The unorthodox plan, Bevin has faith, will lift people into economic self-reliance, ease Kentucky's stubbornly high rates of addiction and ill health, and propel the needy to "derive a sense of dignity by your own power." From this capital city in the state's Bluegrass region, he is buoyed by a sense of mission. "It's a . . . joy that we are doing right by people," Bevin says.
More than a two-hour drive to the southeast in rural Floyd County, where one person in three lives in poverty, word of these coming changes has reached 20-year-old Lakin Branham. She relied on Medicaid when she spent part of last summer in a residential drug-treatment program after wrecking her grandmother's car and serving a brief jail stint for a DUI. Five months clean, she needs the program to pay for medicine to fight depression and two hours of drug counseling every other week.
She hopes to go back to community college part time — too few hours to keep her insurance once Medicaid's new rules phase in later this year. The changes sound "crazy and stupid," says Branham, who for the moment is adjusting to sobriety while helping her grandmother care for her grandfather, who has pancreatic cancer. "People need their Medicaid. . . . If they could work their way out of poverty, they would have already been there."
Which perspective is right — or whether both contain shards of truth — will become evident as the five years of this novel experiment play out, and as researchers and state officials scrutinize the effects.
Whatever they learn will have broad relevance because other states are waiting in line. Nine more — almost all led by Republicans — have applied to the federal Centers for Medicare and Medicaid Services for permission to adopt similar "community engagement" requirements, and others are considering them. There is little doubt that more approvals lie ahead. Before becoming CMS administrator, Seema Verma was a consultant who helped design Kentucky's plan, traveling to Frankfort at least every other week to coach the governor's aides.
For now, those aides are speeding to convert the plan into action. They are starting to strengthen coordination with local job-training offices. They are drafting letters and text messages to try to notify notoriously hard-to-reach people about to become part of Kentucky HEALTH (Helping to Engage and Achieve Long Term Health), as the plan is called.
Meanwhile, consumer health advocates in Kentucky and Washington are finalizing a lawsuit to try to block the state, contending that its action undermines Medicaid's purposes and is illegal.
In the middle are an estimated 394,000 Kentuckians. That is state officials' most recent snapshot of how many of 1.4 million Medicaid recipients are able-bodied people ages 19 to 64 who will not be exempt because of circumstances such as pregnancy, schooling, medical frailty or disability. Officials expect that perhaps 264,000 will not be in compliance when the rules begin between July and November.
The experiment unfolding here is a dramatic about-face from the early years of the Affordable Care Act, when a Democratic governor, Steve Beshear, employed the 2010 law to spread insurance more widely than in nearly any other state.
Then Bevin, an investor-businessman who had run a family bell-making company, took office. Reversing Kentucky's Medicaid expansion under the ACA had been a central campaign promise. But after his election, he assigned staff to design the work requirements and premiums that many on Medicaid soon will be charged — from $1 to $15 a month, depending on their income. The plan also includes a "My Rewards" account for people to earn extra benefits, including dental and vision care that until now has been part of basic coverage, in exchange for healthy behaviors.
In an interview last weekend, the governor said the large drop in uninsured Kentuckians under the ACA "doesn't mean squat" because it has not translated into less obesity, diabetes, opioid abuse or any of the other measures that make the state among the nation's least healthy places.
"Guess what?" Bevin said. "As people engage in their own health outcomes, engage in doing for themselves, they will remove themselves [from the program]. I don't need to do it."
State officials expect that 95,000 fewer Kentuckians may be on Medicaid by the end of the five years as a result of the new rules. They cannot yet predict how many will wean themselves through jobs and rising incomes and how many will be locked out for failing to comply.
Bevin projects confidence that the plan will endure. But if it is blocked in court, he said, he will eliminate the Medicaid expansion, "no question, 100 percent."
During two years of preparation, his aides have defined many details. People covered by the new rules will need to log 80 hours monthly of work, school, job-training, volunteering or caregiving — or any combination. Every month, they must send the state proof of compliance. If they fail to do either, they will have a month to begin following the rules, then one more month before they lose eligibility.
Other important aspects remain in flux. The approved plan says Kentucky will assess whether any areas of the state have too few jobs, training opportunities or public transportation. Adam Meier, deputy chief of staff for policy and the governor's right hand on the Medicaid changes, said that assessment has not yet begun. "If we see huge issues once we roll out, we could back off" requirements in certain counties.
The fiscal effects — a linchpin of Bevin's rationale while campaigning — are still blurry. Meier said savings should come from fewer enrollees, a reduction in benefits such as transportation for nonemergency services, the new premiums and people's improved health. "It's all such a guess at this point," he acknowledged, "because it's never been done before."
Cara Stewart, a leading critic and lawyer at the Kentucky Equal Justice Center, says there are too many unknowns. She is not even sure which parents will fall outside the work requirements. Although state officials say the plan's reference to "minors" means children up to age 18, Stewart fears it might align with a section of federal Medicaid rules that includes only children 6 and younger.
Caught in limbo are people such as Teresa Loman, who lives in working-class Erlanger in northern Kentucky and juggles two part-time bartending jobs while raising Leona, 6½ , and Vivian, 4. Loman is good at her work — friendly with customers and a three-time winner of the Guinness Perfect Pour competition at Molly Malone's Irish Pub in nearby Covington.
The girls have health coverage through her partner, Steve Hunter, and his job as a wine and beer distributor. But Loman, 35, has Medicaid and worries that, if she is not exempted, she could be cut off when Vivian is a little older because her bartending hours do not add up to 80 every month.
Loman knows the importance of Medicaid. It paid thousands of dollars in hospital bills a couple of years ago after a pain in her side turned out to be an inflamed appendix that was about to burst.
When she started at her second job, at Braxton Brewing Co., she was full time for several months. Working opposite shifts to avoid day-care expenses, she and Hunter didn't see each other much, Leona and Vivian did not see them together, and she had little time for healthy cooking. Loman does not think the new rules should force her to choose between her insurance and being a good mother. "I want to be there to teach [the girls] to read and sled and make homemade playdough," she said. "It's not fair to ask someone to give that up."
The Medicaid changes have proponents. Goodwill Industries of Kentucky endorsed them because they are in sync with its mission of helping people overcome barriers and enter the workforce, said Amy Lutrell, the group's president. Still, Lutrell said, "Kentucky will need to step up" and make sure supports are available. And state officials must be realistic about how long changing lives takes, she added.
Wrinkles are common in the lives of people scraping by. Since she graduated from a special-education program in Covington, Pauline Creech's only job was cleaning at a gas station long ago, and her only volunteering was at her now-grown son's elementary school. For more than two decades, Creech got Social Security disability payments, which meant that she also was on Medicare, the federal insurance for older and disabled Americans. Medicare covered her chemotherapy when she first got leukemia.
Two years ago, she got a letter from the Kentucky Lottery, saying she had won $50,000 in a second-chance drawing she entered with tickets from friends. She thought it was a fake, but it was true. The next surprise was that she suddenly had too much money to keep getting disability payments. Her Medicare vanished, too.
Creech, 48, now gets Medicaid, which is the insurance she used for an appointment just before Christmas with her cancer doctor, who told her that blood tests show that the leukemia has returned after seven years of remission. On Monday, after another appointment to decide on her new treatment, she stood in a scuffed Covington bar called Mr. T's Tavern on Main and wept as she thought about the possibility of losing her insurance. "I don't want to miss appointments," she said.
Over in Dwale, her speck of a town in Floyd County, Lakin Branham also is unsure whether she can keep her insurance. She is heeding her drug counselor's advice not to heap stress onto her newly won sobriety. She doesn't have much of a history of doing what the state will require: She dropped out of community college after a few months and was fired from the only job she has ever held — cleaning rooms at a Super 8 hotel.
Her new goal is to be a counselor, but she knows her path will not be quick and will be even harder if she loses health coverage.
Losing Medicaid, she says, is "not the way to get out of poverty at all."