Kentucky.

Tonight I'm Renee Shaw and we thank you so much for joining us this evening.

Tonight we're discussing reforming Kentucky's Medicaid program.

Proponents for transforming the program say the Medicaid budget has more than doubled over the last five years without a significant turnaround in health outcomes of the program's enrollees.

House Bill two implements new federal community engagement or work requirements for certain low income beneficiaries, imposes co-pays and tighter eligibility redeterminations, which some of which causes concern for many health care access advocates.

So here with us tonight in Lexington to tease out this complicated issue are state Senator Stephen Meredith, a Leitchfield Republican chair of the Senate Health Services Committee and member of the Medicaid Oversight and Advisory Board.

Emily Beauregard, executive director for Kentucky Voices for health and State representative.

Ken Fleming, a Louisville Republican and co-chair of the Medicaid Oversight and Advisory Board.

Joining us from our Louisville studio is state Senator Karen Berg, a Louisville Democrat physician and member of the Senate Health Services Committee and Medicaid Oversight and Advisory Board.

We certainly want to hear from you tonight.

You can send your questions and comments by X, formerly Twitter, at Pub Affairs KET, or send an email to KY Tonight at KET dot o r g, or use the web form at KET dot Johnny Nash KY tonight.

Or you can simply give us a call at one 800 494 7605.

Well, welcome to all of our guests here in the studio and Senator Burke there in Louisville.

We're so glad to have you talking about this very important issue.

House Bill two.

But before we talk about the issue itself, I just want to give our audience some perspective on what Medicaid looks like now.

And I'll go to you first, Miss Emily Beauregard, about the folks.

How many Kentuckians are on Medicaid, both expanded population and why we say expanded versus traditional and the services that they're receiving.

And what would happen if there's some reform of the system, as we currently have before us now?

>> So Medicaid has really become the cornerstone of our health care system in so many ways, not only because it covers 1 in 3 Kentuckians at any given time, but also because it's an economic driver.

It covers many of the services that we all rely on here in Kentucky, keeping our hospital doors open.

And it makes sure that we have a safety net for those moments when we least expect that we're going to need it.

Accidents, injuries, tornadoes, flooding, those things that just pull the rug out from under your feet and leave you without the basics.

So Medicaid is there when we need it most.

At any given moment in someone's life.

It's covering people cradle to grave.

It's not a static number one and three Kentuckians use Medicaid at different points in their life.

So about half of the babies born in Kentucky are born covered with Medicaid.

Three and seven people with disabilities have Medicaid coverage, and about 70% of our loved ones in nursing homes are covered by Medicaid.

So when we say cradle to grave, we don't mean that someone has Medicaid coverage for their entire lives.

If you do, but it's that it's there for us when we need it.

>> But of those 1 in 3.

So you're saying it's not always the same people, but it's a hefty portion of the population?

>> That's right.

We have a lot of low wage workers in Kentucky and Medicaid.

Is there providing coverage that their employers aren't and helping them to stay healthy enough to work?

>> So I want to go to this side, representative Fleming, the value of Medicaid and the reform effort that you're putting forward in House Bill two, is it to cut people off of a public service that you think perhaps they may have abused, or what is the overall goal of House Bill two?

>> Well, first of all, thank you very much for having us here.

This is a really very important issue we've got to address when it comes to Medicaid.

You have to think of Medicaid.

This the state is in the business of insurance company.

We are insurance company.

And so we need to take care of those folks, those individuals on the on the program.

And what we're trying to do is to know we're not trying to cut any cut anybody off.

We're trying to to maximize the services that are delivered to those who are least among us.

And to do that, we need to look at an internal internally and what we're trying to accomplish, what we're trying to do.

And there's a lot of challenges we have from the from the program itself when it comes to oversight, oversight, and making sure the program is delivered effectively and efficiently.

And as you mentioned earlier, the cost is doubled.

We know some of the reasons why.

That's why this Medicaid board was was established last year in order to take a very deep dive approach, in order to make sure that the services that we have is being delivered in an efficient and effective way to help those least among us.

And yes, there are many folks that do not have any income or they have very low income.

And so we need to make sure that as our quote unquote, customer, but our, our citizens, they're our next door neighbors that we need to take care of and help them out to make sure that their health is maintained and the quality of services is delivered in the best way possible.

>> But you have said in meetings and public hearings about this particular issue that and I even said it in the introduction about how the amount of money that's being invested into this program, the return in terms of health outcomes and improvement thereof, there's not very much evidence of that.

You still stand by that?

>> I do.

When you look at where we are in ratings, well, we have not moved hardly at all in terms of overall ratings over the past 15 years.

So the state has has opted we can do it internally or we can basically have another organization or organization to do that.

That's the managed care organizations.

And so we have put a lot of money into that process, and we have not seen the returns that we need to we need to achieve.

That's why on House Bill two takes a really serious look at transparency, to look at some dashboard, to look at MCO contracts, you know, to look at other items in there to make sure that what are what are we doing?

How are we going about doing this?

And then basically make some changes in order to, you know, to help folks out.

>> So Senator Berg and Louisville want to come to you now to get your overall view about House Bill two, that is in the possession of the Senate at this particular juncture.

There's not been a hearing there yet, but we know we anticipate that to be coming.

What are your overall thoughts based on what you understand about this measure?

>> You know, overall, excuse me, House Bill two is is actually really a fairly aggressive attempt to.

Hart.

I don't want to say controlling to start impacting the number of people eligible for Medicaid in our state and how services are, how people will be able to stay in the program, what type of services they will be eligible for.

And, you know, it's really.

You can you can applaud Senator or Representative Fleming for really trying to take a big, big bite out of a very, very difficult problem.

Unfortunately, it's it's too much too soon.

And we need, I think, here in Kentucky to take two steps back, find out what we have to do according to the one big, beautiful bill at this point, what we need to do down the road, but we need to make sure that we maintain eligibility for people and that we do not have co-pays and community engagement requirements that basically keep people from accessing health care, because that's contrary to the purpose of Medicaid.

>> And so just to clarify, because of the one big, beautiful bill, the HR one, the federal act that was passed by Congress, doesn't Kentucky have to comply with the work requirement and community engagement requirements.

>> Yeah.

You know, the one big, beautiful bill is, is a very large, very comprehensive piece of legislation that honestly, ideally should have been broken down into multiple smaller pieces and done with a little more attention to the impact of these requirements.

What we've decided to do in Kentucky or what what HB two at this point does, I'm not sure that we're going to decide to do this by the end of the session.

It it speeds up the requirements here in the state and actually goes way beyond a lot of what.

House Bill one or the big, beautiful bill actually requires of us.

So, for example, we are going to be instituting what some people want to call cost sharing, what other people want to call co-pays 21 months earlier than the federal government is going to require us to do that instead of meeting community engagement requirements within a three month period, we've decided, you know, you have to do it within a month, which is not feasible because people don't even know when they're going to get injured or sick.

So you can't predict those dates.

We're talking about a bill at this point, guys, that the estimates are it is going to cost us $141 million just to institute the changes that this bill is going to require us as a state to do.

And, you know, most of this money comes from the federal government.

The vast majority of Medicaid money is not state money, it's federal money.

But still, we're talking about almost $40 million in state money alone, just to start trying to institute the requirements of this bill when we don't even know that the federal government is going to continue these requirements.

There is a lot of discussion that these parts of the bill are not going to achieve their goals and need to be readdressed.

And when I say going to achieve their goals, when you talk about a $20 co-pay for somebody talking about a family of three with $27,000 annual income and a $20 co-pay every time, every time you need to see a specialist.

So for people in cancer treatment, for people in dialysis, you're you're talking about a large percentage of an income that is not adequate already to feed and house.

>> So yeah, yeah, yeah.

Well, I'm going to come back to you because I want to get our audience up.

Yeah.

There's a lot to dissect here.

And before we kind of break down some of these provisions one by one, Chairman Meredith, I do want to come to you and ask you about your overall opinion about if Medicaid needs to be reformed.

And is this the right direction, or do you agree with your Democratic counterpart that it goes too far, too fast?

>> Well, we certainly need to address the issue with Medicaid.

And I think H.R.

one either gets too much credit or too much blame for the transformation we're seeing right now, because even if that bill had not been passed, I'm confident we would be doing similar things.

Now that we're trying to accomplish.

As is noted earlier, when I came to the Senate in 2017, our Medicaid budget was $10 billion.

And I said then it's as large as it ever should be.

If we're improving the health of the population, if we're getting people back to gainful employment and reducing the bureaucracy, there's enough money there.

Roll it forward nine years.

Now we're at $20 billion, and it's just not Medicaid.

Medicaid is kind of a microcosm of the health care delivery system.

In total.

It can't sustain itself.

It's now 20% of our state budget, and we're shifting funds away from other needed services, trying to meet the needs of the people.

We're not getting the results that we need.

So again, H.R.

one, we had to make some federal mandates, but I don't think that's going to make the substantive changes to the program that are needed to let Medicaid survive.

>> So let's break this down a little bit, chairman Fleming, about what's in the bill.

Right.

And let's talk about the cost sharing or co-pays.

It's $20 for each visit.

>> Well, let's, let's, let's put things in a, in a more of a perspective.

First of all, the bill has been broken into two components.

One is a is address that what's coming down the feds on H11 in terms of adjusting that.

The other one is program interrogate integrity.

So we need to go through and look at those two items in a very expeditious but thorough way.

Now, when it was mentioned by, you know, the Senator Berg about the $20 and you just mentioned, that doesn't take effect until October 1st of 2028, we've got several a lot of time to go through and digest this, get more information, get a get an understanding of the data in terms of what's the impact and towards what that is.

So right now, you know, it's a proposed at $20, but that's not gonna happen until October 1st of 2028.

Now, when you look at the copays, there's only two items in the copays.

One is $35 for in hospital services.

The other one is $8 for individuals that are visiting emergency rooms for non-emergency services.

So when you break that down, we're trying to change the mindset to get people to go see their primary care physician, because going that path, there is no co-pay.

And so we're trying to trying to change that.

So when you look at the cost of that right there, that's around $90 million.

We're trying we're we're looking at and trying to adjust address.

>> So you're saying instead of folks using the emergency room for non-emergency issues, that you want them to establish a medical home by which they're seeing on a regular basis, a primary care general physician, right?

>> Because because of the, the er doctors are they've got, they've got to handle a lot of things that are coming through the room.

And so I would hate to see them see individuals sit there for hours on end where they can go and see a primary care physician.

So that's, that's what we want to get to more of a holistic approach to really take care of the of the individual and try to figure out what their issue is.

>> Okay, so let's put a pin there.

Miss Bogut, what do you think of that?

Well.

>> I agree completely that we want everyone to have a medical home.

And primary care is essential.

It really should be foundational to our health care system.

And we don't have nearly enough right now.

And so when I think about how we incentivize people to get the right care at the right place at the right time and primary care before emergency care, we have to make that access easier for people.

It has to be easier to go to your primary care doctor than to go to the E.R.

And right now, it's faster for most people to get into the E.R.

that's not the way our health care system should work.

So that's one reason that I think we need to be careful about these copays, because while I appreciate the incentive to go to primary care, and I think the big, beautiful bill got that right, making sure to exempt primary care and behavioral health services was a good decision.

What the big, beautiful bill didn't do is exempt people based on their health status.

And so I think to Senator Berg's point a little bit earlier, someone who needs specialty care for really serious health conditions like cancer, for something like dialysis, they'll be paying copays for every service that they need.

And that adds up very quickly.

Now it is capped at 5% of your annual income.

But for a family of four making $33,000 a year, that adds up to $1,650.

And if people don't have that money at the point of service, they can be turned away.

There are a lot of good providers out there who don't want to turn their patients away, but for $20 over and over and over again, they're going to be faced with a tough decision because a lot of our providers, hospitals especially, are going to see reduced reimbursements because of the big, beautiful bill.

And I think that they're going to be in a hard position to take on more of that uncompensated care.

>> Renee let me respond to that.

I was a I was a provider.

I ran a mental health center, and we took on the responsibility that we could waive that so providers can waive those, those co-pays, in addition to the Mcos can also waive that.

You can set.

>> Up what's the likelihood that many providers would do that.

>> With the likelihood.

You know, what I've I've talked to several that they're willing to do that.

So, you know, so we're there to serve the individual and making sure that they're they get, you know, they're getting the service and or to do that.

In addition to that, the, there are provisions that will provide the Secretary to waive those in case there are hardships and so forth, so they can go through and have those those those waived.

>> So but there is a process by which they'd have to almost appeal that.

Right.

And how long would that take for and how long would that delay their their contact of care?

>> Well, nobody's going to go to those extremes.

I'm going to tell you quite candidly, particularly in the rural health care environment, copay equals no pay.

And when we talk about it's great to go to your primary care physician.

Super.

Where are they in rural Kentucky, where we have 41% population, only 17% of our primary care physicians are there.

And what drives them to E.R.

more than anything, is a lack of primary care physicians.

6,070% of visits are primary care because of lack of access to primary care physicians.

So this burden and I understand we have to do with the federal government.

This burden is going to fall proportionately against rural health care providers who can stand the cuts the least.

As you know, they already have their back up against the wall with projections.

As many as 50% of our rural hospitals could close as a result of some of these changes.

So that's not going to address that situation at all.

I understand we have to comply, but I think we have to make it as minimal as we possibly can.

>> Senator Berg, I think you wanted to jump in here.

>> Well, just real quickly, I wanted to point out that in 2021, we passed a bill, Senate Bill 55, that eliminated cost sharing in the Medicaid program specifically because it wasn't cost effective.

By the time you try to collect these co-pays, you spend more money trying to collect them than you actually end up collecting.

So doctors lose, you know, the $20, they just lose that.

So for them, it's just another decrease in reimbursements and patients lose access because if they don't have the money, they don't feel like they can go.

Now.

Yes, there are nice doctors out there.

They will waive these co-pays.

There are clinics that will see people without any money, but that is the exception.

That is not the rule.

And when we're talking about a program, guys, 50% of the children in this state are covered by Medicaid.

70% of our nursing home residents are covered by Medicaid.

We have to have really rules that are going to actually work that we can we can put into place, and that will move the system in a positive financial way, not spending tons of time and tons of money trying to comply with regulations that aren't necessary and aren't needed at this point.

>> So I do want to get a point of clarification.

>> Needs.

>> Yeah, let me if you don't mind.

Senator Berg, I just want to really quick clarify.

When we talk about half of the kids and most of the residents in nursing homes, Representative Fleming, would this measure apply to them?

>> No.

And there's there's quite a few exemptions that that that apply.

Like kids don't, children don't get get charged.

The, the medically frail.

Pregnant women, pregnant women, people that are in behavioral, you know, substance abuse.

So there is a quite a few different exemptions that that is included in that.

So we're looking at a very small segment of society that might, may or may not get charged.

And once again, there's, there's some provisions in there to provide individuals to for those things to be waived.

>> So that's right.

These Medicaid copays are for a subset of the population, Medicaid expansion members, making between 100 and 138% of the federal poverty level.

The cabinet for Health and Family Services estimates that that's about 377,000 Kentuckians.

So not a small number.

And of course, many of those are families.

Those are parents, caregivers, people who live with someone who has traditional Medicaid, a child, maybe they're caring for an adult with a waiver.

So it still takes away from the household income and what they're able to spend for rent, for utilities, for other basic needs.

So I do think we need to consider that as an indirect impact of these copays.

But something else that I wanted to mention, the big beautiful bill has these different requirements, right?

Primarily for the Medicaid expansion population.

One is community engagement or work reporting requirements that has exemptions based on your health status.

So for somebody with a substance use disorder or a serious mental illness for a condition like cancer, you're probably going to be able to get an exemption from having to report your community engagement hours.

That doesn't apply to copays.

And I think that's where there's some confusion because unfortunately, the big, beautiful bill just didn't make a consideration for that.

And the the one thing that I think we should be thinking about, and maybe for our policymakers who have relationships with Washington, with our leaders at CMS, is what is the the final rules?

What are the final rules going to look like?

What is that federal guidance going to be?

Will it allow us some State flexibility that we don't we're not aware of right now?

Maybe if we gave it some time and waited until the next legislative session, which I think we could do because like Representative Fleming said, we don't have to comply with this until October of 2028.

Then we would have time to look at whether we could create some exemptions for people based on their health conditions.

And then one other thing I wanted to mention about the big beautiful Bill.

It actually has a very wide range that states are allowed to charge for copays.

So yes, Kentucky is required to charge something, but it can be anywhere from a penny, which is a little bit of a joke at this point because we know it's no longer in circulation, but it could certainly be a dollar up to $35.

That's a that's a big difference for somebody who's on a fixed income.

And that's a big difference for a provider who may end up not being able to collect that co-pay.

So, you know, $20 over and over, you're going to see a huge impact.

That's going to mean rationing care.

That's going to mean providers having to make that decision about whether they eat that cost or turn someone away.

You charge people a dollar and you're really reducing that barrier.

>> So how did you settle on 20?

Representative Fleming.

>> That was settled on looking at individuals who come in and apply for.

We had a scholarship in our in our in the agency that I'm involved with, and we came up with $20 based on what we look at on bank statements and how they spend their money, have been looking at this for about ten years and capable of $20.

There seem to be.

That was pretty much of a balance.

In order to do that.

Now, I'll be the first to admit, and I know the chairman, I you know, sometimes we agree, most times sometimes we disagree.

But that's okay.

I respect him highly.

You know, once again, this this is not stuck in stone because we're not we're not there.

It's not October 1st of 2028.

So I want to try to get some information in order to see exactly what is that number?

Is it $1 or is it $10 or whatever it is?

We do have to charge something because to put.

>> It in statute that it's 20, you'd have to go back and amend this particular if this passes.

Right.

So why why not wait until that data informs what the number should be.

>> Change statutes all the time?

All the time.

>> Well, there was a question then.

I want to go to Senator Burr because I know she wants to weigh in here.

A question from a viewer named Adam that asked, do the new community engagement requirements apply to all Medicaid recipients, regardless of age or disability?

And you mentioned that phrase, the expansion group.

And so for those folks who don't know what is Medicaid expansion from the Affordable Care Act enacted in 2010, of course, Medicaid expansion came under then Governor Steve Beshear for adults that were, what, 138% of the Medicaid poverty level.

So that's known as the expansion population.

But I want to go to you before I go to Senator Berg.

Senator, I want to ask you about the copays.

And you kind of talked about this, how this could really possibly hurt rural providers and maybe even hasten the closure of rural hospitals.

Although we heard debate in your Senate Chamber that that's kind of alarmist thinking that rural hospitals are on the verge of shutting down.

Straighten that out for us.

>> Well, the threat is real.

And when you look at the co-pay, it's just not the co-pay itself.

There's administrative costs associated with that.

And really a $20 co-pay when you add in administrative costs, really the cost of the provider is more like $40 because they had to make some attempt to try to collect it.

And this is going to make the decision to write that off.

But any additional money that's taken away from rural providers, it's just going to hasten their demise.

It's that critical right now.

And the real sad part about this is are we trying to comply with federal regulations, or are we trying to fundamentally change the Medicaid program, which we need to do?

And this will not fundamentally change the program.

It doesn't address the drivers of health care costs to begin with.

It's not that people are over utilizing, it's that we have too much bureaucracy.

We have not improved the health of the population, and we haven't got people back to gainful employment.

If we can do those three things in combination, we can save the Medicaid program and reduce health care expenditures dramatically in Kentucky.

And I would hope to be a model for the nation that we can reduce health care costs at least 20, 30%.

>> Senator Berg.

>> Senator Meredith and I actually agree on this.

If we if we approach this with a smarter way of looking at health care utilization, you know, one of the things that this bill is supposed to end up doing is dis enrolling about 20,000 people in the state for Medicaid, making them no longer eligible.

And it's not really that they won't be eligible.

It's that they won't have been able to jump through the hoops to prove that they are eligible.

And this bill requires us, you know, that they disenroll you and then you have to reapply.

So even if you did meet eligibility, you're still not going to be eligible.

And that's that's the real problem.

The problem with Medicaid is not that we have people seeing doctors, people seeing health care professionals is actually what we want because in the long term that is more cost effective.

If you can keep somebody on blood pressure medicine before their kidneys and before their multiple strokes, you can actually improve both the quality of their life and decrease the cost of caring for that person over the long term.

So trying to get people not to have health care is, is, is the exact opposite of what you really want to do.

What you want to do is you want people to have access to good quality, cost effective health care.

And, you know, part of that is the social determinants of health, housing, education, food.

Part of that is, is your social network of providers, which right now in this state is very, very weak.

We do not have enough health care providers.

So it's a complicated process of you have to pay providers or you're not going to have them.

You want patients to get health care, but then the whole thing ends up costing a lot of money.

And part of the reason that we've had such an expansion of costs in, in this world recently is it's multifaceted, but but one is we started covering mental health care.

We want covering mental health care.

So just the fact that we now cover this type of care, of course, increased our costs, you know, significantly.

We also honestly, in this.

State.

War.

War allowing people to bill for some services at a rate that was really unacceptable.

And I think we're going to fix that this session.

That's supposed to save us $300 million.

Just fixing one CPT code in this state.

There's a lot of things that we can do, but taking a sledgehammer to the system and just saying, now the legislature is in charge, we are going to do this, this, this and this.

We expect you to do this, this, this and this.

Even though people are telling us it's going to cost $141 million, just institute the changes in this bill guys you got to take a step back.

>> You got.

>> To.

Look at the system as a whole.

You have to have people who understand the system better.

Then we go.

>> From brought up the cost.

A couple a couple of components.

Let me let me give you a perspective.

The General Assembly, frankly, is concerned about the information that comes from the administration.

I'll give you an example.

It was it was it was first announced that 200,000 people were going to be disenrolled for eligibility and work requirements.

Then it went down to 70 from the from the technical Medicaid technical.

Then it went down to 32,000.

Then it went down to 28,000.

So we don't know what the we don't understand what's going on in terms of how they're going in analyzing the data information.

You're looking at a spread of 400 million to $2.8 billion in order to do that.

And apparently, there's not a really good understanding of that.

In addition to that, when we got the the budget requests from the agency, it was $37 million in order to look at or 35, $35 million to look at technical changes.

Well, two contractors that's on the list from the CMS said, well, you know, we can help you out from a technology software around $2 million.

So why are we going through with $37 million in order?

We can use the current contractors for $2 million.

In addition to that, we have not heard anything, not one iota, when it comes to community engagement and what they're trying to do, but yet there's $35 million to, to look at, quote unquote, we need to assess the situation.

Well, we've been doing this since, you know, July of the bill came in July of last year.

Where, where's the where's the communication?

What are we trying to do?

We just want to get some answers and try to work with the administration in order to help solve this so we can get a good cost analysis assessment.

So we can go through and do some budgeting of that.

>> You know, I think Representative Fleming makes a really good point.

The numbers have, you know, how many people may be Disenrolled have really bounced around and there's a lot of uncertainty and for good reason, because these policies are only as good as they're implemented.

And some states are going to do a better job of helping people understand what the requirements are, helping people to complete the new reporting requirements and not fall through the cracks.

Other states are going to really struggle with that, and I think Kentucky will struggle if we don't have a good system, a good IT system with connect, our integrated eligibility system in place that really makes this seamless.

And we're going to struggle if we don't have more State caseworkers to do these additional reporting requirements and redeterminations just all of the work that goes along with that.

But I think that our state has every intention of doing it right.

And that's and on both sides, both from the legislative branch to the executive branch, I think everyone wants to get this right as far as making sure that people who are eligible for Medicaid don't lose it.

It is a real balancing act.

And some of those early estimates, whenever the bill, the big, beautiful bill was still being debated in Congress, those came from the Congressional Budget Office.

Those came from some of the national groups like Kaiser Family Foundation, you know, as Kentucky.

And our Department for Medicaid Services is drilling down and really looking into, you know, who are our Medicaid members right now.

Here are some things that we know.

We know that the majority are working, or they're in a household where at least one individual is working.

96% of Kentuckians should already be satisfying the community engagement requirements, but some will do that automatically because they have income data that, you know, can be accessed automatically by the state.

Others are going to have to report, and that's where people fall through the cracks.

The other reason that people will be satisfying this is because their caregivers, they're in school, they have a disability or some other illness that will exempt them.

And another 2% of Kentuckians are actively looking for work.

We only have 2% of Kentuckians with Medicaid coverage who fall into that category of Medicaid expansion, who we're not sure why they're not working.

So that's where we should really be focusing our time.

And I think we'd be better spending our dollars if we were providing more employment training opportunities to these individuals, because Medicaid, at the end of the day, is a work support, having good health coverage, being able to go see the doctor, get your preventive care, you know, take care of any chronic conditions that you may have is actually going to make you more employable, more productive at work, and people have an easier time getting better paying jobs and really climbing the economic ladder.

So we need to think about Medicaid as one of the tools that helps us with our workforce and build on that.

>> Well, that kind of satisfies this question from Deborah and Jefferson County, who asks, is there a process to determine who really needs Medicare or Medicaid?

Excuse me, will there be consideration of new rules to ensure people who actually need it have it?

Very basic question there.

Representative Fleming.

>> Well, I guess part of the my thoughts is like, you have to go through an eligibility to make sure that they are they, they meet the criteria that they are actually need the Medicaid services.

So there's, there's an eligibility process.

And then we basically, from a technology standpoint, we on the bill basically has that the information that's submitted is checked against a numerous number of data sources to make sure that that it's there and making sure that the person is saying, saying what the, you know, that, that, that they don't have any, whether it's low income or, or their, where their situation is, you know, part of what I, what I've seen, Renee.

And that is there is a several folks that have come to me that said that I've got 2 or 3 businesses and I just basically push all my expenses out to the business and I only claim $20,000.

I've heard that more than one time.

I hear individuals that actually see and watch Social Security of these, these items being, I guess, being above the minimums that that you need to that you need to, you know, be qualified.

So when it comes to those sorts of things, we're there is a system that will go through and try to validate and so forth.

Now, you know, if somebody found that they, they are not part, they, they, one of the, one of the data sources basically shows that, that they did not, you know, qualify or something shows up that that sort of puts them in and say, oh, you may not qualify, then the administration, you know, can help them go through that process and go through the appeals process in order to do that.

>> But they don't have coverage in the meantime while they're going through that appeals process.

>> Well, if they're if.

Well, you've got two things going on.

You.

One, you have the redetermination.

So they will they will still be on there.

But if you're applying new.

Yeah.

I mean, right now you still you're still on Medicaid.

You still have to go through and get qualified.

>> So this person has a very specific question, and I hope, Mr.

Gill, that it can be answered for you from Jefferson County.

He asked, how many hours does Medicaid pay for in-home care for a quadriplegic patient for the 160 hours, 24 over seven care during the week?

Very specific.

I'm not sure if you all have information about that or if Senator Burr does.

We appreciate the question, but unfortunately, there's not someone here from centers for Medicaid Services to help answer that.

But perhaps you can get that answer for you and get back to you.

We appreciate the question.

A lot of questions about eligibility.

And there's so much more.

And I do want just for a moment, because during one of the hearings and I think it was the the House a n r committee, we heard from a woman named Maggie Chisolm, whose daughter had died, and she was on the list or waiting to receive a heart transplant.

And she shared some pretty emotional testimony a couple of weeks back.

And here's her story.

>> Evie was born on September 7th of 2016 with hypoplastic left heart syndrome.

Basically, only half of her heart was functional, and by the time she was four years old, she had already undergone three major open heart surgeries.

Evie was also on a Medicaid waiver for the majority of her life, due to her complex medical needs and compromised immune system.

Despite her extensive medical history.

I had to fight every year just to get her waiver renewed.

It was exhausting and time consuming, and the amount of paperwork required was overwhelming.

But I did it.

I did it because there was no room for inaction.

On August 26th of 2024, at seven years old, Evie was hospitalized for heart failure and placed on the heart transplant list.

In September of 2024.

While she was fighting to survive, I was notified that she was going to be removed from her Medicaid waiver because she was not, quote, utilizing services.

Let that sink in.

My child was dying, waiting for a heart that never came.

And I was told her coverage might be terminated because she was too sick to use it.

The very condition that qualified her for care was being used to justify taking it away.

In that moment, resting was not an option.

Waiting was not a luxury I could afford.

Advocacy was not a choice for me.

It was survival.

It was a battle I fought while being swallowed by fear and despair, because doing nothing would have meant losing everything.

I fought because my child's life depended on it.

In my family's case, Evie passed away on November 13th, 2024, before her coverage could be taken away from her.

And yet, to add insult to injury, 13 days later, on November 26th, just five days after I buried my daughter, I received a text message reminding me that her coverage would be canceled on December 1st.

I had to explain through my grief that she had already died and they could remove her from their lists.

Mine is not an isolated story.

There are countless stories of children, of parents, of individuals who do not have the privilege of waiting for systems to improve, people whose lives are measured in days and decisions, not fiscal years.

The system is already failing Kentucky families, and its most fundamental promise to protect those in need to protect our most vulnerable populations.

>> Miss Beauregard, your response?

>> Well, I've gotten to know Maggie.

She is such an amazing advocate, and there are many families who are advocating for their loved ones, you know, children, grown family members with Medicaid.

And and it is a lifeline for them.

And so we have hundreds of caseworkers at the cabinet for Health and Family Services processing this paperwork, all of these eligibility requirements.

We have 1.3 million Kentuckians who need this coverage.

And the process can feel callous until you walk in someone's shoes and really experience what Maggie just described with the paperwork.

It may seem like it's easy to get Medicaid coverage, but there's a lot that you have to document in terms of your income, in terms of your residency, in terms of your household size, to make sure your citizenship status, to make sure that you are approved for Medicaid coverage.

And when you have a waiver, there's even more that you have to document.

And so anything that increases that paperwork burden on families is something that we want to really take a close look at and make sure that it's absolutely essential, because otherwise we are just adding additional paperwork to something that's already kind of a fraught situation and can be really challenging for folks.

And the prospect of losing health insurance for someone who absolutely needs it to survive, or just to a person who wants that security.

We all do.

To know that when you get sick, you're not going to be in medical debt.

You know that that's something that really weighs on people.

I think there's a lot of anxiety around this paperwork.

And so when we look at some of the eligibility verification, the program integrity in the bill, that's where I think, again, we really have to find that balance because there are two sides to this coin.

Kentucky actually has a very low error rate.

It's less than 1%.

We are among the states.

>> And what do you mean by error rate.

>> So when you're looking at eligibility determination errors where you're essentially determining somebody eligible who is not eligible because they do audits.

So they look at that paperwork, they dig into it more.

And, you know, through those audits, CMS, the federal government determines an error rate.

Ours is 0.8%.

And that's very low.

That's great.

That means we're doing a good job.

We have a good system in place.

It can always be improved.

But generally speaking, I think that we're handling that pretty well.

The other side of that coin is, and this is not measured by the error rate.

How many people are we denying Medicaid who are actually eligible?

We need to be thinking about that when we make these decisions about paperwork, because for every additional measure you put in, you may be incorrectly, unfairly denying somebody their coverage.

>> Mr.

chairman, was that a consideration.

>> That we can talk about something that's a success, such as an error rate, but yet the health measures were seen on the bottom of the nation from any of those things.

We talked time and time again about the bureaucracy around health care, but we never address the fundamental problem.

We know that we're spending $0.30 of every health care dollar on the administration of the program, double y the industrialized nations are doing, but yet we don't take that leadership position to address that.

And we have to we have to come from a fundamental belief that there's enough money in the system already to take care of everyone.

We just spend it the right way and measure the right things.

And we're not doing that.

>> And I mean, a chairman.

Meredith, is that right?

And Emily brought up some some good points as well.

So when I first started talking about this, I come to realize if we're not a funding problem, it's a management problem.

And there are some there are some concerns about paperwork and trying not to burden some folks.

That's why I think coming from a, I guess an insurance insurance company perspective, even though I'm not an insurance taking a business approach to this to say, what can we do to be more creative, to cut the paperwork down, to serve our clients and the administration needs to do a whole lot more.

Now what the General Assembly has done with this House bill, we've looked at on the waiver program, we're looking at basically having a doctor assess at the very beginning to make sure that, okay, this person needs this information or this person needs these services.

In addition to that, we're going to have the administration go through and assess the acuity of that of that individual to make sure to do that.

So right now it's duplicated.

There's there's two processes going on, but not doing that.

And so we're trying to combine that, reduce the paperwork in order to provide a better understanding of, of that individual and what they need so we can deliver services.

So we are, we are looking at this from an operational standpoint.

>> You know, something else that House Bill two does, and I think it's Wright is more data checks that are automated built into the system, state and federal data sources.

There are more than a dozen that are used to determine eligibility or to check eligibility to verify.

And I think that's a good way of reducing the paperwork burden on the individual, the household, the family, and putting it in the hands of the caseworkers and using any data that we have at our disposal before we have to request something that the state probably already has access to.

Now, what concerns me about the bill is some language around, you know, what happens if there's inconsistent data, if there's a state or federal data source that flags, you know, something a little bit different than this other data source.

And there are lots of reasons why they could be inconsistent.

They're coming from different, you know, places, maybe different time periods.

But when that happens, it will trigger a redetermination period that could happen at any time throughout the year.

And someone could lose their coverage before they're given the opportunity to submit additional documentation to reconcile what that conflict might be.

And that, I think, is a relatively simple fix that we could make to just make sure that people always have the opportunity to reconcile something.

Now they may not be able to, and then they would lose their coverage, but people should at least have that chance.

>> Right?

>> Any my frustrations always been when we discuss data is we don't act on the data that we do have.

And we get to, I think micro and macro, it's great that somebody may have eligibility for coverage, but if they can't access health care provider, what good does that coverage do them?

And I think one of the biggest challenges we have going forward is building a strong primary case or primary care base across Kentucky.

If we're really going to improve the health of the population.

I think that's where the most significant savings come from by improving the health.

But if we don't address those health Health manpower shortage areas, we're not going to make any significant headway.

I don't care how much eligibility people have.

>> We're under MCO model Chairman Meredith has been advocating for several years to look at a different model in terms of providing care.

We're also in the bill, we're looking at dentists and we're looking at carving them out.

That will not only give them a little more understanding and control of how the process and the claims work from administrative services organization, that's what it's called.

But we're also we're taking a really serious look.

And I've talked to our at least a House A and R to look at reimbursement because right now, Dennis, it's dismal.

They're they're leaving in particular when it comes to.

Eastern.

Kentucky.

And so we've so that's a workforce issue as well.

So we need to do a whole lot more.

And I don't know if Chairman Meredith would want to comment on that, but but it's a different unique thing that we need to flush out to see.

Exactly.

Is this a is this a good alternative?

>> It's a foundational problem with Medicaid.

Managed care does not work.

It cannot work if we're going to focus on reducing the cost of health care, because the managed care organizations are not incentivized by spending less dollars, they're incentivized by spending more dollars.

That's why we haven't seen significant improvements.

And there's a better way to do this.

And we can't ignore those social determinants of health.

We say we don't have enough money to address those things.

Yes we do.

We have $20 billion Medicaid budget.

It's spending the dollars in the right place at the right time to get the best outcomes.

And we don't have a system that's focused on doing that.

So I'm proposing that we go with accountable care organization that's community based, owned by local communities, owned by providers, and put them at risk for managing the health of their population in whatever savings we achieve.

I think potentially there could be 20, 30% that stays within that community to help.

For those social determinants of health and build the infrastructure they need to be successful, like job creation.

>> One of the goals of your HB two House Bill two is to get at fraud, right, and encourage more transparency.

Well, this comment and question from Tyler Glick, and it's directed to Chairman Meredith, but I think Chairman Fleming, you can also chime in a recent story by Joe Zanca of the Louisville Public Media detailed the massive fraud allegedly perpetuated by addiction recovery care.

The Department of Medicaid Services did not heed warnings from Mcos about red flags.

The General Assembly actually took the side of AAC and attacked Mcos for making cuts to reimbursements to questionable providers.

Was this a systemic failure of both branches?

>> I think that's a fair indictment.

I think maybe on the legislative side, it's because we saw a problem, news of crisis, and we try to address it in the best manner that we knew how to at the time.

We're recognizing now that it's probably not the best situation.

We're still struggling with.

Substance abuse disorders, is the best model to use to get the most effective outcomes.

So that's ever evolving.

But at that time, I think that's the best thing we have available to us, the best tool we have at hand.

But obviously it was abused, not the first instance in the medical health care delivery system of that.

You can look at the pharmaceutical companies, the prices are charging for medications, and that's another major abuse.

That's the fleecing of America, such as Ozempic, which we have talked about.

It costs us almost $1,000 a dose to do that.

The manufacturer has decided they're going to reward us by reducing that the $250 per dose.

But ask the question in committee, why can't we get the same price as Australia, which is $100 a dose, and the cost of producing that drug is like $5.

You can charge $10 and get 100% profit on that.

So there's abuse throughout the system.

And I think maybe this is going to be a wake up call for America, that if we don't control health care delivery costs, it's going to collapse our economy quite literally.

>> Representative Fleming, I just I mean, I look at this as our budget at home or even when I was running a business Allen expenses usually usually have, you know, put a mark on there, 5 or 10% of a fluctuation in your expense item.

And so when you have a particular, I think Mr.

Glick was referring to one particular code.

And that was, I mean, a couple of years ago is around, I don't know, like 1.4, $1.5 million.

Then it skyrocketed up to like 15, $16 million.

And that was over a year and a half.

So where was the where was the control measures?

Where's where is the quality?

Where's the oversight?

Where is the leadership in order to, to do all that?

So that that that's happened in that particular situation, but it's happened in other, other areas within Medicaid.

>> Right.

Senator Berg, I'll give you about 30s.

>> Well, I just, you know, where's the leadership?

Where's the oversight?

It was the legislature legislator that made the decision in that case to cover this particular code.

And then, I mean, anybody could have told honestly, pretty early on that there was a big, big, big problem because all of a sudden, Kentucky had more recovery beds than any other state in the country, which means, guys, something's wrong.

That's what we need to be worrying about because that's where the fraud in Medicaid actually happens.

>> Yeah.

Senator Berg, thank you so much.

I hate to cut you off, but our time is is nigh and at the end, and I appreciate you so much for joining us from Louisville.

And I appreciate our panelists here in Lexington.

We'll have more coverage of the 2026 Kentucky General Assembly next week.

On Kentucky night, we'll talk about the budget.

Cross our fingers.

That will be on at 8:00, and then you can keep on track of what's happening in Frankfort each week.

Night at 630 eastern, 530 central on Kentucky edition.

I'll see you tomorrow night.

And thanks for being with us tonight.

[MUSIC] Talk to you soon.