♪ >> Shakespeare said a rose by any other name would smell as sweet well, how about a government health care plan designed to help those in need?

Stay with us.

As we talk about Kevin Martin about Medicaid and all that includes next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the foundation for a healthy Kentucky.

♪ >> Last week DR Kevin Martin gave us a good insight into Medicare and briefly touched on how it differed from Medicaid today.

We are changing gears.

This time.

We're going to dive deeper into Medicaid over the 60 years since its inception, Medicaid, like so many other government programs has morphed or some may say ballooned to meet the changing needs of our society.

The most recent iteration was the 2014 Patient Protection and Affordable Care Act.

Sometimes derisively call Obamacare, which expanded the criteria for those elves would receive Medicaid in Kentucky.

Then Governor Steve Beshear rolled out, connect, which was the Kentucky version of expanded Medicaid at the time.

Connect was seen by many as a model for the expansion of health insurance coverage to those who previously had been without as to the overall benefit of expanded Medicaid.

A 2024 article from the Center on Budget and Policy Priorities authored by Laura Parker and Brianna, Share noted that the people who gain coverage have grown healthier and more financially secure while longstanding racial inequities in health outcomes, coverage and access to care have shrunk.

We, too, have seen such benefits in Kentucky.

To take us through the maze of terms and programs out a collective called Medicaid.

We have is our guest Dr. Kevin Martin.

He will take us to talk about what is Medicaid and how we're going to work through all these things.

Dr Martin is a graduate of Vanderbilt University School of Medicine.

We also that his core general surgical training before transferring to complete his training at the Baystate Medical Center in Springfield, Massachusetts.

This was followed by research and clinical fellowship in vascular surgery and the Department of Surgery at University of Cincinnati School of Medicine prior to retiring, he was a practicing vascular surgeon and the Saint Elizabeth Healthcare system for 26 years.

Dr Martin served on the Medicare Kerry Advisory Committee for the Commonwealth of Kentucky is now an adjunct assistant professor in the University of Kentucky College of Medicine Dr. Martin, thanks for being back with us again.

My pleasure.

I want to ask you to surgery.

It came down to it and the sounds kind of corny.

>> First time I saw an aneurism repair and they thought the clamps often the patients in the lead in the tech fixed.

I was hooked.

>> I can imagine it meant.

How do you go from being a vascular surgeon to a guy who's gonna spend time looking at health care plans like Medicare and Medicaid.

>> That's a good question.

Most of our colleagues, if you start talking to them about policies.

CPT codes, ICD 10 codes.

All of this highs glaze over and they have all of this stuff.

Yeah, but the foundation of how are we as a profession are able to help take care of the patients.

We have to interact with all of these insurance companies, Medicare, Medicaid, Tricare, the hold gamut of companies and it comes down to needing to understand some of the policies and helping to have a seat at the table so that the bureaucrats to come up with some really crazy ideas.

>> Well, I've found that even somebody who was in the business and thought what was going on.

Really, really do so.

Remind us again, Medicaid, Medicare, one of the differences with a similar.

>> President Johnson back in 1965.

Signed the legislation creating both Medicare and Medicaid.

Medicare was for the holder.

More of the tour population.

I'd like to call it that.

I'm on Medicare and you are met.

>> And Medicaid, he's for the less fortunate.

Medicaid is a partnership between the federal government and the states.

But the states have been put in can change some of the rules with approval of the federal government so that Medicaid is different in every single state on a variety of different things.

But the core policies are still basically the same.

Now, the eligibility?

By and large is that you can sign up for Medicaid if you have less than 138% of federal poverty level for that area.

Through Medicaid at very low rates.

Now with, as you mentioned, Obamacare or the Affordable Care Act, the health care market place in which exists in most states, but not all you can then buy into Medicaid coverage.

But then you're paying a premium and that is one of the areas that really expanded the Medicaid bros, especially during the pandemic.

And it's.

A lot of people think that Medicare, he's a lot bigger.

Medicare has about 65 million people on the rolls into Medicaid has over 80 million on the rolls and that its peak over 90 million now, if you want to talk about dollars in Medicare is much bigger because the a tour of us have more health problems, Medicaid covers a lot of relatively young patients that our health and so the cost per patient per month.

There's only a fraction of what it is and Medicare, but it's still a huge amount.

If you take a look at what the U.S. has set up, the federal government pays at least half of the costs of Medicaid.

Also at that.

So this is a payment where the government federal government is paying into the states.

They both have a contribution there.

>> Correct.

Okay.

And it comes down to it's based on a ratio of per capita average income of the state against the U.S. National average and those states that our well fear, shall we call it.

They only get 50% of the cost of the Medicaid covered the states who have ridge per capita income is less than the average they get Trying to help spread the wealth, so to speak now for.

what that comes down to is a federal financial participation rate.

Some people call it a federal medical assistance percentage for this next year is 71.4 8%.

Now that's the base rate that the federal government is supposed to pay of all the Medicaid costs.

Now.

It used to be that simple.

It's not that simple anymore.

And the chip program, the Children's Health Insurance Program, which came into effect couple decades ago, the ACA patients, when they see a passion for bulk area for care when some of those came on the federal government was paying 100% of that for the first couple of years.

And then it was going down too 80 to 90% and they're in the pandemic.

The federal government's pay at least 80%.

And for Kentucky, they were paying 90% so that now that the pandemic is over, they are stepping down the percentage that the U.S. is pay.

And as a result.

Kentucky's having to pay a little bit more.

>> But why would a state?

Not want to participate?

In Medicaid, especially one of the poorer states.

>> When Lou, the more needy of the states would be getting more.

>> To care for it says its.

>> In my opinion, there's absolutely no reason why you wouldn't do that.

Now if your legislators, a lot of them, I'm very concerned about the costs.

Yes, because in this state of Kentucky, you have to understand there's over one and a half million people on.

We're talking a 3rd of the population of Kentucky is on Medicaid.

That's a huge number to us.

And so if you take a look at the program, it is it's the largest part of the budget.

It is 29% of the budget.

And that seems like a huge amount.

And if you take a look at it, it's really 20 billion dollars a year.

Kentucky's only paying about 2.8 billion a year because of this federal participation so that they're only paying about 14% of the costs.

Right now we take a look at this pie chart that, you know, you said me because >> I'm trying to get my head around this.

So break this thing.

Doubtful OK, by the way, I like pies.

So thank you time.

So do I Medicaid is the single biggest part of the Kentucky but budget.

If you take a look, this is a pie chart straight out of the.

>> Kentucky budget.

The budget member of PHI 136 million dollars.

Billion dollars.

I'm sorry.

He's a two-year budget.

So the numbers I'm really going to talk really only year.

One year instead of 2 years says some sharp eyed people may pick up that there's a difference there.

But doesn't matter.

It's a huge amount.

It is the largest single part of the Kentucky budget.

But of that 20 billion dollars.

The state he's only paying 14% of it are 2.8 billion dollars so that they're getting a tremendous economic stimulus package.

And if you start to think about, well, that money that comes in not only the Kentucky spending, but the vast majority that the feds are spending.

There's also income tax revenues, their sales tax revenue.

And so if you start looking at it from an economic stimulus package in Kentucky's really paying only about one and a half billion at most for this benefit of 20 billion dollars.

So it is one of the best economic stimulus packages that you can get.

Just on the money before you start talking about better health care, access to care, getting taken.

Thanks.

Care of when they're simple and easy to take care of.

>> So help me to understand.

Why there seems to be such animosity.

Torres.

Extending the health care plan like this.

>> I think it comes down to money back.

A lot of things.

It comes down to money and 20 billion dollars and the legislators being shown pie charts.

Its 29% of our budget already.

And they're not given the rest of the story very easily that.

The more we spend, the more we make.

I hate to use that analogy.

You know, the more you spend, the more you say, well, that's kind of what's really going on here.

And a lot of the other states to cop that sooner than what Kentucky did.

But what we are.

More than willing.

>> To provide funding for a company to invest.

In our state.

In many states do that with the proviso that they're bringing in jobs, those jobs will pay taxes and will drive do that.

If I'm living in a rural area here in Kentucky.

And I have now improved the health care of people.

I'm probably helping that hospital bringing in health care jobs right?

>> You're helping everything because now you're going to have a more stable workforce because hopefully they're not going to have as many days off to the elements.

Sickness, you're helping the local physicians help take care of those patients.

That's money to the hospitals.

But one of the problems that we still have is that the physician fee schedule in Kentucky for Medicaid is woefully inadequate.

If you take a look and we talked last time about how poor the Medicare fee schedule was for position here.

At most.

They're paying 80% of Medicare.

And for the most common.

Office faces the things that really support the primary care is especially in the real Erin.

They're paying only 50 to 55% of Medicare rates and Medicare rates are not really sustainable.

And so now you're really trying to get people to operate the last scene.

And that is not sustainable.

Now you take a look at the rule areas, especially that is where you have a higher concentration of Medicare.

I'm sorry, Medicaid patients.

So it's no longer only one-third of your patient population, maybe half or even more.

And then with these very low rates, it becomes challenging to KET fear rural primary care offices open.

It becomes almost impossible to try to attract a primary care in private practice.

I have to be hired by the hospitals.

The hospitals are strapped for the same reasons.

And so it is you have a lot of healthcare issues, not just in the urban areas, but also especially in the rumors.

It's not just primary care, primary care is.

Incredibly important because they're directing the health care.

They have the primary relationship with the patient, but they're also the ones that identify and send people off to specialty care.

And you have to try to get the specialty care.

And I'm talking about obstetricians surgeons, people that really you've got to have the care there.

Nobody wants to drive 100 miles to go to deliver baby, have an operation.

So it is very important that we try to do things to increase the rates so that we do have the care available for the people.

So Medicare fee schedule said federal government.

Yes.

What about Medicaid is that set them by the state?

So that also set by the fence that's set by the States.

>> K so.

How much?

Of that pie chart that you showed me that 29% and then you broke it down to save Inslee.

It's only about a 5%.

How much of that includes physicians, fees and what happens if you brought it up to paint positions, Medicare rates.

I don't have the figure to break it down to how much is physician fee?

>> It's small.

Piece of that is really going to the hospitals.

Drug costs because Medicaid has.

Top not only with the equivalent of the Indy under Medicare, Get your prescription drugs that year, inpatient.

And it's year.

Our patient and physician fee, it's everything.

And so you and what they do offer that is not covered under Medicare is a lot of transportation.

So the transportation to and from dialysis it is the transport that is also becoming more and more expensive as we have more and more ill patients are so if you take a look and what it would take to increase the fee schedule to Medicare.

We're talking about a fraction of one percent.

Of the budget and Kentucky for the past 3 years has had over billion dollar surplus every year and the projected to continue because of the Medicaid changes that we've instituted >> they fed the surplus because costs down across the board and everything.

>> What is the total you mentioned about having to drive 100 miles for a petition?

This is so are we seeing a negative?

Manpower?

Here in Kentucky because of payment in certain areas or in the state itself because of these things.

>> We've we're seeing a dearth of physician availability in all specialties, basically across the whole state, but especially in primary care.

And when you get to the rural areas, it is absolutely critical and because cause physicians retire and we eventually die off.

Nobody's coming in to replace such or so.

And that's one of the major problems obstruct obstetrical care has been an issue and may become more of an issue.

Do the other factors?

My perception and looking at the numbers.

>> That as we instituted expanded Medicaid that we started seeing a healthier populous emergency room visits down.

And people were better.

Has that been a reality?

I believe so.

>> I can't, quote, exactly caused the emergency room visits.

But if they don't have a primary care that they can call and going and see for a variety of the health care issues.

Then the blood pressure gets out of control and they have an emergency that that show up in the air.

I have to go to the ER for a sore throat.

That's that's crazy.

But it's a reality that that's what this had to happen.

As you increase Medicaid, given the rates have been poor, they do have more access because now they have some coverage and as they're able to get into some doctors, they're able to take the pressure off the emergency rooms that helps lower our overall health care costs.

You have a better, healthier population.

You can get parents to get their kids into C the doctor on a regular basis rather than waiting for a problem.

And that helps the creature absenteeism at your employers as well.

>> As we saw with Medicare.

Their advantage program.

So there you see the same thing with Medicaid or are there medicate advantage for us?

Kentucky has basically forced a whole the Medicaid population into managed care.

And you can think of it sort of as the Medicare advantage.

The program, whatever company has the contract is now managing all of that care.

There's still a small number of people that are on a traditional Medicaid.

The are institutionalized that will never come out there.

I want to say warehouse, but they're never going anywhere.

Those people are still on a traditional Medicaid and it's a very small percentage of the.

Managed care.

You basically don't have a lot of options now and they're different options and different parts of the state.

Now they are covering all of your needs and they sometimes have slightly different policies and sometimes they from a provider standpoint.

A pain to deal with because they will die.

Thanks tonight, things tonight things and you have to go through the appeal process which heats up your time and resources.

For a very poor paying the schedule.

And so some physicians.

Have stopped taking Medicaid.

That's a real problem.

Got.

Something that Medicaid and Medicare.

There what's called the dual eligible.

Other words, if you are more maternal, that is over 65.

And and you signed up for Medicare and you have low income.

You meet the criteria for Medicaid.

The new year dual eligible, you have Medicare and you have Medicaid.

Medicaid now picks up the 20% of a traditional Medicare that you normally would need to go get a supplement for medicap policy here.

Medicaid covers that.

Active of a provider.

What that means is you get a Medicare payment and Medicaid doesn't pay.

You heard anything, if anything at all.

Because they're paying 80% of Medicare.

Well, you've already been paid.

>> Where are we with this and nursing homes, nursing home care, covered by Medicare.

Or do you have to get into this thing called the spend and that's a good point.

>> Medicare by and large does not cover nursing homes.

>> Now you may be.

>> Seeing some areas where the nursing home has a skilled nursing facility.

Yes, so you're in the same building.

Same facility.

>> But you're getting skilled nursing facility cause you're getting some rehab and other things for short term that may be covered by Medicare, but long term.

Nursing home is not covered by Medicare, Medicaid can cover again for the indigent population and you get into these strange things where every state's a little different, but there's limits on how much assets you can have, how much income you can have to get and Medicaid payment for the nursing home.

And so the spend down programs are okay.

We will cover.

We will start covering the nursing home costs at a certain point after you've spent has set down and this has led to a industry, if you will, of lawyers doing a state planning to move in massage assets out of the fly out of the estate.

So that they now qualify and not have to sell the home or whatever to get them into Medicaid, nursing home.

Now, Medicaid, nursing racism are not nearly what the traditional.

Pay as you go.

People.

In other words, if you can afford a nursing home on your own, they will take you over Medicaid.

So the most nursing homes only have a few Medicaid beds available.

I want Cesar fall.

They don't want to take him because like everything else, they complained that the rates that they're being paid her much less.

Yeah.

And it is.

Not very good.

And so sometimes you have nursing homes that refused to take Medicaid and they offer.

Nicer services because they're getting more money and more revenue.

Instinct intricate >> do you anticipate seeing any changes in the way Medicaid is covered coming forward, Megan, we just had an election.

We don't know who's going to what cracked, but >> we don't.

The interesting things are the one there's always financial pressure because we now have these huge progress talking about 90 80 million people on Medicaid, 6, 5 million Medicare and these costs are going up.

Never mind the fact that the feds have put a lot of rules and regulations and there and what they've done is driving those costs.

Add up.

But there's going to be pressured to change that.

As the new heads of HHS come in to us, he's may try to make more focus on prevention, but he's going to have to be legislative action before that they can actually do things because of what's regionally written into the law that establish Medicare and Medicaid.

So it's it's hard to say what's going to really happen.

Will there be changes?

There always are changes and they're they're trying to limit the cost and yet the liver, the good they put on the spot this.

>> Overall what you say connect this has been a good thing or bad thing for the Commonwealth of Kentucky.

>> I would say it's been a very good thing.

Want to get established because you're covering patients so that they can get the care that they need to make them a healthier workforce.

A healthier population and getting them on the Medicaid rolls that they couldn't get on otherwise is dragging a lot of money into the state that would not otherwise be coming in and it becomes an economic engine.

So there's no question in my mind.

It's been a wonderful thing.

>> It's kind of funny to hear you say in just one of the things that was reported was that this is gonna kill jobs and yet keeps you alive.

Keeps is working.

Correct?

And I think a lot of it comes down to people just looking at the sheer.

>> Number.

Yeah, 20 billion dollars.

That's a big number.

29 1% of the times that number.

>> Kevin, back to Martin.

Thank you very much for being with us and discussing this most interesting topic with get you back again.

I like to thank you for being with us today.

Expanded Medicaid is shown benefit here in Kentucky just as there is no free lunch when it comes to providers, hospitals and patients.

Some groups have the right more benefit than others.

That said here in Kentucky, we have seen improvement in health status since the implementation of the expanded Medicaid covers.

There are many services available in since Medicaid is the state-federal program.

If you are in Kentuckyian you have questions encourage you to reach out to the Cabinet, the health and family services.

If you want to watch the show again, watch our coverage is please go online.

Look at Celtic 18 dot org or slash health.

If you have questions or comments, we can be reached that Kyi health at KET Look forward to seeing you again next time on Kentucky health and take care of something.

♪ >> Kentucky Health is funded in part by a grant from the foundation for a healthy Kentucky.

♪ ♪ ♪ ♪