Gov. Beshear: 413,000 sign up for health care in Ky.

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by Joe Arnold

Posted on April 22, 2014 at 1:40 PM


FRANKFORT, Ky. (WHAS11) — Governor Steve Beshear could hardly wait to reveal Kynect’s new totals, directing a large sign in a Capitol meeting room be turned to show the figure, 413,000 Kentuckians– about ten percent of the state’s population–have signed up for health insurance through the state exchange.

“From the beginning, I knew that Kynect would change the course of Kentucky’s history by helping hundreds of thousands of Kentucky families,” Beshear said.

Even after the federal government’s more generous introductory reimbursement rate expires in three years, Beshear says a healthier Kentucky will translate into a more prosperous Kentucky and a net positive for the state budget.

Beshear said a Price Waterhouse Cooper study projected 17,000 jobs and a $15 billion economic impact of Beshear’s embracing of the Affordable Care Act.

“Overall, this will end up from a budget standpoint as a plus over the next eight years and not a minus,” Beshear said.

“This is working,” Beshear said.  “That’s the bottom line. It’s working. We started out with 640,000 uninsured Kentuckians. It’s estimated that 75 percent of these 413,000 never had insurance before.”

David Adams, the Tea Party activist suing Beshear to stop the state based exchange, said the administration is inflating the Kynect numbers by including pending application in its enrollment totals.

“In America, we have been wildly overestimating the number of uninsured for a long time,” Adams said.

According to the state’s numbers, 330,615 Kentuckians, about 80 percent of the 413,410 new enrollees, qualify for Medicaid.

It appears that Kynect has fallen far short of projections of those who would buy private health insurance on the exchange.

According to the U.S. Centers for Medicaid and Medicare Services, Kentucky’s share of President Obama’s goal of 7 million people signing up for private health insurance through government exchanges is 220,000 people.

But, the governor’s office says 82,795 people have purchased private insurance on Kynect, or about 37 percent of that target.

The Cabinet for Health and Family Services said the numbers don’t reflect people who bought insurance outside of Kentucky’s exchange.

“We do not have the numbers of all the people that did not belong to Kynect but went directly to their health insurance company,” Audrey Tayse Haynes, the Secretary of the Cabinet for Health and Family Services, said.


As Deadline Nears, State Insurance Exchanges Still A Mixed Bag

February 21, 2014 3:35 AM

With a bit more than a month left for people to sign up for health insurance plans set up under the Affordable Care Act, the federal website known as finally seems to be working smoothly — in 36 states.

But what’s happening in the 14 states that are running their own exchanges?

Some are doing quite well, thank you. California, for example, said Wednesday that enrollment has already exceeded its projection for the entire enrollment period, which ends March 31.

Other states, however, are having trouble, some of it severe.

Oregon, for example, has only just gotten its website up and running this week, and it’s still not fully open to the public. Until now, Oregon had been using paper applications.

So what makes a state health exchange successful? Joel Ario, who helped launch the exchange program for the federal government and now consults for states and others working to implement the health law, says the states doing best are generally the ones doing the least — at least when it comes to their websites.

“The states that said, ‘This is complicated, we’re going to focus on the most essential issues,’ those were the states that tended to do better,” he says.

Among places in that category, according to Ario, are not just California, but also Kentucky, New York and Connecticut.

In contrast, Ario says, many of the states that are now struggling may simply have overreached.

“Unfortunately states that I once touted as the leaders — Maryland, Oregon, Minnesota,” are among those bringing up the rear, he acknowledges. “This is a complicated undertaking, and so people who tried to do too much in [the first year], I think, had some problems with that.”

Maryland and Minnesota haven’t had the same problems as Oregon, but their websites have both been worked only intermittently, and enrollment has lagged. Just as with the federal website, part of the problem has been on the information technology side.

“We’ve seen in some states that some vendors have not been able to deliver, and states have struggled with the IT implementation,” said Heather Howard, who advises states for the Robert Wood Johnson Foundation.

In Maryland, fixing the exchange has been complicated by the fact that two of its IT vendors are suing each other. Massachusetts and Vermont have both had issues with CGI, the vendor that was found responsible for most of the messy rollout of the federal site,

But experts say blame for failure — and credit for success — doesn’t all belong to the outside IT contractors. It’s also due in large measure to how well those contractors worked with state officials. Audrey Haynes oversees Kentucky’s largely successful exchange, Kynect. She says one key to making it work was putting the exchange in the same department that runs Medicaid.

“Anyone knows that Medicaid has to have a pretty super IT department that supports it,” she said at a recent event sponsored by the Robert Wood Johnson Foundation. “So we have a lot of experience … at bringing up large IT structures.”

And where do state exchanges go from here? Republican members of Congress from Marylandand Oregon are asking the federal government to investigate the limping exchanges in those states. That’s because both received millions of federal dollars to set up their health insurance marketplaces.

In principle, says consultant Joel Ario, figuring out what went wrong is not a bad idea. “I certainly think we want to look carefully at what happened and learn some lessons here. I don’t think anybody’s going to find any improprieties here, because they’re going to think it was all well-intentioned activity.”

And in the long run, once the states that are lagging work out their IT problems, they will probably end up, much like California, doing better than the states being run by the federal government. Heather Howard says that’s because states running their own exchanges also have more resources for consumer outreach.

“They have consumer assistance infrastructure, grants out to community-based organizations, and they’re building and doing a lot more marketing,” Howard says. “And their consumers are hearing much more about the options.”

All of which merely underscores something important about the health law that hasn’t changed: What’s available to you depends very much on where you live.

Judge denies injunction on Kentucky Medicaid expansion

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Mike Wynn
The Courier-Journal

FRANKFORT, KY. — A Franklin Circuit Court judge ruled Friday that expansion of Kentucky’s Medicaid program can move forward while the court considers a legal challenge from the tea party.

Gov. Steve Beshear said in May that Kentucky will add about 308,000 beneficiaries to Medicaid rolls next year under the federal Affordable Care Act, known as Obamacare.

Tea party activist David Adams has filed suit, challenging Beshear’s decision and seeking a temporary injunction to halt the expansion.

But Judge Phillip Shepherd denied the injunction Friday, reasoning that the case should conclude by October — about three months before the expansion takes effect. If the suit succeeds, relief would be available before implementation, he wrote in the three-page order.

“If the governor prevails on the merits, the injunctive relief granted at this time could cause severe hardship on the many citizens who would be eligible for expanded benefits, and such relief would create havoc for the state officials charged with implementing this policy,” Shepherd ruled.

Beshear has said expanding Medicaid will provide a windfall of federal funding and create $15.6 billion in economic benefits for the state, although critics have raised questions over costs.

Adams contends the governor does not have authority to opt into Medicaid expansion without authorization from the legislature.

But the administration argues that Medicaid is governed by regulation — rather than statute — and that Beshear has clear authority to change regulations.

Adams said Friday that Shepherd’s ruling still provides a pathway for victory in the case by allowing discovery and arguments over the constitutionality of the expansion to move forward. Shepherd also found that Adams can refile for an injunction if the case is not resolved before open enrollment begins Oct. 1.

Reporter Mike Wynn can be reached at (502) 875-5136.

TN, KY are miles apart on Medicaid

By: Tom Wilemon, The Tennessean

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Deanna Piotrowski wound up on the wrong side of the Kentucky-Tennessee border.

She suffers from chronic conditions, cannot afford her medicine and is without health insurance. If she had settled 10 miles up the road, she would be getting Medicaid coverage.

“That’s ridiculous,” Piotrowski said. “That’s really a shame.”

Portland, Tenn., where Piotrowski lives, is not that different from Franklin, Ky., the next town up along a two-lane highway that runs past cornfields and modest homes.

Kassandra Clark says she’s lucky to live in the Kentucky town. Uncertain of prospects for health coverage at her new job, she’s grateful politicians in her state have given her a backup option.

“It shows that they care about their people, that they are there for them,” Clark said.

Kentucky has accepted federal funding from the Affordable Care Act to expand the government insurance program for the poor. Tennessee, where political opposition to “Obamacare” runs strong, has not. Kentucky is an anomaly in the South. Most Southern states have taken actionsto either block or hinder the implementation of the federal health law. Supporters of the law say it is foolhardy of politicians to refuse generous federal funding for ideological reasons, but the law’s critics say the money comes with a hefty financial hitch.

The federal government will pick up 100 percent of the costs of insuring new people brought onto state Medicaid rolls through 2016. It then phases down to a permanent 90 percent matching rate in 2020.

Joseph Smith, executive director of the Kentucky Primary Care Association, said politicians there made a pragmatic decision.

“It’s a silly decision based on ideology to refuse health care coverage to the citizens of any state,” Smith said.

Kentucky will expand coverage to an estimated 308,000 state residents with its decision.

‘We don’t have that kind of money’

But a decision about whether to expand Medicaid in Tennessee is a bit more complicated after the numbers are crunched, the state’s TennCare experience is considered and the political reality confronted. Tennessee expanded Medicaid in the 1990s, then learned it couldn’t handle the cost and had to scale back, forcing people off the program. It is a state with a larger population, which means about 100,000 more new enrollees would be eligible for its Medicaid program. And, unlike in Kentucky, Republicans are firmly in control of state government.

Fiscal responsibility matters to Republicans, said Rep. Glen Casada, who argues that Tennessee can’t afford the 10 percent match the state would have to provide beginning in 2020.

He said estimates run between $198 million and $250 million, which he believes is the closer mark. Democrats in the legislature, however, say Medicaid expansion would ultimately save the state money by lowering its cost for uncompensated care by as much as $1.6 billion.

“We’re talking probably $250 million in year four,” Casada said. “That’s a lot of money. We don’t have that kind of money just sitting around. So the question is: Do we raise taxes or what do we cut?”

And he doubts the federal government will stand by the 90 percent commitment.

“The federal government is fast approaching insolvency,” Casada said. “They cannot continue to spend money like they are spending because either the country will collapse or they will have to start cutting. The first place they are going to start cutting is the sweet deal of a 90-10 match to the states on Medicaid.”

John Graves, a Vanderbilt University professor who formerly worked for the Obama administration on health care reform, said Tennessee could protect itself from any possible future decline in matching money.

“Some other states have considered a ‘circuit breaker’ option that limits their downside risk,” Graves said. “That is, these states say they will expand for now, but if the federal government suddenly reduces its share in the future, that would immediately discontinue the expansion.”

Haslam’s plan

Gov. Bill Haslam has been trying to find a way for Tennessee to use the federal money for a state-tailored plan that would prevent a repeat of the prior TennCare expansion, when thousands of people were added to the rolls and quickly racked up medical bills. Haslam favors a plan similar to a private insurance model, in which shared costs curb the overuse of benefits. Instead of expanding TennCare rolls, the money would be used to help poor people buy private insurance, with some co-payments on medical visits and procedures. Adults on TennCare currently have co-pays only for prescriptions.

Haslam’s path is a difficult one. He has to get his plan past the Obama administration and then before the Republican-controlled state legislature.

Arkansas Gov. Mike Beebe, a Democrat, got the Republican legislature in his state to pass an expansion plan that has some similarities to what Haslam has proposed. Federal officials are working toward approving it as a demonstration project. Under the plan, the state would use federal money as “premium assistance” to buy private coverage for people eligible for Medicaid.

Kentucky Gov. Steve Beshear, also a Democrat, envisions Medicaid expansion in his state as a job creator, not a financial drain. He projects expansion will have a $15.6 billion economic impact and create nearly 17,000 jobs between 2014 and 2021.

Hospitals will take hit

The problem with boiling down the Affordable Care Act to any kernel of fiscal certainty is that the recipes differ, according to whoever is mixing the numbers.

However, one certainty is that hospitals in Tennessee will lose money without some form of Medicaid expansion. The federal law reduces special payments to hospitals that treat a disproportionate share of the poor and uninsured. Those patients were supposed to gain coverage in every state through Medicaid expansion. The law had language that would have effectively forced states to expand coverage by cutting off Medicaid funding to those that refused. But the U.S. Supreme Court struck down that portion of the law.

Vanderbilt University Medical Center, which provides more care to the uninsured than any other hospital in the region, announced last week that it is cutting expenses and eliminating jobs. The Tennessee Hospital Association has warned that small rural hospitals might be forced to close without some type of Medicaid expansion.

Renard Murray, the regional administrator for the Centers for Medicare and Medicaid Services (CMS), said there is no deadline for Tennessee to make a decision.

“That option is always on the table for a state,” Murray said, noting that when Medicaid was first created in the 1960s, some states delayed offering the optional program.

“But after several years, several decades have passed, every state now has a Medicaid program,” Murray said. “Medicaid expansion is no different.”

Kentucky is the only one of the eight states in CMS region 4that has agreed to expand its Medicaid program. Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina and Tennessee have not.

2 women, 2 scenarios

Piotrowski, who moved to Portland, Tenn., from Michigan this summer, knows little about Tennessee politics. She does know she can’t afford her medicine. A doctor in Michigan who had treated her family for generations charged her only $30 a visit and gave her drug samples for hypertension, diabetes and depression.

She left that medical arrangement and came to Tennessee so her children would have better job opportunities and live in a place with less crime. She applied for TennCare coverage and got denied.

She is trying to connect with community health centers and faith-based clinics in the area that treat people regardless of their ability to pay.

“Everything else in Tennessee I love,” Piotrowski said. “I really was disillusioned. I know there’s a lot of people that are worse off than me, but my health issues could be serious.”

Up the road in Franklin, Ky., Ashley Austin, a part-time job juggler without health insurance, smiled as she helped children with the Boys and Girls Club sell vegetables they had raised at the farmers’ market.

“I also work at Hobby Lobby,” she said. “If we are a part-time employee, our hours got cut because they do not want to provide insurance for us.”

Austin had been on her mother’s plan until she lost her job. But come Jan. 1, she’ll have health insurance because she lives in Kentucky.

Contact Tom Wilemon at 615-726-5961 or


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Health care law opponents dominate advertising wars

Fredreka Schouten, USA TODAY 5:58 p.m. EDT July 10, 2013


WASHINGTON — Opponents of the 2010 health care law have out-spent supporters by nearly 5-1 on the airwaves — as conservatives seek to cast doubts about its effects and pledge to keep it at the forefront of federal, state and local races, an analysis shows.

Critics of the Affordable Care Act spent at least $385 million from March 2010, when Congress enacted the sweeping health care measure, through the end of last month, according to an analysis of TV advertising nationwide by Kantar Media.

The biggest spender among opponents: Crossroads GPS, a political advocacy group affiliated with Republican strategist Karl Rove. It pumped at least $40 million into advertising that mentioned the law. Backers, led by the U.S. Department of Health and Human Services, spent roughly $78 million.

Kantar’s Campaign Media Analysis Group predicts spending on the law will hit $1 billion by its fifth anniversary in 2015, according to the analysis released this week.

“There’s been no other law we can think of that has been the focus of this much ad spending” immediately following its passage, said Elizabeth Wilner, vice president of the Campaign Media Analysis Group. “The gap between enactment and implementation has created an opening for this to continue to be a point of attack for its critics.”

A new round of advertising hit the airwaves this week.

Americans for Prosperity, a non-profit advocacy group co-founded by billionaire industrialist David Koch, launched a $700,000 TV advertising campaign, largely in Virginia and Ohio, that features a pregnant mother worried that the law will restrict her family’s health care choices and drive up premiums.

The law’s proponents also are gearing up to defend the law and encourage uninsured individuals to begin seeking coverage in new state health insurance exchanges. Enrollment in the exchanges begins Oct. 1.

Organizing for Action, an advocacy group linked to President Obama, released an ad this week touting the law’s elimination of lifetime caps for health-insurance benefits. The ad, featuring Phoenix mother Stacey Lihn, whose young daughter has undergone multiple surgeries for a heart defect, is part of what the group says is a series of commercials over the summer that will cost a total of “seven figures.”

“When people understand the concrete examples of what this means for them, they like the law; they are excited about the law and they want to tell people about it,” said Jon Carson, the group’s executive director.

On Wednesday, two large health care companies — Walgreens and the Blue Cross Blue Shield Association — rolled out a new website to encourage enrollment.

“The overwhelming majority of the public is tired of the political back-and-forth contentiousness and really just wants to know how the Affordable Care Act will help them in the future,” said Ron Pollack, who is executive director of Families USA and a founder of Enroll America, a non-profit group promoting the law.

He said the groups have raised millions to promote enrollment and will target their efforts on counties with big populations of uninsured residents. They include Los Angeles County, home to about 2.2 million people who lack health care coverage — or nearly 5% of the nation’s 46 million uninsured.

The advertising flurry comes as Republican leaders on Capitol Hill vow new attempts to roll back key provisions of the law — emboldened by the Obama administration’s surprise decision last week to impose a one-year delay on the mandate that larger employers provide insurance to their employees or face penalties.

The law “is never going to be ready for prime time,” Senate Majority Leader Eric Cantor, R-Va., said on Fox News this week. “We need a permanent delay.”

In one sign of how volatile the issue has become, the National Football League recently declined to become involved in promoting the law. The league’s decision came after two leading Republicans, Senate Minority Leader Mitch McConnell and Texas Sen. John Cornyn, warned the NFL and other professional sports leagues that promoting the health care exchanges would “risk damaging” their “apolitical” brands.

Kantar’s analysis shows the issue also has reached contests for local offices that have little role in the law’s future.

Last month, the Republican State Leadership Committee ran ads that sought to tie the law to Democrat James Kay during a special election in Kentucky for a state House seat. Kay prevailed in the three-way contest, allowing his party to retain its 10-seat advantage in the chamber.

Kentucky Democratic Party Chairman Dan Logsdon said voters are “starting to block out” the health care attack ads. “Folks can distinguish between sending someone to the state Legislature … and supporting Obamacare,” he said. “People aren’t stupid.”

RSLC’s president, Chris Jankowski, said his group will press the issue in legislative races in Kentucky next year — a state Obama lost by more than 22 percentage points in 2012 — and other state and local contests across the country in the coming years.

“We believe there are gains to be made for Republicans in Kentucky,” he said. “We think President Obama definitely is going to be an issue at the state level in Kentucky in general, and we think the Affordable Care Act, specifically, is going to be front and center as it begins to affect the public more directly.”

Contributing: Kelly Kennedy

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Affordable Care Act has been good for temporary staffing agency

June 26, 2013, 11:09am EDT | Business First of Louisville

Malone Solutions clients are reluctant to hire permanent workers because they don’t know how strong the economic recovery will be and because of the uncertainties involved in which employees will need health insurance coverage under the Patient Protection and Affordable Care Act.

Although the Patient Protection and Affordable Care Act is not fully implemented yet, it already is benefitting at least one local business — staffing agency Malone Solutions.

Companies’ reluctance to hire permanent workers because of the unknowns involved in the implementation of the act has prompted a boom in revenue at Louisville-based Malone Solutions, said the company’s financial consultant, Brad Knight.

Last year, the company grew from $48 million to $78 million in revenue, he said in an interview, and this year he expects it to top $100 million. “We’re getting a lot of inquiries and talking to a lot of people,” he said.

The company employs more than 3,000 temporary workers in 20 states, Knight said. Most of the temps work in the auto industry.

The employers for which Malone provides temps are reluctant to hire permanent workers because they don’t know how strong the economic recovery will be, he said, but also because of the uncertainties involved in which employees will need health insurance coverage under the terms of the act.

“In the fact of the unknowns, they are increasing their contingent work force,” he said. “It’s a lot easier for our customers to put the burden of those unknowns on us than to make a long-term commitment to employees.”

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Where each state stands on ACA’s Medicaid expansion

A roundup of what each state’s leadership has said about their Medicaid plans

June 14, 2013 | Posted on The Advisory Board Company,


The Supreme Court’s ruling on the Affordable Care Act (ACA) allowed states to opt out of the law’s Medicaid expansion, leaving each state’s decision to participate in the hands of the nation’s governors and state leaders.

Based on lawmakers’ statements, press releases, and media coverage, the Daily Briefing and American Health Line editorial teams have rounded up where each state currently stands on the expansion.

We will continue to update this map and list as more information becomes available. Send us news, tips, and feedback by commenting below or emailing

Click to expand a quick-to-scan graphic or an interactive graphic. (Note: The interactive graphic may not be optimized for all mobile devices.)

A state-by-state look at governors’ stances

Text last updated on June 14, 2013. States are categorized based on statements from governors or enacted state laws.

* indicates a state’s participation in the multistate lawsuit against ACA


  • Alabama*: Gov. Robert Bentley (R) on Nov. 13 announced that Alabama will not participate in the Medicaid expansion because the state “simply cannot afford it” (Gadsden Times, 11/13).
  • Georgia*: Gov. Nathan Deal (R) in an Atlanta Journal-Constitution/Politico/11 Alive interview on Aug. 28 said, “No, I do not have any intentions of expanding Medicaid,” adding, “I think that is something our state cannot afford.” When asked about the insurance exchanges, Deal said “we do have a time frame for making the decision on that I think, especially on the exchanges,” adding that “we have just a few days after the election in order to make a final determination on that” (Wingfield, “Kyle Wingfield,” Atlanta Journal-Constitution, 8/28/12).
  • Idaho*: Gov. C.L. Otter (R) in his 2013 State of the State address delivered on Jan. 7 said that while “there is broad agreement that the existing Medicaid program is broken,” the state “face[s] no immediate federal deadline” to address the situation. He added, “We have time to do this right … [s]o I’m seeking no expansion of” the program. Otter said he’s instructed the state Health and Welfare director to “flesh out a plan” that focuses on potential costs, savings and economic impact, which he plans to introduce in 2014 (Ritter Saunders, Boise State Public Radio, 1/7/13; Young, Huffington Post, 1/7; Petcash, KTVB, 1/7/13).
  • Louisiana*: Gov. Bobby Jindal (R) in an NBC “Meet the Press” interview on July 1 said, “Every governor’s got two critical decisions to make. One is do we set up these exchanges? And, secondly, do we expand Medicaid? And, no, in Louisiana, we’re not doing either one of those things” (Barrow, New Orleans Times-Picayune, 7/2/12).
  • Maine*: Gov. Paul LePage (R) on Nov. 16 said that Maine will not participate in the Medicaid expansion. He called the expansion and the state-based insurance exchanges a “degradation of our nation’s premier health care system” (Mistler, Kennebec Journal, 11/16/12).
  • Mississippi*: Gov. Phil Bryant (R) on Nov. 7 said Mississippi will not participate in the Medicaid expansion, reiterating previous statements that he had made about the ACA provision (Pender/Hall, Jackson Clarion-Ledger, 11/7/12).
  • North Carolina: Gov. Pat McCrory (R) on Feb. 12 announced that his state will not expand Medicaid or establish its own health insurance marketplace under the Affordable Care Act. McCrory said state officials conducted a comprehensive analysis to determine the advantages and disadvantages of expanding Medicaid and the right type of exchange option in the state, and concluded that it is “abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange.” He said the review included discussions with other governors, White House officials, health care providers, and leaders in the state Legislature (Binker/Burns, “@NCCapitol,” WRAL, 2/12/13; Cornatzer, Raleigh News & Observer, 2/12/13).
  • Oklahoma: Gov. Mary Fallin (R) on Nov. 19 said Oklahoma will not participate in the Medicaid expansion. “Oklahoma will not be participating in the Obama Administration’s proposed expansion of Medicaid,” she said in a statement. She noted that the program would cost the state as much as $475 million over the next eight years (Greene, Tulsa World, 11/19/12).
  • Pennsylvania*: Gov. Tom Corbett (R) on Feb. 5 sent a letter to HHS saying he “cannot recommend a dramatic Medicaid expansion” in Pennsylvania because “it would be financially unsustainable for Pennsylvania taxpayers.” He noted that the expansion would necessitate “a large tax increase on Pennsylvania families” (Tolland, Pittsburgh Post-Gazette, 2/5/13).
  • South Carolina*: Gov. Nikki Haley (R) on July 1 announced via Facebook that South Carolina “will NOT expand Medicaid, or participate in any health exchanges.” The state Legislature is expected to make a decision on the Medicaid expansion during the 2013 session (Gov. Haley Facebook page, 7/1/12; Holleman, Columbia State, 11/9/12).
  • South Dakota: Gov. Dennis Daugaard (R) in his annual budget address on Dec. 4 said he does not plan to participate in the Medicaid expansion. “I really think it would be premature to expand this year,” he said, adding that he hoped for more flexibility for the state program (Montgomery, Sioux Falls Argus Leader, 12/4/12).
  • Texas*: Gov. Rick Perry (R) in a statement on July 9 said, “If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under ObamaCare.” Perry also sent a letter to HHS Secretary Kathleen Sebelius on July 9 asserting this position. The Dallas Morning News reported that on Nov. 8, Perry reiterated his opposition to the expansion, saying, “Nothing changes from our perspective” (Office of Gov. Perry release, 7/9/12; Gov. Perry letter, 7/9/12; Garrett, Dallas Morning News, 11/11/12).
  • Wisconsin*: Gov. Scott Walker (R) on Feb. 13 announced his rejection of the Medicaid expansion. He proposed an alternative plan that would expand coverage to low-income state residents through private health care exchanges (Spicuzza, Wisconsin State Journal, 2/13/13).


  • Alaska*: Gov. Sean Parnell (R) on Feb. 28 expressed opposition to the Medicaid expansion. He said he will not ask the state Legislature to consider expansion this session, but he will continue to examine the issue (Bohrer, AP/Alaska Journal of Commerce, 3/1/13).
  • Kansas*: Gov. Sam Brownback (R) has punted the decision on Medicaid expansion to Kansas’ Republican-controlled legislature. Lawmakers have not reached consensus on the issue, and a state budget amendment that is expected to pass would prohibit Brownback from expanding the program without the support of the legislature (Celock, Huffington Post, 5/6/13).
  • Nebraska*: Gov. Dave Heineman (R) in a statement on his website on June 28 said, “As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased. If some state senators want to increase taxes or cut education funding, I will oppose them.” Heineman on July 11 sent a letter to state lawmakers saying the state could not afford the expansion, but he stopped short of saying that the state will not participate in the expansion, according to Reuters (Office of Gov. Heineman release, 6/28/12; Wisniewski, Reuters, 7/11/12).
  • Utah*: Gov. Gary Herbert (R) has not yet announced a decision on Medicaid expansion. He has asked the state health department to convene a workgroup to examine cost-effective alternatives that would expand coverage for low-income residents (Dobner, Salt Lake Tribune, 4/23/13).
  • Virginia*: Although Gov. Bob McDonnell (R) has not made an official announced on the Medicaid expansion, he has expressed opposition to the ACA provision, according to the Virginian-Pilot. However, the Pilot notes, the future of the state’s Medicaid expansion will likely depend on the outcome of the November gubernatorial election: Democrat Terry McAuliffe support expansion, but Republican Ken Cuccinelli opposes it (Walker, Virginian-Pilot, 4/11/13).
  • Wyoming*: Gov. Matt Mead (R) on Nov. 30 recommended that Wyoming not participate in the Medicaid expansion, but added that his position could change in the future and urged “everyone to keep an open mind on this.” The state legislature will make the final decision on whether to expand the program, the AP/Jackson Hole Daily reports (Brown, Wyoming Tribune Eagle, 12/1/12; Graham, AP/Jackson Hole Daily, 12/1/12).


  • New York: Gov. Andrew Cuomo (D) in a statement on his website on June 28 said he was “pleased the Supreme Court upheld the [ACA]” and looks forward “to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers.” On July 26, Danielle Holahan—project director for New York’s health insurance exchange planning—said the state “largely meet[s] the federal required Medicaid levels already.” Although Cuomo’s office has not officially announced a decision, the Associated Press reported on Nov. 13 that New York will expand Medicaid (Office Gov. Cuomo release, 6/28/12; Grant, North Country Public Radio, 7/27/12).

PARTICIPATING (26 states and the District of Columbia)

  • Arizona*: The Arizona Legislature on June 13 approved a fiscal year 2013-2014 budget blueprint that includes a plan to expand the state’s Medicaid program under the Affordable Care Act. Gov. Jan Brewer (R)—who in January announced her support for the expansion, which would extend Medicaid coverage to about 300,000 additional state residents—is expected to the sign the budget measure (Viebeck, “Healthwatch,” The Hill, 6/13; Schwartz, Reuters, 6/13/13; Christie/Silva, AP/Yahoo! News, 6/14/13).
  • California: Gov. Jerry Brown (D) in a statement on June 28 said the Supreme Court’s ruling “removes the last roadblock to fulfilling President Obama’s historic plan to bring health care to millions of uninsured citizens.” California got a head start on expanding its Medicaid program in November 2010 with its “Bridge to Reform” program, which aimed to bring at least two million uninsured Californians into Medicaid (Office of Gov. Brown release, 6/28/12; DeBord, “KPCC News,” KPCC, 6/28/12).
  • Colorado*: Gov. John Hickenlooper (D) on Jan. 3 announced that his state will participate in the expansion. In a news release, his office said the move would extend Medicaid coverage to about 160,000 low-income residents and save Colorado an estimated $280 million over 10 years without affecting the state’s general fund (Stokols, KDVR, 1/3/13; Wyatt, AP/Denver Post, 1/3/13).
  • Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted in March 2010. Soon after the Supreme Court ruling on June 28, Malloy said “it’s great … [and a] very important decision for the people of Connecticut. 500,000 people would have lost coverage if Republicans had their way” (Davis, WTNH, 6/28/12).
  • Delaware: Gov. Jack Markell (D) in a statement on June 28 said, “The Supreme Court’s ruling enables Delaware to continue to implement provisions of the Patient Protection and Affordable Care Act to provide access to health care benefits for Delawareans.” He added, “On the Medicaid front, Delaware already voluntarily expanded the state’s Medicaid coverage program in 1996 to cover many Delawareans not previously covered” (Office of Gov. Markell release, 6/28/12).
  • District of Columbia: D.C. Mayor Vincent Gray (D) in a statement on June 28 said, “The District is not at risk of losing any Medicaid funding as a result of this ruling, because District officials have already begun implementation of the ACA’s Medicaid-expansion provisions and will continue to implement the expansion” (Executive Office of the Mayor release, 6/28/12).
  • Florida*: Gov. Rick Scott (R) on Feb. 20 announced that the state will participate in the ACA’s Medicaid expansion, citing HHS’s conditional support for a waiver to shift most of the state’s Medicaid beneficiaries into a managed-care program. However, Scott said that Florida would only participate in the expansion for three years before reevaluating the decision. Supporters of the ACA heralded Florida’s shift as a major reversal; Scott mounted his successful campaign for governor in 2010, in part, by being one of the nation’s foremost critics of President Obama’s planned health reforms (Kennedy/Fineout, Associated Press, 2/20; Office of Gov. Scott release, 2/20/13).
  • Hawaii: Gov. Neil Abercrombie (D) in a statement on June 28 welcomed the Supreme Court’s ruling and said the ACA “is our ally” in the effort to “support a health care system that ensures high quality, safety and sustainable costs.” Pat McManaman, director of the state Department of Human Services, said Hawaii’s Medicaid eligibility requirements in July would fall in line with the law’ guidelines, meaning an additional 24,000 people will be eligible for the program by 2014 (Office of Gov. Abercrombie release, 6/28/12).
  • Illinois: Gov. Pat Quinn (D) on June 28 praised the court’s decision and said he “will continue to work with President Obama to help working families get the healthcare coverage they need,” including expanding Medicaid (Office of the Governor release, 6/28; Thomason, Rock River Times, 7/3/12; Ehley, Fiscal Times, 8/20/12).
  • Kentucky: Gov. Steve Beshear (D) on May 9 announced that Kentucky will participate in the Medicaid expansion. He called the decision “the single-most important decision in our lifetime for improving the health of Kentuckians” (Halladay, Louisville Courier-Journal, 5/9/13).
  • Maryland: Gov. Martin O’Malley (D) in a statement on June 28 said the Supreme Court’s decision “gives considerable momentum to our health care reform efforts here in Maryland,” adding that the state will move forward to implement the overhaul (Office of the Governor release, 6/28/12).
  • Massachusetts: Gov. Deval Patrick (D) in late June said Massachusetts is “an early expansion state as you know and we’re expecting further resources from the federal government to sustain the experiment here in Massachusetts.” Patrick called the ruling “good news for us” (Walker, YNN, 6/28/12).
  • Michigan*: Gov. Rick Snyder (R), in a statement released on Feb. 6, announced that his fiscal year 2014 budget proposal includes a plan to expand the state’s Medicaid program under the Affordable Care Act. The plan would extend Medicaid benefits to about 320,000 eligible residents. Snyder said the plan contains safeguards that will ensure the financial stability of the program and protect against changes in the government’s financial commitment to the expansion (Office of Gov. Snyder release, 2/6/13).
  • Minnesota: Gov. Mark Dayton (D) said in a statement on June 28, 2012, said, “Today’s ruling will be met with relief by the Minnesotans whose lives have already been improved by this law.” On Feb. 19, 2013, Dayton signed a bill authorizing expansion the state (AP/KARE 11, 2/19/13).
  • Missouri: Gov. Jay Nixon (D) on Nov. 29 announced that Missouri will participate in the Medicaid expansion. Nixon said he will include the expansion in the state budget proposal he submits to lawmakers. “We’re not going to let politics get in the way of doing the best thing for our state,” he said (Crisp, “Political Fix,” St. Louis Post-Dispatch, 11/29/12).
  • Montana: Gov. Steve Bullock (D) in January 2013 said he planned to expand Medicaid in Montana. However, the state Legislature defeated all bills that would expand the state health care program in 2013. On the last day of the legislative session, Bullock said, “Let me be clear, we will reform healthcare in Montana. We will do it with or without the Legislature’s help” (Johnson, Billings Gazette, 1/5/13; KXLH, 5/2/13).
  • Nevada*: Gov. Brian Sandoval (R) on Dec. 11 announced that the state will participate in the Medicaid expansion. “Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court,” Sandoval said in a statement, adding, “As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage” (Damon, Las Vegas Sun, 12/11/12).
  • New Jersey: Gov. Chris Christie (R) in his Feb. 26 budget address announced that New Jersey will participate in the Medicaid expansion. The ACA provision is expected to extended Medicaid coverage to about 300,000 uninsured New Jersey residents (Cheney, Politico, 2/26/13).
  • New Hampshire: Gov. Maggie Hassan (D) in her Feb. 14 budget address said that New Hampshire will opt into the ACA’s Medicaid expansion because “it’s a good deal…[that will] allow us to save money in existing state programs, while increasing state revenues.” A state report estimates that the expansion will cost New Hampshire about $85 million through 2020, but will bring in $2.5 billion in federal funds and help reduce the number of uninsured residents from roughly 170,000 to 71,000 (Ramer, AP/, 2/14)
  • New Mexico: Gov. Susana Martinez (R) on Jan. 9 announced that her state will participate in the Medicaid expansion, which potentially could extend health coverage to nearly 170,000 additional low-income uninsured residents. Martinez noted that contingency measures will be established if federal funding for the expansion diminishes, which would mean scaling back the expansion by dropping newly covered beneficiaries from the Medicaid rolls (Schirtzinger, Santa Fe Reporter, 1/9/13; Reichbach, New Mexico Telegram, 1/9/13).
  • North Dakota*: Gov. Jack Dalrymple (R) in January said the politics associated with the ACA should not prevent North Dakota from participating in the Medicaid expansion. In April 2013, he signed a legislation that expanded Medicaid in the state (AP/Prairie Business Magazine, 4/16/13).
  • Ohio*: Gov. John Kasich (R) on Feb. 4 announced that the state will be participating in the Medicaid expansion, the Cleveland Plain Dealer reports. He made the announcement in his two-year budget announcement, but warned that Ohio would “reverse this decision” if the federal government does not provide the funds it has pledged to the expansion (Tribble, Cleveland Plain Dealer, 2/4/13).
  • Oregon: Gov. John Kitzhaber (D) said on June 28 that he is confident that the Oregon Legislature will approve a state Medicaid decision. In an interview with the Oregonian just hours after the Supreme Court issued its ruling on the ACA, Kitzhaber said, “We’ll make a decision on whether or not to expand the Medicaid program really based on, I think, the resources we have available in the general fund for that purpose going forward” (Budnick, Oregonian, 6/28/12).
  • Rhode Island: Gov. Lincoln Chaffee (I) in a statement on his website on June 28 said, “I have fully committed to ensuring Rhode Island is a national leader in implementing health reform whatever the Supreme Court decision, and this just reinforces that commitment.” According to Steven Costantino, the state’s secretary of health and human services, “The expansion is easy to do and makes sense.” Moreover, on July 12, USA Today reported that Chaffee planned to participate in the expansion (Chaffee statement, 6/28/12; Wolf, USA Today, 7/12/12; Radnofsky et al., Wall Street Journal, 7/2/12).
  • Vermont: Gov. Peter Shumlin (D) on June 28 said Vermont’s Medicaid program already meets the requirements under the health reform law’s Medicaid expansion (Steimle, WCAX, 7/1/12).
  • Washington*: In an email responding to a query by American Health Line, Karina Shagren—a deputy communications director in Gov. Chris Gregoire’s (D) administration—in early July said “the governor supports the Medicaid expansion—and Washington will move forward.” U.S. Rep. Jay Inslee (D)—who supports the expansion—was elected governor on Nov. 6 (Shagren email, 7/5/12; Washington Secretary of State website, 11/12/12).
  • West Virginia: Gov. Earl Ray Tomblin (D) on May 2 announced that West Virginia will participate in the Medicaid expansion. “At the end of the day, we have weighed the options and believe expanding Medicaid is the best choice for West Virginia,” he said (Boucher, Charleston Daily Mail, 5/2/13).

Participating through an alternative expansion model (4 states)

  • Arkansas: Gov. Mike Beebe (D) in February announced that HHS had approved a plan to expand coverage to expansion-eligible residents through the health information exchanges. As with the Medicaid expansion, the federal government has agreed to cover 100% of the premiums for the first three years and 90% of the premiums after 2020 (Ramsey, “Arkansas Blog,” Arkansas Times, 2/26/13).
  • Indiana*: Gov. Mike Pence (R) has proposed a plan to expand coverage to expansion-eligible residents through Indiana’s Healthy Indian Plan (Sikich, Indianapolis Star, 4/1/13).
  • Iowa*: Gov. Terry Branstad (R) on May 22 said he will support a compromise deal that would extend health insurance coverage to 150,000 low-income state residents through a new state plan or through the state’s insurance exchange. The Senate approved the compromise deal on May 22, and the House approved it on May 23 (Lucey, AP/Modern Healthcare, 5/23/13; Petroski, Des Moines Register, 5/24/13).
  • Tennessee: Gov. Bill Haslam (R) on March 27 announced in an address to a joint session of the General Assembly that the state will not participate in the Medicaid expansion. Instead, he said he favors an alternative option, under which the state would use federal funds to shift Medicaid-eligible residents into private health plans (Humphrey, Knoxville News Sentinel, 3/27/2013; Goodnough, New York Times, 3/27/13).

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A Louisville Clinic Races to Adapt to the Health Care Overhaul

June 22, 2013


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LOUISVILLE, Ky. — One morning last month, a health clinic next to a scruffy strip mall here had an unlikely visitor: a man in a suit and tie, seeking to bring a dose of M.B.A. order to the operation.

A dozen clinic employees, who spend intense, chaotic days treating an unending stream of Louisville’s poor and uninsured, stared stonily at handouts he had brought as he made his pitch.

The visitor was Danny DuBosque, a “coach” hired to help the nonprofit clinic adapt to the demands of the federal health care overhaul. He had come to discuss a new appointment system, one that will let patients see a doctor or nurse within a few days of calling, instead of weeks or months.

“It’s a huge satisfier,” he declared — management-speak that fell flat with Dr. Michelle Elisburg, a pediatrician who was scheduled to see 26 patients that day.

“It puts me on edge,” said Dr. Elisburg, who has spent her career treating the poor. “Under this model, it’s first come first served, whoever calls fastest. But that’s not necessarily the patient who really needs to be seen.”

Mr. DuBosque, 35, raised his arms, a plea for patience. “We’re going to take the next few years going through and untangling all these issues,” he said before hurrying to another meeting.

“It’s frightening,” Dr. Elisburg, 42, murmured as Mr. DuBosque left.

The debate that morning was just one expression of the tensions rippling through medical offices around the country in the countdown to January, when the Affordable Care Act will require most Americans to have health insurance or pay a tax penalty. For doctors and their staffs, this is a period of fevered preparation for the far-reaching changes that are soon to come as the law moves out of the realm of political jousting and into the real world.

To follow how the historic law is playing out, The New York Times will look periodically at its impact in Louisville, a city of 600,000 that embodies both the triumphs and the shortcomings of the medical system in the United States.

The nation’s first hand transplant was performed here, as was the world’s first implant of a self-contained artificial heart. One of the nation’s largest insurers, Humana, is based here, and the city’s downtown area alone has four hospitals and a medical school. Health care increasingly fuels the local economy, accounting for many of the largest employers and a growing number of start-ups.

Yet for all the resources and expertise, the health outcomes in Kentucky remain “horrendous,” as Gov. Steven L. Beshear, a Democrat, put it recently. The state has some of the nation’s highest rates of smoking, obesity and deaths due to cancer and diabetes. At this point, the only sure thing about putting the law’s many pieces in place here is that it will not be easy.

The potential benefits are huge. Some 90,000 people could get medical coverage in this city alone. It could create thousands of jobs in Kentucky and, if its aspirations are realized, provide better care at lower cost. Yet the law still provokes suspicion and confusion, among both health care providers and the uninsured population it is meant to help.

Community clinics like the one Mr. DuBosque was visiting, one of seven in a network here called Family Health Centers, are at the front lines of the change. They expect that their patient load could double, even as they struggle to recruit doctors and other staff members. They serve people who, because of poverty or entrenched habits, often have a hard time staying healthy and tend to put off preventive care. Now these clinics are anticipating competition from private providers who may see newly insured patients — no matter how poor — as opportunities for profit. So they are working on improving the patient experience and their own efficiency.

The legislation allots $11 billion over five years to improve and expand community clinics across the nation. Family Health Centers is getting $5.4 million to renovate a clinic for the homeless and move a downtown clinic to a much bigger building, adding dental and X-ray departments and a pharmacy. The organization hopes to eventually serve 10,000 additional patients at that site alone, if it can hire enough doctors and nurses to treat them. Meanwhile, it is using federal stimulus money to convert 60,000 paper charts to electronic medical records, and trying to improve patient access with the new scheduling system and other changes.

“We have to change from being the provider of last resort to the first choice for the community we serve,” said Bill Wagner, the longtime executive director of Family Health Centers. “Everything we do needs to say, ‘You’re valuable to us.’ ”

Soft of voice and low-key, Mr. Wagner, 60, nonetheless acknowledges that the stakes for Family Health Centers are unnervingly high. He gets to work at 6:30 a.m. these days, relies on a steady stream of caffeine and clears his head with weekend motorcycle rides.

“We couldn’t have more balls in the air right now,” he said.

Patients and Problems

The West End of Louisville is a patchwork of poor neighborhoods, where asthma, high blood pressure and other chronic conditions are stubbornly common. In Portland, a neighborhood of one-way streets and faded shotgun homes, the biggest Family Health Centers clinic provides basic care to some 16,000 patients per year, regardless of ability to pay.

Here, Alaina Brohm, a brisk nurse practitioner, treats a diverse and challenging population: the unemployed, the chronically depressed, the obese, patients with advanced diabetes and feeble hearts. Ms. Brohm, 30, could be making more money at the retail clinics popping up in drugstores and supermarkets, diagnosing strep throats and bladder infections. Maybe someday she will. But for now, she wants a bigger challenge.

“I knew I would see it all here — a lot of chronic conditions, the worst of the worst,” she said. “I know a little bit about everything.”

Few in Louisville may feel the effects of the new health care law as tangibly as the uninsured patients who churn through Ms. Brohm’s cramped exam rooms — and how they will respond to the law is one of the crucial questions that will determine whether it succeeds. For now, many seem either wary of it or uninformed.

Marchelle Edwards, 55, had been absent from the clinic for more than a year when she arrived there one Monday in May. She had a painful infection in her foot, linked to uncontrolled diabetes. She had stopped taking medicine to control her blood sugar after her prescription ran out months earlier. She also had a bladder infection and a thyroid condition that was making her hoarse. Her daughter Tammy, who had driven her to the clinic, reported that she was subsisting on Pepsi and junk food and feeling tired all the time.

Ms. Edwards seemed to be a walking example of the potential benefits of the same-day appointment system that Mr. DuBosque had been pitching. “I just couldn’t get an appointment in here,” she said, alluding to the long wait time and why she had not bothered trying.

“Even if you made an appointment and it was two months out,” Ms. Brohm softly chided, “it would be a lot sooner than waiting a year.”

The last time Ms. Brohm had seen Ms. Edwards, in April 2012, she had referred her to a podiatrist affiliated with University Hospital, which provides most of the city’s specialized indigent care. But Ms. Edwards, a former food service worker, said she had stopped seeing the podiatrist because he charged $35 per visit.

“I stay at home and I hurt,” she said.

Ms. Brohm started her back on two medicines: one to regulate her blood sugar, and another to help with pain in her feet, a result of nerve damage from the diabetes. One would be free through a pharmacy discount program for the poor; the other would be $6 a month, an expense Ms. Edwards said was prohibitive.

“There’s only so much I can do with your toes, O.K., without surgery,” Ms. Brohm told her. “You’re going to need another referral to a podiatrist, another appointment with a financial counselor. Let me grab you a list.”

She left the room to get one, but Ms. Edwards stalked out, scowling, before she could return. Her daughter shook her head.

“Not having insurance,” Tammy Edwards said, “not being able to get the treatments and stuff that she really needs, it’s depressing for her.”

Ms. Edwards will almost certainly qualify for Medicaid under an expansion next year, which means she would pay nothing or a few dollars for most drugs and medical care, with a maximum of $450 a year.

Yet Ms. Brohm wonders whether Ms. Edwards will pursue the care she needs even if she gets Medicaid. “She’s scared of health care,” Ms. Brohm said after the appointment. “She’s one of the ones that’s more in denial. I guess it’s her defense mechanism: ‘If I don’t find out, then I won’t know.’ ”

Ms. Edwards’s case raises a crucial question about the health care law: Will insurance necessarily make unhealthy people healthier?

David Elson, 59, who has congestive heart failure and chronic kidney disease, skipped an appointment at the clinic in April because he could not afford the fee. He earns enough to pay the highest fee on the clinic’s sliding scale: $65 per visit, he said, and more if he needs blood work. He came one recent evening for an urgent visit, laboring to breathe.

Mr. Elson, who has his own business installing alarm systems, used to pay $125 a month for health insurance, he said. But then he developed diabetes, and his premium soared to more than $500 a month. He dropped the policy years ago.

His nurse practitioner, Susan Elrod, quickly determined that he had fluid in his lungs. Ashen and slumped, he had gained 50 pounds in two months — all water weight, she said — because his weakened heart had not been pumping efficiently enough. He now weighed 309 pounds, and his legs had swelled so much that large lesions had opened on them, fluid seeping out.

“We’re going to have to send you to the emergency room,” Ms. Elrod told him. “Do you feel strong enough to drive, or would you like me to call an ambulance?”

Mr. Elson grimaced, realizing he now faced a far greater expense than what he had saved by skipping his last appointment. He was already struggling to pay for his insulin — $240 a month, he said — and other drugs, which filled a plastic bag he had brought with him.

“I can’t afford to go,” he said, looking blank, after Ms. Elrod had left the room.

He went nonetheless, but not until the next morning, when a neighbor could drive him.

Mr. Elson said he earned about $24,000 a year, too much to qualify for Medicaid even under the expansion. It will cover people with incomes up to $15,856 for a household of one.

But Mr. Elson could still get federal subsidies starting next year to help him buy private coverage through the insurance marketplace, or exchange, that Kentucky is creating under the law. People with incomes up to 400 percent of the poverty level — about $46,000 for an individual — will be eligible for such subsidies if they buy coverage through an exchange. But Mr. Elson said he was certain the cost would still be too high.

“I don’t see it helping anybody,” he said, “just making everybody get insurance.”

In fact, Mr. Elson might pay about $130 a month for coverage if he signed up for a medium-cost plan, according to an estimate by the Kaiser Family Foundation, a nonpartisan research group. He would qualify for a subsidy that would cover 80 percent of his premium costs. The law will also prohibit insurance companies from turning him away or charging him more because he is sick.

Even Ms. Brohm, the nurse practitioner, is suspicious of the law and confused about the changes it will bring. For one thing, she worries that poor people who become eligible for Medicaid under the expansion will be required to pay a part of their medical costs.

“If it does help out with the expensive stuff, that will be very exciting,” she said. “But my concern is if they have to pay anything, will things still be done? Sometimes even a small percentage is too much for people.”

The law’s divisiveness, meanwhile, makes her uncomfortable. She knows of a restaurant chain that may be sold, she said, because the owner cannot afford to provide insurance for his employees, as the law will soon require.

“If it becomes something a lot of people argue about,” she said, “that frightens me.”

Changes on the Way

At a meeting of the Family Health Centers medical staff in May, Ms. Brohm and her colleagues listened as Dr. Peter Thurman, the medical director, delivered a pep talk of sorts. He was pressing them to complete a day’s worth of online courses about the electronic records system that the clinics were poised to adopt. More training would come later in the year.

“It’s self-preservation, in my opinion,” Dr. Thurman said.

The topic shifted to the new appointment system, which only one of the clinics, known as Fairdale, had adopted so far. The early news was good: the average no-show rate had dropped from 21 percent in March to 10.5 percent in May.

“This thing is working,” Dr. Thurman proclaimed, and went on to credit Mr. DuBosque. “Danny’s been a godsend for us, I’ll just be honest with you.”

Later that day, Mr. DuBosque drove to the Fairdale clinic on the south side of Louisville, to get some firsthand feedback. The staff had more good news: fewer patients were turning to private urgent-care centers, a growing source of competition for Family Health Centers.

“They’re acting shocked: ‘What, we can get in today?’ ” said Saundra Kay Webb, a receptionist.

Technically, Mr. DuBosque’s job is to help Family Health Centers get certified as a “patient-centered medical home.” Under that model, teams of providers take a highly organized approach to patient care, with a focus on customer service. Better access is a central goal, which is why Family Health Centers is cutting its wait time for appointments.

Electronic medical records are also essential to the medical home model, partly to reduce what Mr. DuBosque called “the sheer work of keeping tabs on things with paper charts.”

Among other things, he is learning that change sometimes comes more slowly in community clinics than in the fiercely competitive hospital sector, where he used to work. For example, Mr. DuBosque thinks it would be smart to start and end the workday later at Family Health Centers, because patients are reluctant to show up for early-morning appointments. But the idea is not catching fire.

“There’s a whole host of things we’re going to have to fight through with that,” he said. “We have a lot of staff with some established routines and schedules. But I think it’s a no-brainer.”

Doctors working full time at Family Health Centers earn about $127,000 a year, far less than many of their counterparts in private practice. In the last year alone, the clinics lost five doctors, including one who moved, one who retired and one who took a higher-paying job at a hospital. Nurse practitioners are filling the void. They now make up 60 percent of the medical staff at the seven clinics, and their role will continue to grow.

But they, too, are in high demand, and their salary at Family Health Centers, about $67,000 a year for a full-time position, comes up short compared with the private sector.

If Family Health Centers sees enough new revenue, raising salaries will be a top priority. But as with so much of the Affordable Care Act, there are still far more questions than answers.

“Will it allow a community health center to be competitive on M.D.’s against the hospitals?” Dr. Thurman asked. “I just don’t know.”

Financial Considerations

One afternoon last month, Mr. Wagner, the director of Family Health Centers, canceled his appointments and hurried to the Kentucky State Capitol in Frankfort, about an hour away. Governor Beshear was announcing that he would expand Medicaid in the state, a measure called for under the health care law but one that many states are opting out of. By the governor’s estimate, it would allow up to 308,000 additional Kentuckians into the program, almost half of the state’s uninsured population.

Mr. Wagner was eager to bear witness to an announcement that he deemed historic, the culmination of a goal he has spent his career trying to achieve. The Medicaid expansion could also solve Mr. Wagner’s budget problem. Family Health Centers is facing a deficit of about $3 million in its overall annual budget of $30 million, largely because so many of its 42,000 patients, 54 percent, are uninsured.

“Right now we’re living off our reserve fund, and that can only last so long,” Mr. Wagner said.

Then it was back to his office in Louisville to keep planning. That day he learned that community clinics around the country would receive $150 million to help sign up people for insurance. Family Health Centers anticipates getting about $300,000, which it will use to get the word out starting this summer. Under the law, people can start signing up in October for coverage that starts in January.

“We will undoubtedly be hiring staff who will sit in the lobbies with patients — with laptops, with tablets — to provide assistance in enrolling online,” Mr. Wagner said.

October will be a critical month at Family Health Centers. The insurance sign-up period will begin just as construction on the new downtown clinic gets under way. At the same time, the huge Portland clinic will go live with the electronic medical records, and it will have just adopted the new appointment system.

Ms. Brohm, the nurse practitioner, will be married by then, returning from her honeymoon to what may feel like a strange new world. Ms. Elrod, her colleague, will have cut her hours at Family Health Centers and started working in the relative calm of a private doctor’s office. Short of a miracle, neither Ms. Edwards nor Mr. Elson, their chronically ill patients, will have health insurance yet. But if the outreach campaign succeeds, they will have learned of their options and may be poised to sign up.

The day after Mr. Elson was admitted to the hospital, Ms. Elrod called to check on him. His breathing had improved, and the hospital had prescribed a different diuretic to help him excrete water. He had lost 10 pounds so far and would lose 20 more by the end of his five-day stay. She told him to follow up at the clinic after his release.

“Get on my schedule for Tuesday night, O.K.?” she said, then paused for his response. “O.K., if you have the money. I understand, Mr. Elson. O.K. Bye.”

Kentucky Medicaid commissioner says managed care is improving health

Written by Jessie Halladay

The Courier-Journal

Jun. 13, 2013 

FRANKFORT — Medicaid Commissioner Lawrence Kissner told a legislative committee Thursday that he’s pleased with the way managed care is working for Medicaid patients in Kentucky.

Members of the Program Review and Investigations Committee met Thursday morning, hearing from Kissner on the status of Medicaid managed care after its first year of implementation. Kissner also briefed the committee on the expected benefits of expanding Medicaid, which Gov. Steve Beshear has said will happen in Kentucky starting Jan. 1.

“We are driving significant improvement in healthcare outcomes,” Kissner said of using managed care to deliver Medicaid.

For example, he said Coventry Cares, one of the managed care companies, saw diabetes testing increase from 6 to 59 percent. That same company showed access to primary care doctors increased for children age 12- to 24-months went from 39 to 97.6 percent.

Kissner also acknowledged that there have been some stumbles in the implementation of managed care.

He asked for an external audit of how the managed care companies have handled the appeal and grievance process. The audit found that two companies, Kentucky Spirit and Coventry, were deficient in their handling of cases, including not responding as quickly as required.

Both companies have been given improvement plans and are working to address the problems, Kissner said. After the meeting, Kissner said he believes many of the problems occurred in the early months of implementation and that improvements have already begun.

Some members of the committee continued to express their concerns about whether managed care, and the pending Medicaid expansion, is the right approach for Kentucky.

Sen. Tom Buford, R-Nicholasville, said he worries about the cost of Medicaid expansion in the coming years. Under expansion, the federal government will pay 100 percent of the cost for the first three years, eventually reducing its contribution to 90 percent.

“I’m very concerned for the taxpayers, the General Assembly,” Buford said. And he suggested that more effort should be spent on improving the quality of service provided, especially since so many Kentuckians rely on Medicaid for their healthcare but state health rankings remain among the worst in the nation.

Expanding Medicaid will qualify an additional 308,000 uninsured Kentuckians and, Kissner said, significantly help the working poor. Enrollment for those newly eligible is scheduled to begin Oct. 1.

Reporter Jessie Halladay can be reached at (502) 582-4081 or on Twitter at CJ_JHalladay.


Americana Center World Festival celebrates cultures with music, food and wares

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by Maggie Huber

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Iroquois Amphitheater played host Saturday to the 23rd annual Americana Center World Festival, Where Louisville Meets the World. Hundreds sampled the festival’s music, food and wares.

With musical acts playing and dancers performing on two stages every half hour, there was plenty to stimulate the ears and eyes. For example, Mamta Subba, 18, performed a traditional Nepalese dance with her friends.

“It’s a rare opportunity to see different kinds of musicians in town,” said Alexander Udis, 28, the community garden coordinator at the Americana Center. “The festival started as a block party for the center and has grown to be the big event of the year when we not only get to advertise what we do at the center, but give a spotlight to all the nationalities that live in Louisville.”

For others, such as Lauren Humpert, “the highlight of this festival is the food,” she said as she waited for someone to cover her Fiberworks booth so she could indulge in food from one of the more than six food vendors.

Odette Nyirahuku agreed as she made beignets for her “Mama Boling” booth. Nyirahuku learned to cook the dishes at the Americana Center as part of a class. “Everybody needs our food,” she said.

Americana Community Center provides a spectrum of services based on the Louisville area’s cultural, ethnic and economic diversity.

Americana World Festival: Americana World Festival | Scenes and interviews (Video by ANGELA SHOEMAKER/Special to the Courier-Journal

Olivetta Uradu, 20, left, and Kade Tambo, 22, right, watch as a band performs on the Hilltop stage at the 23rd annual Americana World Festival at the Iroquois Amphitheater. June 01, 2013

Joyce Augustine, 10, participates in a hula hoop contest for kids during the 23rd annual Americana World Festival at the Iroquois Amphitheater. June 01, 2013

Joyce Augustine, 10, participates in a hula hoop contest for kids during the 23rd annual Americana World Festival at the Iroquois Amphitheater. June 01, 2013