Medicaid narrative hurt by statistics in Kentucky

ADVOCATES of Medicaid expansion argue, correctly, that it can drive down the uninsured rate. Whether a lower uninsured rate translates into better health outcomes is less certain, as a comparison of Oklahoma and Kentucky demonstrates.

Oklahoma and Kentucky are demographically and culturally similar and often compared. Officials in Kentucky expanded Medicaid to include many ablebodied adults, as allowed under the Affordable Care Act. Oklahoma officials did not. Since then, Kentucky’s uninsured rate has fallen to 5.38 percent, which is eighth-best nationally. In contrast, Oklahoma ranks 49th with 14.16 percent of residents uninsured.

The question isn't whether Medicaid expansion lowers the uninsured rate, but whether Medicaid coverage improves health access and outcomes. Each year the United Health Foundation issues a health ranking of the 50 states. In 2017, the most recent year available, it ranked Oklahoma 43rd in the nation. Kentucky ranked 42nd.

The foundation found Kentucky continues to have a high prevalence of smoking, a high cancer death rate, and a high preventable hospitalization rate. In the past three years, the report found diabetes increased 24 percent in Kentucky, and in the past 10 years drug deaths increased 85 percent.

Of 33 core measures reviewed, the foundation gave Kentucky negative marks in 22.

Since 1990, the highest ranking Kentucky has received in the foundation report is 39th in 2008, which was before Medicaid expansion, and the lowest was 47th in 2014, after Medicaid expansion.

The foundation’s Oklahoma findings ding the state for a high cardiovascular death rate, high infant mortality rate and declining immunization rate among children. Since 1990, Oklahoma’s worst ranking was 49th in both 2007 and 2009 with modest improvement recorded since then.

In both states, poor health rankings appear tied to personal behaviors as much as or more than insurance coverage. People who smoke, don’t exercise and have poor nutritional habits are going to have more health problems regardless of insurance status.

It’s been argued Medicaid expansion benefits hospitals’ financial stability, particularly in rural areas. Some research has shown Medicaid-expansion states have experienced a slower rate of hospital closures than non-expansion states. But it’s notable that earlier this year when Becker’s Hospital CFO Report compiled a list of the seven states with the most rural hospital closures, Kentucky was among them. Since 2010, four rural hospitals have closed in Kentucky. And, according to recent news reports, another hospital could soon be added to that list: 462-bed Jewish Hospital in Louisville, which primarily serves the poor and elderly.

While federal funds cover most costs of Medicaid expansion, the state must still provide matching funds. In August, The Associated Press reported Kentucky’s Medicaid program faced a nearly $300 million state shortfall. Keep in mind, Kentucky is among the states hit by teacher strikes this year. More money for Medicaid constrains spending elsewhere, including schools.

Supporters of Medicaid expansion imply lower rates of uninsured citizens will translate into across-theboard health improvement among citizens. The fact that Kentucky continues to rank alongside Oklahoma suggests otherwise.