>> Changes in Medicaid eligibility are afoot.

So what is the potential impact on the health of Kentuckians?

Stay with us as we talk about the impact of proposed Medicaid changes on safety net facilities.

[MUSIC] With Doctor Bart Irwin CEO of Portland Family Health Centers.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Medicaid is a joint federal state program that was created in 1965.

It provides free or low cost health coverage to millions of low income adults, children, pregnant women, elderly adults, and people with disabilities.

While Medicaid dollars are being reduced, that which remains must now cover even more services.

The issues facing Medicaid are varied and include changes in fiscal policy, the total number of available providers and those who are willing to accept Medicaid payment, changes in eligibility requirements and pressures exerted by an aging population.

Changes in Medicaid funding will have a direct effect on the poor.

But these changes will also have an indirect impact on all the rest of us.

To discuss the impact of proposed Medicaid changes on safety net facilities and all of us in Kentucky, we have as our guest, doctor Bart Irwin Doctor Irwin received his PhD in Social Work from the Kent School of Social Work at the University of Louisville.

He began work at the Family Health Center in 1992, and over the years has worked in numerous capacities, including for the past 15 years as chief administrative office.

In 2021, he was named the CEO and has done a great job since then.

Doctor Irwin Bath, thanks for being with us today.

>> Thanks for the invitation.

>> How does a guy get into this line of work?

I'm sure there's somebody out there say, I want to do what he does, but how did they do it?

>> Well, I came to Louisville, actually, to go to the Baptist seminary and decided that's not the path I wanted to take.

So I took a job in one of Louisville's first family shelters.

And pretty quickly, I realized that my Master of Divinity degree did not prepare me for that.

So I went to Kent School of Social Work and got a master's degree.

And it happened that eventually wound up at family health centers doing their health care for the homeless project as the coordinator of that project.

>> You know, it's kind of said nowadays that empathy is getting out of style, but it seems that you're an empathetic person.

Has that helped you with what you're doing?

>> I think so.

I think if you're empathetic, you're probably mission driven.

And Family Health Centers has a great mission, and I was am glad to be a part of it.

>> So what are family health centers?

>> Family health centers.

Which family health center is a particular name for a community health center, a federally qualified health center.

And there are 1500 organizations across the country that are federally qualified health centers, with about 17,000 locations of community health centers serve 30 million Americans each year.

Family Health Center does that.

In Jefferson County, there are three federally qualified health centers.

In Jefferson County, there's family health centers.

We serve about 40,000 patients.

Park Duvalle and Shawnee Christian Health Center.

And so we all try to work cooperatively to serve the persons of Jefferson County.

>> What does it mean to be federally qualified?

>> Federally qualified as a designation that we do receive some funding from the federal government, community Health Center dollars, and in return, we have to meet certain criteria.

And two of those criteria are we have to have a board of directors that are 51% patients at least.

And so you don't find that in many health care systems.

We also offer a sliding fee scale, which I'll talk about in a bit.

And there are other criteria like we have to meet certain clinical measure standards and so on.

So there's a lot to it being a federally qualified health center.

>> So let's go to that now because so patients who are being seen at your center are also paying for some of the services.

So tell me how that works and what other sources of funds other than the federal dollars.

>> Right.

That's correct.

We're not a free clinic.

We we at least ask patients to pay $25.

And how that works is if you come to family health centers and you're 100% of poverty, we ask you to pay $25 for your appointment.

And that would cov.

>> That covers lab work as well.

>> They're each more than the 25.

>> Doesn't cover their cost of care, for sure.

>> You take Medicaid.

We do.

Do you take Medicare also?

Yes.

What's the difference between the two?

>> Difference between Medicaid and about 50% of our patients are Medicaid patients 20,000 a year, and about 10% are Medicare.

Now, as you mentioned in the opening, Medicaid is a joint venture between the federal government and the state, and Medicare is a solely federal program that insures persons who are 65 or older or some persons who are disabled.

Medicaid is really based upon income and family size.

>> Okay.

Because it's a joint Medicaid, being a joint federal state, what's the breakdown about how much federal and how much estate?

>> Well, I say that that Medicaid for Kentucky is a great deal and an important deal as well.

Kentucky ranks fourth in regard to the amount of funds that the federal government provides for Medicaid services and for Kentucky, for every dollar that the federal every Medicaid dollar, the federal contribution is 79%, and the Kentucky contribution is 21% or 27%.

Yeah, that so we receive a lot more funding from the federal government to afford Medicaid than do a lot of states.

And that's because we are a poor state.

>> A couple of years back, we had the expanded Medicaid program.

What was that about?

>> Yeah.

Let me tell you a little bit about Medicaid, and then it'll help you understand what the expansion was about.

So if you are 100% of poverty, which means if you earn as an individual, 26, $26,000, roughly, you would be eligible for Medicaid 26 or below.

And if you were a family of four, if you earned 30, if your household income was 30, was $33,000 or less per year, which is about $90 a day.

Wow.

You would be eligible for Medicaid.

That's traditional Medicaid.

Okay.

In 2014, the federal government expanded Medicaid.

That's through the Affordable Care Act.

Or some people call it Obamacare.

So what does that mean?

So I'd mentioned that if you're 100% of poverty, you had to meet those certain income guidelines and family sizes to get the federal government allowed states, and not every state chose to do this, to expand that to 138% of poverty.

So if you're an individual, I believe the amount that would you could make would be $21,000 a year or below.

And if you're a family of four, if traditional Medicaid was 33,000, if you could make up to $44,000 and you would be eligible for Medicaid.

So it really expanded the opportunity for people in the state of Kentucky to have insurance through Medicaid.

>> That's huge.

>> It is huge.

And I'll tell you the effect that it had on our health center in 2014.

We were serving about the number of patients we served, now about 40,000 a year.

Yeah.

And 50% of our patients were uninsured, 50%.

We didn't know how we were going to survive.

>> Uninsured, uninsured.

So that was that person who would have to pay $25.

That's right.

Okay.

>> That's right.

And we would have to find some way to to afford their care.

So when the Affordable Care Act came into existence and the governor in Kentucky expanded it right away, our uninsured rate dropped down to 14% from 50% to 14%.

>> That's at your center.

Yes.

Okay.

>> Alone.

I have to say, it's crept back up.

It's about 25% now, but the Affordable Care Act has had a profound effect on community health centers.

>> So if you had a quarter of your patients or half not being able to pay, just out of curiosity, what would happen if somebody couldn't come up with $25?

>> Well, we asked them three times to pay us.

We do.

We use a soft collection agency.

They send out a notice saying, you owe Family Health Centers $25.

We do that three times and then we just write it off.

>> Okay, I was wondering, so if you had half your people only paying $25?

We talked about lab costs.

You have technicians, other staff people, nurse practitioners, physicians and other ancillary health or people, I mean, professionals working in your facility.

>> We have about 400 employees.

>> Okay.

So if you're running, I imagine, on a bare bones skeleton crew.

Well, I shouldn't say it that way.

You if you suddenly get an influx of people getting paying you for services, does that translate into you being able to provide more services because you can bring in more people?

>> Absolutely.

Yeah.

If our Medicaid rate went up to 75%, we could we could fix the air conditioning unit at the Portland facility.

We we could do a lot of infrastructure things, and we could also expand services that aren't aren't covered by Medicaid, like health education or case management.

We do that with the any excess revenue that we may generate.

>> Wow.

So the health of your populace would get better?

Theoretically.

>> Assuming so.

Yeah.

>> Interesting.

Interesting, interesting.

What services are not covered by Medicaid that you can't do under and get compensated for by Medicaid?

>> Medicaid is a pretty generous provider of insurance, pretty generous.

It won't cover things.

And these are services we don't offer cosmetic surgery or experimental medical treatments or fertility treatments.

Those kinds of things are not covered under Medicaid.

And I have to say that for dental services and eye care, it's not great, but it's it does cover some.

So for the most part it's a pretty.

And beyond community health center.

It pays for long term care facilities.

It pays for hospitalization.

It a really a wide gamut of services offered by the health care community.

>> Well, that's important because Medicare doesn't cover for dental, hearing or.

>> Exams.

Right.

>> And the older we get funny how that doesn't even cover.

But but that's for another show.

Now, there has been talk, as we alluded to in the beginning about some cuts in Medicaid funding.

To me as a practitioner, they seem to be very severe.

What can you tell us about from your perspective as a CEO of a family health center?

What are some of these cuts and how will they impact the health of Kentucky?

>> Right.

Well, the federal government proposed to to cut $880 billion.

That's almost $1 trillion from Medicaid, a.

>> Trillion with a T.

>> A trillion with a T, just about $1 trillion over a period of ten years.

And I calculated how much that would mean to Kentucky.

It was like $880 million, something like that.

So there were several ways the federal government could have had that happen or make that happen.

They've really chosen a couple, and certainly they could they have not come and said, well, we gave you $14 million in 2024 from our federal resources to to do Medicaid, which they did.

I mean, $14 billion.

>> Billion dollars.

Okay.

>> Yeah, it's an expensive program.

We'll give you 12 this year.

That's not what they did.

There were a couple things.

And one, it doesn't affect family health centers, but it does affect providers in the community like hospitals and nursing homes.

And that's a reduction in the provider tax.

And as I understand it, the hospitals like UofL Health pay a tax to participate in Medicaid.

And this tax goes to the state.

And the state uses that money to match the federal amount that is provided, so that 21% or 27% that Kentucky has to pay, that's how they match it.

So the federal government said, we're going to reduce the percent of tax.

You can charge the hospitals or the nursing homes or other care facilities.

We're going to reduce that.

And so there won't be as much of that money flowing to Frankfort to match the federal amount.

The match goes down on Kentucky's part.

The match goes down on the federal part as well.

So the federal government saves money because they're not sending the state as much.

That's that's got the hospitals very concerned.

It's a huge amount of money.

>> I bet.

Also have the the practitioners concerned.

>> Absolutely.

>> It it sounds to me that if we're going to decrease the ability of individuals because let me put it this way, as we saw in expansion of Medicaid, I think we saw an improvement overall health of people living in Kentucky.

And did you see that in your population at the Portland Family Health Centers?

>> Yeah, we're always struggling to improve our measures.

Yeah.

I think that it resulted in those persons who didn't have access to care before getting access to care.

And what happens when you don't have insurance is you don't go to the doctor when you need to.

You don't buy the medicine that you've been prescribed.

If you do, go to the doctor.

So it does have a profound effect on on health.

>> So to put it in, I'm not a business person, clearly.

Otherwise I wouldn't be sitting in this chair.

But the return on investment of Medicaid dollars always seem to me is something that and we talk and I've heard before in other other hospitals in rural areas, they seem to be able to hire physicians, dietitians, other people.

And also people were getting healthier.

So are we.

What is it?

Cut off your nose to spite your face.

Here.

>> You'll end up paying for health care somehow.

>> Yes.

>> Whether it's through the emergency room.

If a person doesn't have the insurance now to go to a community health center or other health provider, they're going to go to the emergency room.

Expensive care, inefficient care.

So we do pay for it some way.

>> Even though the majority of us are not, or at least half.

We talk about your population, but the patients that you're seeing, even though the majority of us are not in Medicaid program, if we see a decrease, how does that impact those who have private insurance?

The health of those people?

Yeah.

I'm just wondering, you know, some of these hospitals that we're depending, as you talked about, the depending upon funds coming back to them are going to lose them.

That means they've got to cut services to in our rural hospitals, maybe.

Will that happen with you too?

>> Yeah.

If we decide to if the hospital decides to provide uncompensated care, they're going to have to find those funds somewhere else too.

And maybe that's higher insurance rates or higher co-pays on the persons who do have insurance.

It's you're going to pay for it someway unless we're willing to let just just let people be sick.

>> Which is very costly at that point.

>> Because if we eventually choose to do something about it.

Yeah.

>> So do you anticipate seeing a increase in number of people visiting the family health centers of the world and not being compensated for that care?

>> Yeah, I think that's that's going to happen.

Let me talk a little bit about the work requirement for Medicaid.

>> Please.

>> Which is a second kind of tactic that federal government is using to to reduce the number of persons on Medicaid, which it doesn't sound like that's the case at first, but I'll show you how that works and tell you how that works.

So the federal government said each state has to, if they want to participate in Medicaid program, develop a work program, Medicaid work program.

So the breakdown of Medicaid recipients, this is how it's broken down.

64% of the Medicaid recipients are working either part time or full time.

44% are working full time, 12% are caring for either a child who's ill or an aged person who's ill, who's disabled.

12%.

>> Yeah.

>> 10% are persons who are declared disabled.

So that's 10% of the Medicaid population.

7% of the Medicaid population are students, not not children, but students in college.

And so there that's 7% of them have.

And then 7% are persons who are retired or are looking for work.

That's 7% is the focus of the Medicaid work requirements.

Seven and for Kentucky, that's about 75,000 people.

This my calculation.

So this program will directly affect 75,000 people.

They will have to 80 hours a month, 20 hours a week or so will have to work or be in a training program or being in an education.

The state of Kentucky has been pretty generous with this, or you have to volunteer somewhere in order to maintain your Medicaid.

And there are a lot of problems, a lot of challenges with that in rural areas, transportation, even in urban areas, transportation.

Can you get to that volunteer job?

Can you look for work?

Yeah, unemployment rate 4.5% in Kentucky right now.

There aren't a huge number of jobs available.

And my guess is that 75,000 people may not be qualified for the jobs that are available.

Some of them don't read, some of them don't write.

There are a lot of impediments.

Transportation may not have transportation.

It's going to make it tough to comply with those regulations.

>> Wow.

75,000 people.

>> We're going to design.

The state's going to design a complicated reporting system.

Yeah, I think the estimates I've seen would be over $2 million to $2.7 million to develop this for 75,000 people, although those 75,000 will be affected.

The broader Medicaid population, adult population will be affected as well, because they will have to prove or provide proof that they're not part of the 75 that needs attention from the state that they are they are working, or they do have a disabled person they have to care for.

They're going to have to demonstrate that to probably twice a year.

>> And from my experience, this paperwork is not easy to fill out.

>> It is not easy.

It probably will be an electronic computer system.

Okay.

We work with the connect system, which is a good system, but it has glitches, it has downtimes, there are mistakes, so there are going to be all kinds of these factors involved.

>> I'm wondering at a place like a and I'm giving you an unfunded mandate, but are places like the family health centers going to have computer services and or someone there to help them navigate this sort of thing?

Or is this left up to the individuals themselves?

>> Yeah, we do have eight what we call connectors on site who help enroll in Medicaid.

I imagine we'll expand that to, to help them reenroll if they get knocked off.

Okay.

Let me ask you a question.

Yeah.

What do you think the reason is that we're requiring these this work program for Medicaid recipients?

>> Unfortunately, I think my opinion is going to be biased, and it's going to be that we're shortsighted in trying to cut dollars for providing health care to direct those funds to something else.

And that's why I ask, if we're not going to be cutting our, you know, spiting our faces or cutting our noses to spite our face because we're doing a great disservice to a large number of people and it's going to cost us in the end.

>> I think it's that and there's this old trope that the 75,000 people are just laying around.

Yeah, living off the government.

>> I was trying not to put it that way, but clearly that's what we have ever since the days of the welfare Queen, we have.

Exactly.

We have denigrated individuals who have required public health services or public services.

>> And I just don't think that that's the case.

>> Again, speaking with my clinician hat it also seeing people out in the streets.

I don't think so either.

I think we have a lot of good people.

You got people out there beating the system.

Let's make I'm not going to be pollyannish about that.

And you see it too, like you said, when you got to send three letters out to somebody and they don't.

But I think we're using the wrong instrument.

What services do people have over there?

Portland Health Family Health Center that they can get access.

>> Can I mention one more thing?

>> Go right ahead, sir.

>> Okay.

In regard to work requirements, we know what happens when those are instituted.

Because in 2018, Arkansas for about a year instituted work requirements.

It did not have any effect on Medicaid recipients getting work didn't work.

What did happen was that persons who are even who were working, who were caring for those children, or they were the they were the folks that were falling off Medicaid, 18,000 eligible recipients were let go from the rolls of Medicaid because of this bureaucratic process that we were talking about messing up with, reporting didn't get the letter, the machine didn't work right.

Those kinds of things.

The result of that, to your point, is people didn't go to the doctor and so their conditions got worse.

People without insurance, some of them ran up huge medical bills because they did go to the doctor or they had to be hospitalized.

And finally, people didn't take their didn't buy their medications that they needed.

So you ended up creating poorer health in the attempt to get those few people you think were just laying around.

>> Out of curiosity, right now in Frankfort, one of the good things I'm seeing is the emphasis looking at nutrition and things we can eat right.

Are you able to have programs like that at Park?

At Park at Portland Family Health Center?

>> We do, but it's limited because those things aren't funded.

We have a health educator, we have a part time health educator and a full time, and they do things like arrange aerobics classes, yoga classes.

They provide healthy cooking classes.

So we do have an emphasis on that.

It's just not it's not reimbursable.

And we have to find the money to do those kinds of things.

>> And if you're looking at having a decrease in the amount of funds, this is a program that you can't run.

>> They'll be the ones going first.

Yeah, we'll cut those.

>> Those are the kinds of things that are going to go away.

So we know that nutrition or food is medicine right.

But you can't prescribe it.

>> We.

Right.

Yeah.

>> Yeah.

>> What we do have to care as well.

I mean we have to care on site.

So we do do that.

Yes.

>> Yeah.

Just out of curiosity, real briefly, as you talk to your fellow CEOs at the family health centers, what is the general milieu or attitude and feeling that they have about the future?

>> Well, community health centers, although they've always had bipartisan support.

And they actually the good news is community health centers.

Overall, the program had received a small increase for the next fiscal year, the new budget.

So that's good news.

But even though that funding is certainly welcome there, the effect of Medicaid cuts, the effect of housing and urban development programs changes, and a lot of things like that.

It's always a challenge.

Every day we wonder what's going to come next.

So people are people are tired.

I mean, it's a struggle every day to to try to cope and figure out how to address these various cuts or potential cuts that are coming.

>> Real short.

The lights aren't getting ready to go off for you, are they?

>> Not today.

>> Not today.

It's going to be still a little bit.

And if you've never been past the Portland Family Health Center, if you're driving down 64 headed west, you can see it.

And there's this wonderful marine hospital building there, which I still have yet to figure out what's going on there.

Thank you for being with us today.

Thanks.

It's a pleasure.

And thank you for being with us today.

From declining numbers of health care providers, the closing of clinics and hospitals in a reduction in the number of patients who are insured, we are facing many challenges to our health care system.

It is not certain what the future holds, but clearly changes are afoot and we all have a role in maintaining a system that works for every one of us.

If you wish to watch this show again or watch an archived version of past shows, please go to WW Ket.org Stephanie Lang.

If you have a question or comment about this or other shows, we can be reached at KY Health at ket.org.

I'll look forward to seeing you on the next Kentucky Health.

And my reference to the Marine Hospital is for Bill Wagner, a man of great distinction.

Please take care of yourself, be informed and follow what's going on.

And if you have a friend who needs healthcare, please make sure you seek out Family Health Centers.

Thank you and see you.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

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