requirements on Medicaid beneficiaries. The first thing that comes to my mind when they say “work requirements” is that sign at the entrance to Auschwitz saying that work makes you free. In Kentucky, the Republicans argue that work makes you healthy. Same thing. So, what are those monstrous work requirements? Medicaid recipients who are not children, who are not below the poverty line, who are not elderly, who are not pregnant, who are not disabled, who are not medically or mentally frail, who are not providing care to children or other disabled individuals, who are not experiencing hardships such as domestic abuse or homelessness or other disruptions in their lives, must spend approximately 4 hours a day in school (any school), training (any training), apprenticing, acquiring useful skills, volunteering in the community, searching for a job or actually working somewhere.

Wait, wait…. Don’t raise your eyebrows and don’t think or say anything. If you are reading this, you are most likely rich, likely white, well-educated and perhaps even male. Medicaid beneficiaries are none of these things. We all know that any of those endeavors could be truly insurmountable hardships for people who are poor, black or Hispanic, uneducated and female. We know that because we are not racists, misogynists or just plain bigoted SOBs, like the Republicans running Kentucky and that insufferable man running the country (or so he thinks).

Besides, most Medicaid beneficiaries who don’t fall in the exempt categories are already working. The ones who don’t work, or study, or do anything beneficial for themselves or others, are experiencing circumstances beyond their control. Helping them gain control over their lives is not Medicaid’s job because health and wellbeing have nothing to do with socioeconomic circumstances. And even if Kentucky wanted to “nudge” people into, say, getting their GED by funding a special rewards account, the bureaucracy involved in tracking all sanctioned activities, all exemptions and special circumstances is just too daunting for “these people” to navigate. Trust me on this one, I read it straight from the keyboards of Hollywood celebrities and several current and former big health care executives.

The second affront to humanity in the Kentucky plan is to charge poor people premiums for health insurance. Not only that, but those who can’t pay the premiums may be kicked off Medicaid. Granted the premiums range from $1 to $15 (in lieu of regular copays), and all the exemptions for ill health, frailty and poverty do apply here as well, but that still leaves a sizeable number of poor people who could be denied medical care just because they forgot to pay the monthly dollar twice in a row, or couldn’t afford the higher premium. These highly discriminatory practices targeting the poor are unheard of in other industries or even in the commercial segment of health care itself, where insurance premiums are largely voluntary.

To be fair to Kentucky, there is a mechanism by which people who did not pay their premiums on time can regain their Medicaid coverage, which brings us to provisions reminiscent of the Jim Crow days in the South. The Kentucky plan, you see, has a literacy provision for regaining access to care. This is obviously targeted at people of color and immigrants from what the GOP Leader calls “shithole” countries, which as every wealthy person in Bel Air knows, cannot read or write, and as evidenced by the thumbprint (or large X, depending on the State) appearing on most Medicaid applications. I have zero doubt that the Attorney General of the State of California will be taking the depraved Governor of Kentucky, and the Trump administration that enabled him, to court, and I have no doubt that the 9th Circuit Court of Appeals will find in favor of justice and equality, as it always does.

Until then, it seems that some Medicaid beneficiaries in Kentucky may have to sit through torturous health literacy or financial literacy classes, where they teach boring stuff about how to deal with debt, how health insurance works and how one can navigate these treacherous waters. There is no mention of a test or anything at the end, but this still seems like an unwarranted and blatantly racist imposition on “these people”. Even more outrageous though is that Kentucky is providing incentives, which can be used to purchase gym memberships, for Medicaid beneficiaries to take other classes, such as chronic care management or nutrition or drug addiction coping skills. What do illiterate people, drug addicts and all “these people” need gym memberships for? It’s like telling them to “eat cake” ….

And on and on goes the Kentucky HEALTH plan, listing one offensive section after another. The problem with this plan, which will live in infamy until the Sun goes supernova, is the cold, heartless and blatantly racist assumption that people who need Medicaid are as capable of functioning in modern society as anybody else. It ignores decades of teachings. It ignores hundreds of years of slavery and Anglo Saxon colonialist supremacy. And it ignores basic Christian values, because Jesus didn’t just sit there giving classes on how to fish. He gave people fish, and it worked great for Him and for His followers, eventually. If you see yourself as the Lord and Savior of huddled masses, you will want to do what Jesus did. If you feel equal to people who need Medicaid, but perhaps a bit luckier at this moment, you will dismiss everything I wrote here as total bullshit.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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34 replies »

  1. Well, of course, they could turn this into a nightmare or a stepping stone. I believe in “big” government, so I have to keep my fingers crossed that they will execute in a reasonable way.

  2. Margalit, we’ll see in one to two years how onerous this becomes, but my point is the focus is all wrong, as usual from Repugs who want to punish the least powerful cause it makes them feel good.

    Did you find what this will cost Kentucky to administer, oversee and verify? For instance who’s going to verify if the Medicaid recipient is doing home care (usually unpaid) of a family member? How many times will a recipient have to report and verify a exemption? What paperwork will a recipient have to fill out on a continuing basis? What happens when a recipient is cut off from Medicaid and then gets sick, will an ER treat them?

  3. Peter, there is no narrow “work” requirement. Looking for work counts. Going to school counts. Volunteering counts. Other activities count. All the people in the article are obviously not going to be affected by the Kentucky Medicaid waiver.
    They are penalized by many other societal things, including the lack of understanding of why fast food workers need a GED, but this has nothing to do with the Medicaid waiver discussed here.

  4. There is a total solution for all those able bodied non-workers that don’t want to work in Kentucky. Go to California and declare illegal immigrant status. 😉

  5. “With a community college degree in hand and a university degree coming soon, Childers says she has been applying for more or less every decent job within three counties of tiny Campton, a rural Kentucky community with two dollar stores and not much else.”

    “Childers, 25, said she doesn’t have the money to move to a big city, to spend her time donating her labour instead of looking for work, or to get a car that would let her broaden her job-search horizons. Bevin’s rule, she said, penalizes people for circumstances they have nothing to do with.

    “There is an immense lack of jobs in Eastern Kentucky. Where is everyone on Medicaid going to find work here?” she said.

    So this is the Republican plan to control Medicaid costs and spur poor people to get jobs? Even you said this won’t reduce Medicaid costs and will only affect a very small portion of people on Medicaid. And why do fast food workers need a GED? I’m not sure of why the use of hyperbole in your article – unless this plan is just good raw meat for the Regug base.

    “A last-minute change to the just-passed tax plan that would benefit real estate investors like Donald Trump should surprise no one. He loudly opposed 1986 tax reform legislation because it shut down tax shelters for real estate investors like him. So, it’s only natural that the Trump-GOP tax plan creates new loopholes for real estate investors and makes the tax code more complicated.”

    Maybe some of that tax could have gone to help Christina Childers buy a car and help her move to a place that has jobs. Or maybe the expulsion of the Dreamers in Kentucky will open up a lot of jobs for Christina or help to raise those fast food wages.

  6. I don’t get that article from the Toronto Star, which I assume is Canadian. All the people they talked to in the article are above and beyond the so called work requirements…. not sure why they are upset, other than the irresponsible and cruel “reporters” who scare them for clicks….

  7. Here is a today article on exactly what Kentucky (and maybe other states) is doing. Maybe not such a good thing eh Margalit when you get down to street level?

    Republicans route to prosperity is attack and punish the poor while giving obscene tax cuts and loop holes to the rich.

  8. This isn’t about work and it’s not tied in with sparing cash. It’s tied in with giving a chance to individuals who were deserted by every single other framework. All things considered, in its proposition refered to as one of the fundamental drivers a colossal in individuals getting their GED, and by giving them livens in this program, ideally they can backpedal to class.

  9. “Or did you amicably agree to disagree? Why is it different now?”

    Because most people opposing this aren’t making unhinged arguments. Most of those opposing it are suggesting it may have negative consequences, and laying out why they think that tis true. Yes, there are people making unhinged arguments. As I noted, you are choosing to argue against the worst, most unhinged arguments from the worst people. That is what partisan hacks do. It is tilting against straw men. It is much easier to do, I will grant you that.

  10. “with little consistent evidence that reform led to an increase (or decrease) in poverty or a worsening of (or improvement in) child well-being.””

    I believe that’s because poverty is institutionalized within family dynamics. The old adage that, “the fruit does not fall far from the tree” is very true – even for Trump. Few breakouts from family/neighborhood momentum occur. We attack the problem at the wrong end.

  11. From Washington Post editorial May 2016,
    “As it happens, welfare reform is one of the most intensively studied policy changes of recent history. The findings support neither unbridled enthusiasm nor the dire hindsight Mr. Sanders voices today. “A broad summary of that voluminous literature,” write economists Marianne Bitler and Hilary Hoynes, “is that welfare reform contributed to a significant reduction in welfare participation and an increase in female employment, with little consistent evidence that reform led to an increase (or decrease) in poverty or a worsening of (or improvement in) child well-being.”

  12. At the very least, the 1996 welfare reform work requirements helped to remove people who were already working off the books and collecting welfare too. The caseloads dropped drastically and stayed down through the subsequent recessions.

    In healthcare there is lots of fraud and care of dubious or no value to the patient in Medicare and Medicaid especially in places like southern FL. Favorite areas include PT, particularly in nursing homes, durable medical equipment and home healthcare. Just to be clear, doctors and hospitals are not the problem here though there are a few rotten apples in every profession.

  13. “It has plenty to do with those who think that anything tangentially related to his existence has to be bitterly opposed.”

    Maybe that’s because he has researched his policy issues, given thoughtful consideration to a solution, and consulted with all sides and then sat down with the political stakeholders to forge a DEAL, because deal making is his strong attribute.

    Or maybe it’s just his moronic tweets that send non-factual, confusing, changing positions, where no one knows (even Repugs) what he wants – except adulation from his core supporters.

  14. Yes, I took a leap…. I tried to make a point of style. Tried to mimic the hysterical responses to every single policy we slightly disagree with at the moment….
    I obviously failed miserably 🙁

  15. 1- No. The best way would be to offer free college education to all and turn public schools everywhere into palaces of learning. I would be willing to fund that with taxes. The majority of people in this country would not. So we do the best we can with what there is.
    2- Tiny percentage probably, maybe single digits, but I have no numbers
    3- Most certainly it won’t reduce Medicaid costs. It will probably increase them.
    4- I have no idea. Probably for the same reason Democrats did and didn’t respectively.

  16. I think the nuns were doing that, or close to that. I think health care went down the drain when the last nun CEOs retired and their legacy was turned into revenue seeking enterprises. Maybe Pope Francis should take a look at what is being done with the property of the Church…..

  17. For me, this has nothing to do with The Trump.

    It has plenty to do with those who think that anything tangentially related to his existence has to be bitterly opposed. Bill Clinton introduced work requirements for food. Not for insurance. For food. Bill Clinton was a democrat.
    Did you also think that people who agreed with Bill were vitriolic partisan hacks? Or did you amicably agree to disagree? Why is it different now?

    (btw, the hyperbolic style carried through is intended to serve as a mirror for the unhinged “resistance” – and I don’t mean you personally)

  18. Is denying access to health care the best way to get poor people to work?

    With all the exceptions what percentage of Medicaid recipients would be required to participate in this program?

    Is this the way to reduce Medicaid costs? Why do Republicans focus so much on poor people’s access to health care and not on reducing costs for those in private plans?

  19. And I would bet that would largely not be true. So, Trump is your guy, so I guess you have to go to extremes to defend him, but this hyperbolic, vitriolic style that you carry through a whole post is far beneath the standards of this blog, and frankly, below the standards of your usual writing. Like most partisan hacks you have chosen the worst arguments of the worst people to oppose. If this is just therapy writing, then go for it I guess.


  20. We also had an economic boom. If you look, and I have done so many times, you will find widespread disagreement on whether work requirements helped put people back to work. AFAICT, there is nothing along this line for health care.


  21. I usually love your writing, Margalit, but this one I can’t understand. I think too much sarcasm or something.

  22. We should try somewhere, sometime, an experiment making hospital care a public good. No billing. No billing office. Everyone on salary. Drugs purchased from cheapest sources around world. Funding by local taxes, philanthropy. Admission into hospitals by triage and algorithm: Is the condition likely to kill or disable or cause bankruptcy?

  23. The inherent error of our nation’s healthcare reform is the belief that it has the know-how to eventually figure out the details for solving the problems associated with its low efficiency and unreliable effectiveness. The scientific model will eventually win out. There is absolutely no evidence that this has any likelihood of success.

    It is well known within the folks who do “street outreach” to engage the homeless is the following: a person’s decision to “be housed” in supportive housing is almost always a relationship dependent process. It is virtually the only process that is reliable. Ultimately, TRUST is the most important, continuing attribute of a caring relationship. When a person’s life is filled with betrayal from short-term relationships, a person’s self-care becomes nearly impossible. Thus, we have chronic pain disorders of various types, worsening maternal mortality, increasing teenage pregnancies with premature infants, and worsening age 1 through 25 years death rates from homicide and suicide.

    None of these issues will be solved without a revival of a community-centric focus on the COMMON GOOD of each community of @400,000 citizens, nearly 800 nation-wide. Nationally initiated, regionally monitored and assisted, and locally supported by the recognizable stakeholders of each community, these citizens already exist. We need only a means to coalesce their focus to improve their community’s level of Social Capital as the basis to improve our nation’s social mobility.
    see http://www.nationalhealthusa.net/communityhealthforum/ for one concept.

  24. Re your query if work requirements have a history of success:

    “Time limits and work mandates were key parts of the 1996 welfare reform that opponents said would destroy America’s safety net. Instead, we witnessed significant and sustained reductions in welfare caseloads and increases in labor participation and incomes among single moms. After Maine attached work requirements to able-bodied food stamp recipients in 2014, their incomes more than doubled on average” Jason Riley Manhattan Institute. If you look you will find widespread agreement that tanf work incentives in 1996 were positive.

  25. This is the process by which we are being re-enslaved. There is practically zero probability of escape. Whatever it is today, it is much better that it will be tomorrow.

  26. A life-time spent enduring the endless stream of betrayed promises leaves a person with little in the emotional bank for managing a Personal Survival Plan required for restful sleep (a Home), good food (including people who you care about to share the food), exercise ( including a safe place to share it with others) and the emotional energy to do the things necessary to keep all that going. The monthly check of some sort goes first to the car payment, then the home rent, then some food and the rest to the Casino or other endless barrel. 30% of our citizens continue to live in this vicious cycle without their community’s efforts to vitalize the COMMON GOOD for all of citizens. This applies, especially, to the social discourse necessary to resolve the many social dilemmas encountered within the civil life of every community. We have no community by community effort to solve this issue, made worse by so many misguided Federal efforts to improve the level of social capital within each citizen’s community.

    During the last 50 years, social mobility for citizens who grew-up in a family living with the lowest family income quintile and retiring in the highest quintile has changed from 13% to 00%. Read Robert D. Putman’s book “OUR KIDS: The American Dream in Crisis” 2015 for a thorough analysis of this impact on our citizens.

  27. Why do we make this about work? The waiver has all sorts of options. Work is just one of many. Why not call it volunteering requirements, or education requirements?
    Why is the assumption that people who reached a dead end are lazy? Maybe they need help and in Kentucky Medicaid wants to help.
    Why is it okay for employer insurance to penalize for non-participation in wellness or for “bad” health indicators? Why is it okay to make “irresponsible” fat smokers pay 50% more, and perhaps make it prohibitive for them to have insurance?
    Why is everything perpetrated by the donors in their private capacity as “job givers” is fine and dandy?

    We are a mean society, and we are encouraged to be mean by puppet-politicians from both parties, and sometimes I feel that my ex-party is actually worse and certainly more cruel, because it peddles grand visions that they have no intention or ability to put in place (no more than the GOP had to repeal and replace).

    The donors are the same for both political parties. They give the same and want the same and get the same. Only the means are sometimes different.

  28. Because in this most powerful and rich nation, the number of people who feel powerful and financially secure is getting lower every day. We have the worst Gini among developed nations. We have majorities who cannot come up with $400 for an emergency.
    When people are worried about their next meal or mortgage payment, when they see their kids doing even worse, there is very little desire to contribute additional money to take care of other people even if those other people are nice and hardworking, let alone if they cannot be bothered to at least go to school or volunteer for half a day.

  29. I’d be slightly more amenable to the people who want lazy medicaid recipients to work if they hadn’t just recently passed a “tax” bill that ensures their donors’ great great great great great great grandchildren never have to

  30. Well, I am obviously no expert, but the ACA expansion added childless adults up to 138% FPL to Medicaid and KY expanded the program. Most non-SSI adults in Medicaid (almost 80%) live in families where someone works and the majority are themselves employed. Most are obviously employed in exceedingly low paying jobs.

    This is not about work and it’s not about saving money. It’s about providing an opportunity to people who were left behind by all other systems. Actually, in its proposal KY cited as one of the main drivers a huge drop in people getting their GED, and by giving them perks in this program, hopefully they can go back to school.

    You can look at this as some draconian, vindictive thing, or you can look at it as a good faith attempt to reach people who maybe live in isolation, maybe gave up, maybe don’t know where to turn to, and give them resources and a little nudge to help themselves.

    I bet if the previous administration introduced education and employment assistance centers for the poor, people who oppose this would be applauding and calling it a good investment.

  31. Overwrought writing that is very hard to follow. So, how about some useful stuff. As those of us who follow health policy know (I thought you were on of those but hard to tell with this piece), Medicaid largely doesn’t cover healthy people who can work. So who will this really affect in Ky? Next, your absolute faith in big government is kind of nice, but isn’t it likely that they make some mistakes in deciding who to cover? Do these kind of work programs have a history of success? What is the cost/benefit ratio? It sounds like it will make you feel so good just to have them working that you don’t care how much it costs. Being a pragmatist, and a numbers guy, feelings don’t matter much to me, so I would like a bottom line estimate. (Wasn’t it Florida that was going to spend more on drug tests than it was going to save by finding people on drugs?)

    If the blog knows anyone knowledgeable, it would be nice if they wrote on this topic.

  32. Why is it that the most powerful, and by some measures the richest, country on earth cannot consider health care a human right?