Leveraging Health Reform to Combat a History of Cancer: Kentucky to Expand Medicaid, Increase Clinical Trials as U of K Markey Center Gains NCI Status
Published Online: August 20, 2013
Mary K. Caffrey
Governor Steve Beshear did not sugarcoat the data May 9, 2013, when he said Kentucky would take an offer it couldn’t refuse. With his state ranked worst in the nation in smoking and cancer deaths, and not far behind in heart disease, Beshear was “tired of being at the bottom.” 1
It was time for strong medicine–in the form of $608 million in new healthcare spending, which will come January 1, 2014, when Beshear accepts federal help to put 308,000 new people on Medicaid.1 Another 800,000 Kentucky residents are already in the program.2
The decision followed Beshear’s 2012 call for Kentucky to create its own exchange to sell health insurance under the 2010 Affordable Care Act (ACA). In theory, all 640,000 uninsured Kentuckians should be able to gain health coverage.3 Cutting Kentucky’s cancer rates is a tall order, and Beshear is candid about the link between that grim history and his state’s economic conditions. Taking the Medicaid money, in his view, was the only choice that made sense.
“Kentucky is one of the least healthy states in the nation. In 2012, Kentucky’s overall health ranking was 44th. Kentucky is at or near the very bottom of many national health rankings,” Governor Beshear told Evidenced-Based Oncology. “A multitude of state and national reports have shown the positive impacts on health status that occur when an individual becomes insured. They are more likely to get preventive care and seek out medical treatment when they need it. They miss fewer days of work and school. And they live longer and more productive lives.
“By the time we reach 2020, I believe we will have seen such a measurable impact on prevention of disease, management of chronic health problems, and overall health of our workforce that to withdraw or shrink from Medicaid expansion would be unthinkable.”
Beshear, a prostate cancer survivor, feels he is on solid footing, morally and practically. The expansion affects single persons with incomes of up to $15,856 per year or a family of 4 with an income of up to $32,499;3 many of these are working poor. The infusion of healthcare spending will create 17,000 jobs and $15.6 billion in economic activity,1 reduce absenteeism, and improve job performance to make Kentucky workers more attractive to industry.
Over time, Beshear believes, healthier children will miss fewer days at school, and the commonwealth will see economic benefits from a healthier population.4 All this will require confronting Kentucky’s historic links to coal and tobacco, and resulting rates of cancer, especially lung cancer. “While my primary concern is for the improved health outcomes that will be possible for many of our citizens through the expansion of Medicaid, my decision was not solely based on the obvious health benefits that extending insurance coverage will provide to the people of Kentucky. It was also based on the far-reaching economic benefits of expanding Medicaid,” Beshear said.
“If a company was willing to invest $15.6 billion in Kentucky in the next 7 years, creating nearly 17,000 jobs and significantly reducing the uninsured population, while greatly improving the health of our citizens, we would not hesitate to welcome them into our state. Medicaid expansion is no different.”
Kentucky health officials must overcome political and logistical hurdles, not to mention cultural ones. A fee-for-service delivery system, saddled by ignorance, poverty, and occasionally the belief that “God’s will” would determine the outcome, had to be replaced by one that relied on regular screenings and outreach. Healthcare advocates and observers said the record of failure meant that when the state’s poor interacted with the medical system, there were few expectations. “Folks are not accustomed to getting healthcare and having healthcare work,” said Susan Zepeda, PhD, president of the Foundation for a Healthy Kentucky. “They may have family members who were diagnosed so late that the diagnosis was a death sentence.”
But critics of Kentucky’s approach say the state has rushed too quickly into managed care, in a quest to upend delivery systems that caused some low-income or rural residents to wait too long to seek treatment.5 In the breathtaking sprint to move 70% of the state’s 800,000 Medicaid recipients into managed care organizations (MCOs) for the first time, Kentucky Medicaid Commissioner Larry Kissner admits there were many bumps.
Over the long haul, however, Kissner insists the accountability of managed care under health reform will make a difference: In the first year, he said, officials are reaching more than 80% of Medicaid patients for regular screenings; once that baseline is established, officials will be able to track progress in measurements like blood sugar over time. Better still will be when more consistent healthcare shows up in higher test scores among school-age children, or lower smoking rates in the next generation of adults.
From academia to government, those who know Kentucky’s system hope to finally bridge a gap that has long existed: In a commonwealth with world-class healthcare at universities in Louisville and Lexington, there are aching needs among some of the most isolated, impoverished poor in the nation.
On paper, Kentucky envisions a system of federally funded health centers and managed care networks, providing regular screenings like colonoscopies and mammograms. Telephone calls would remind cancer patients when to come in for care, and will provide follow-up that the old system never could.
It remains to be seen whether cancer care delivery under Kentucky’s new model can serve a rural population. Steven W. Wyatt, DMD, MPH a veteran of the Centers for Disease Control and
Prevention (CDC) who returned to his native state to become dean of the College of Public Health at the University of Kentucky, said getting more rural people enrolled in Medicaid is only the first step. “Just because you remove the cost barrier doesn’t mean you are going to increase the access,” Wyatt said. “It’s all about other things that surround the payment of services.” Things like transportation, or missing work, or not having anyone to watch a child or grandchild, or just the fear factor of coming to a modern campus like the Markey Cancer Center in Lexington. “Navigating a university setting can be intimidating,” he said.
Zepeda concurred. Although Kentucky has a “more robust” network of federally funded health centers than existed even 5 years ago, she said, expanding Medicaid rolls and subsidized insurance mean “there will be capacity issues, particularly in rural areas of the state.”
PDF is available on the last page.