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August 18, 2018

Via Electronic Submission:

U.S. Department of Health and Human Services
200 Independence Avenue S.W.
Washington, DC 20201

RE: Comments on the Kentucky HEALTH Medicaid Section 1115 waiver

The Center for Medicare Advocacy (Center) is pleased to provide comments during the re-opened comment period for the Kentucky HEALTH Medicaid Section 1115 waiver demonstration application. The Center, founded in 1986, is a national, non-partisan law organization that works to ensure fair access to Medicare and quality healthcare. At the Center, we provide education and advocacy on behalf of older people and people with disabilities to help secure fair access to necessary health care. We draw upon our direct experience with thousands of individuals to help educate policy makers about how their decisions affect the lives of real people. Additionally, we provide legal representation to ensure that people receive the health care benefits for which they are eligible, and the quality health care they need.

We offer general comments along with comments about Kentucky HEALTH below:

General Comments

The threat of losing insurance is not a proper way to promote work among Medicaid beneficiaries. Studies show that Medicaid has assisted beneficiaries in finding or maintaining employment. For example, 52.1 percent of beneficiaries in Ohio state that “attaining coverage made it easier to secure and maintain employment.”[1] Nationally, 60 percent of non-SSI adults are already employed and working; however, most beneficiaries who work full-time still have “annual incomes . . . low enough to qualify for Medicaid.”[2] As the data indicate, these beneficiaries are employed in vital industries where they earn low wages. Many of these beneficiaries work in our nation’s hospitals, home health care services, and nursing facilities.[3]

Studies also show that Medicaid improves the financial security of beneficiaries. One study finds that “Medicaid expansion was associated with a significant reduction in people’s unpaid bills and the amount of debt sent to third party collection agencies.”[4] Another study finds that “Medicaid expansion was associated with an average decline in credit card debt of around $200 . . . .”[5] Such improved financial security may lead to better overall health outcomes. For instance, 58.6 percent of beneficiaries in Ohio believe that coverage makes it easier to purchase food and 48.1 percent say that Medicaid makes it easier to pay for housing.[6] In another report examining the impact of Oregon’s expansion, Medicaid coverage is said to have nearly removed “the risk that health care needs will lead to catastrophic financial costs, undercutting a primary cause of homelessness.”[7]

Most importantly, studies indicate that work requirements will push beneficiaries out of the program, causing a significant decrease in health care coverage. For instance, Kentucky estimates that 15 percent of adult beneficiaries—about 97,000 individuals—will lose coverage due to such requirements.[8] Similarly, the state of Wisconsin estimates that 27 percent of adult beneficiaries “with no income would lose coverage under the state’s work requirement proposal.”[9] Creating access barriers to health care will reverse gains in the utilization of preventative care and care for chronic conditions, leading to higher long-term care costs for individuals and the entire health care system as people wait to seek treatment.

Kentucky HEALTH Comments

Kentucky HEALTH should be rejected as it will lead to substantial coverage losses due to its proposal to take health coverage away from individuals who cannot document that they meet rigid work requirements, including those who are working or eligible for an exemption but fail to meet the paperwork requirements. While most Medicaid enrollees who can work, do so,[10] many might fail to meet work requirements for other reasons, such as having seasonal employment, fluctuating work hours or because they simply weren’t able to submit the right type or amount of paperwork by the right deadline to prove they are exempt or will have problems meeting strict reporting requirements.

While the Council of Economic Advisors claims that work requirements in programs like Temporary Assistance for Needy Families program have been effective, these claims are inaccurate and misleading.[11] In fact, the percentage of TANF recipients who were employed in 2013 was the same as it was in 1996 – 63%.[12] In another study of 13 TANF programs from 1996-2000, only two of the 13 programs were found to have significantly reduced the share of families living in poverty.[13]

In addition to the proposal to take coverage away from individuals who don’t meet work requirements, Kentucky HEALTH proposes other policies that will primarily hinder access to care and cause harm as a result, and therefore do not promote the objectives of Medicaid. For example, the state seeks to lock individuals out of coverage under four different circumstances – not paying premiums, not complying with the work requirement, not renewing on time and not submitting information affecting eligibility in a timely manner. These proposals will do nothing to furnish medical assistance and are also unprecedented policies that are not used by other forms of health insurance, despite the state’s claims that they are attempting to “mirror the commercial market.”

Comments on Affordable Care Act Implementation  

The Affordable Care Act’s (ACA) Medicaid expansion did much to expand the population of consumers with insurance and a prescription drug benefit. We believe the Department’s time and resources would be better spent implementing the ACA and encouraging states to expand and not restrict Medicaid. The ACA is the law of the land, and the government is legally obligated to implement the law as we stated multiple times in various comments to previous proposed rules and requests for information.   

We have consistently raised concerns about action the Administration has taken to undermine the ACA and adversely impact the care of millions of consumers. Most concerning have been cutting the ACA enrollment period in half; slashing funding for enrollment assistance; refusing to participate in enrollment events; shutting down during critical times; refusing to pay cost-sharing reductions; and allowing the sale of inadequate insurance plans, such as short-term limited-duration insurance.

We are also concerned about a recent report from the Sunlight Foundation’s Web Integrity Project that found that HHS removed pages of information about the ACA from the Medicaid website. According to the Sunlight Foundation, the removed pages “provided information such as eligibility requirements under Medicaid and the ACA…” The Foundation also states that “Other Americans who are newly eligible for Medicaid through Medicaid expansion under the ACA could have used this information to understand how the ACA affects their Medicaid benefits and services they can receive.”

All endeavors that could weaken the ACA’s guaranteed consumer protections, cut Medicaid, raise costs, and destabilize the market must be rejected.


We appreciate the opportunity to submit these comments. Medicaid expansion has proven to be a lifeline for the working poor, allowing beneficiaries to fill important positions that might otherwise go unfilled due to low wages and the lack of health coverage. Perhaps this lifeline is why “national, multi-state, and single state studies show that states expanding Medicaid under the ACA have realized budget savings, revenue gains, and overall economic growth.”[14] Building barriers to health care coverage not only hurts Medicaid beneficiaries, who have come to rely on Medicaid coverage as a means for securing employment and fighting financial insecurity, but also the labor market and the overall economy. Kentucky HEALTH fails to achieve any of the goals HHS explicitly sets for Section 1115 waivers.[15] The Center respectfully urges states not to seek Medicaid waivers that place unnecessary burdens on beneficiaries, the Medicaid program, and the economy.


[1] Loren Anthes, The Return on Investment of Medicaid Expansion: Supporting Work and Health in Rural Ohio, Georgetown University Health Policy Institute, Center for Children and Families (Jan. 10, 2017),
[2] Rachel Garfield and Robin Rudowitz, Understanding the Intersection of Medicaid and Work, Kaiser Family Foundation (Dec. 7, 2017),
[3] Id.
[4] Dee Mahan and Nygel Williams, Medicaid Expansion Improves People’s Financial Stability, FamiliesUSA (Sept. 8, 2016), (citing Luojia Hu et al., The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Wellbeing, National Bureau of Economic Research (Apr. 2016),
[5] Id. (citing Nicole Dussault et al., Is Health Insurance Good for Your Financial Health? Federal Reserve Bank of New York, Liberty Street Economics (Jun. 6, 2016),
[6] Loren Anthes, The Return on Investment of Medicaid Expansion: Supporting Work and Health in Rural Ohio, Georgetown University Health Policy Institute, Center for Children and Families (Jan. 10, 2017),
[7] Oregon Study shows Obtaining Medicaid Improves Financial Security, National Health Care for the Homeless Council, (last visited Aug. 13, 2018).
[8] Hannah Katch et al., Taking Medicaid Coverage Away From People Not Meeting Work Requirements Will Reduce Low-Income Families’ Access to Care and Worsen Health Outcomes, Center on Budget and Policy Priorities (Aug. 13, 2018),
[9] Id.

[10] Rachel Garfiled, Robin Rudowitz, Understanding the Intersection of Medicaid and Work, Kaiser Family Foundation, December 7, 2017,
[11] LaDonna Pavetti, PhD, Evidence Counters CEA Claims on Work Requirements, Center on Budget and Policy Priorities, July 30, 2018, See also Ed Dolan, Do We Really Want Expanded Work Requirements in Non-Cash Welfare Programs? Niskanen Center,  July 23, 2018,
[12] Center on Budget and Policy Priorities, Policy Basics: An Introduction to TANF, June 2016,


[13] Jeffrey Grogger, Lynn A. Karoly, Jacob Alex Klerman, Consequences of Welfare Reform: A Research Synthesis, RAND, July 2002, See also Jessica Gehr, Doubling Down: How Work Requirements in Public Benefit Programs Hurt Low-Wage Workers, CLASP, June 2017, in-Public-Benefit-Programs-Hurt-Low-Wage-Workers.pdf; LaDonna Pavetti, Work Requirements Don’t Cut Poverty, Evidence Shows, Center on Budget and Policy Priorities, June 2016,
[14] Larisa Antonisse et al., The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review, Kaiser Family Foundation (Mar. 28, 2018),
[15] About Section 1115 Demonstrations,,


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