KY and a dry screw

Kentucky submitted their Medicaid Expansion waiver today. and it is a doozy.  There are a couple of interesting and potentially useful nuggets ( I liked the wrap-around policies so that a family that qualifies for multiple categories of aid stay on one plan for simplicity’s sake), a couple of things that I could live with but don’t like and then work requirements tied to health insurance which CMS has always shot down.

Below is a pair of screen shots from the cost justification section of the waiver that I found utterly fascinating.  The top shot is what the state projects will be the enrollment and cost per person per month (PMPM) growth without the waiver.  The  bottom is what the state projects would happen to enrollment and costs with the waiver.  The 1115 waiver is supposed to be at least budget neutral and coverage neutral.

TLDR: Fewer people enrolled at higher costs.

Let’s look at the data below the fold:

KY Waiver

The section on kids who qualified for Legacy Medicaid is fairly boring. They are projecting the waiver will minimally touch them as kids are exempt from most of the requirements. This makes sense. The Legacy Medicaid analysis for eligible adults is slightly more interesting to me. Enrollment trends go from a .5% gain per year to a drop of 2.2% per year while per member per month costs barely move by a tenth of a point in trend.

Looking at the adults eligible for Medicaid expansion is where the waiver gets screwy.  Membership growth trend goes from a gain of .5% per year to a decline of 2.3% per year.  Those are the numbers circled in green.  Even more interestingly, the numbers circled in red are the PMPM trend assumptions.  With no waiver, they are projected to grow at 7% per year.  With the waiver, they are projected to grow by 7.4% per year.

Kentucky projects that this waiver would reduce total Medicaid expenditures by roughly 2%.  Their own projections show no change in behavior of Legacy eligible kids.  Their own projections show minimal change in cost trend for Legacy eligible adults.  Their projections show a significant uptick in cost trend for Expansion adults.  Their cost side is either functionally flat or up.

The only way money is being saved as per person costs are either the same or higher is by covering fewer people.  The way that Kentucky will cover fewer people is by putting up half a dozen barriers to enrollment.  Premiums, health savings accounts, limited open re-enrollment periods, benefit lock-outs and job training requirements all are barriers.  Individually any of those barriers might only knock a few people out from the pool, but they are a bewildering array of complexity when put together.  The goal of this type of waiver design is to reduce costs by making more people go without insurance.


13 replies
  1. 1
    Baud says:

    Is there no “feature, not bug” tag?

  2. 2
    rikyrah says:

    You always tell the truth, Mayhew.

    ANd, I wish that I could feel for these people..

    But, they elected the muthaphucka that TOLD THEM THIS IS WHAT HE WAS GOING TO DO!!

    I mean, unlike most of the GOP, he didn’t even lie or dogwhistle his intentions.


  3. 3
    JGabriel says:



    Yep. Somehow, a significant percentage of voters keeps thinking Republicans won’t do what they say, because they don’t think any politician is crazy enough to do what Republicans promise. They just can’t process the idea that an entire political party has gone insane and has been that way for a significant part of the post-WW II era.

    So they’ve been voting under the assumption of Republican sanity for decades, despite the decades of contrary evidence – which means I don’t see much cause to think they’ll change. Younger voters, however, seem to be both more liberal and more likely to understand that the GOP is actually crazy, so I do see some small cause for hope there.

  4. 4
    rikyrah says:


    Did Bevin threaten to kick everyone off of Medicaid if the waiver was not approved?

    Approve or all of them will get no healthcare?

  5. 5
    Botsplainer, Neoliberal Corporate Shill says:

    This governor has also been relieving entire boards (pension, university, nominating) and stacking them with megachurch adherents loyal to him. This clearly goes against statute, and litigation is roaring into being.

  6. 6
    RSA says:


    ANd, I wish that I could feel for these people..

    Not everyone who is affected voted Republican, in case that helps.

  7. 7

    @rikyrah: That is his threat with the Expansion population (~450K IIRC)

  8. 8
    gvg says:

    Reminds me of my dad’s frustration with mom’s parents who voted Reagan. He said he would cut social security, why did you vote for him?

  9. 9
    NCSteve says:

    @rikyrah: The real problem in Kentucky was hundreds of thousands of voters who were benefiting from Kynect but had somehow been convinced that convinced that everything was so rigged against them that they’d lose their benefits no matter who won so voting was irrelevant. Self-disenfranchisement becomes self-fulfilling prophecy.

  10. 10
    Paul in KY says:

    @rikyrah: true dat.

  11. 11
    Paul in KY says:

    @Botsplainer, Neoliberal Corporate Shill: He said he had that powa. Does he have any legal leg to stand on or is he just brazenly lying?

  12. 12
    hovercraft says:

    As long as they can keep the focus on ‘those’ people the Bevins of the world will keep getting elected. Which in turn leads to slashing budgets and more poorly educated people who will continue to vote against their own interests. Most of these people are the most loyal Trump supporters, and they refuse to listen to reason. I do feel sorry for their kids.

  13. 13
    ET says:

    I am curious as to where the people are supposed to work to meet those work requirements. This is KY we are talking about? My friend was unemployed for 2 years and was hard core looking before landing something. This is just buy into the myth is that there are a lot of jobs out there but people are too lazy (and by people I mean black people because white people have too much pride to be unemployed, they are just “better,” or some other myth).

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