At their August meeting, members of the state legislature’s Administrative Regulation Review Subcommittee heard testimony from healthcare advocates, providers and Medicaid recipients seeking approval for new Medicaid benefits made available this year.
In a renewal of Medicaid benefits for 2023, the federal government offered the option to add or enhance dental, vision and hearing benefits for adults. Gov. Andy Beshear signed on for the new benefits, which went into effect in January.
The move provided new benefits for the 900,000 adult Kentuckians receiving Medicaid. Recipients suddenly became eligible for services not covered previously under the program including root canals, crowns, dentures, hearing aids and glasses. People under age 21 already qualify for many of these benefits.
“When you’re living paycheck to paycheck, and just trying to make ends meet every month, there’s no extra to pay for root canals, crowns, glasses, hearing aids,” said Emily Beauregard, executive director for Kentucky Voices for Health. “That’s what we’ve been hearing from Kentuckians who have been reaching out to us to support these regulations.”
Cabinet for Health and Family Services staff — including Department of Medicaid Services Commissioner Lisa Lee, health and family services general counsel Wesley Duke and Regulatory Advisor Jonathan Scott — presented the cabinet’s case at the subcommittee hearing.
Beauregard also testified at the hearing. She said her organization had received hundreds of comments and was presenting them to the committee.
“The utilization numbers that we’ve seen so far really speak for themselves,” she said. “We have seen tens of thousands of people getting contact lenses, eyeglasses, frames, bifocals, trifocals. There have been 220 cornea procedures, more than 3,000 crowns, 2,000 root canals, 6,000 partial or complete dentures, almost 4,000 bite guards and night guards and 7,100 hearing aids. And that’s just in the first six months alone. These services are life changing for people.”
‘I feel like I can get back into the swing of life’
Through written and taped testimonies, the committee heard from patients and caregivers about how the lack of dental, hearing and vision care has affected them and how having opportunities for better care under the new benefits has dramatically changed their lives.
When COVID-19 hit, Holly Williams was working as a certified nursing assistant at a nursing home. She said she and her coworkers were called heroic, although she did not feel like a hero. She kept going to work each day, bearing witness to the destruction caused by the disease, and yet, she noticed something about herself during that time.
“COVID deaths ravaged an entire unit at a time once it found its way into the nursing home,” Williams said. “My own mental health was challenged. And yet, in a funny way, I found some confidence behind the mask.”
While the mask was keeping her — and her patients — safe, the mask had another effect on her.
“It also gave me a personal shield so folks didn’t have to see my mouth and the shape my teeth are in,” Williams said. “I could smile freely behind the mask and nobody would see the hurt and trauma going on inside my mouth.”
After the nursing home, Williams, a Scott County resident, found per diem work through medical staffing agencies that took her to jobs all over the state, but a series of circumstances caused her to lose her transportation, and for now she has been unable to find enough work. She relies on Medicaid.
“Having access to this dental coverage means everything to me right now,” Williams said. “I couldn’t afford the procedure or dentures until these new regulations took place in January. Even though it took me seven months to find a dental practice to accept my insurance, I’m very grateful that it’s all coming into play now. I feel like I can get back into the swing of life. I can’t even find the right words that would describe the level of gratitude I have for being given this opportunity.”
The committee also heard from Tiffany Hayes, an oncology social worker who works at a cancer center serving Central and Eastern Kentucky. She noted that many of her patients, from some of the poorest counties in the state, already have poor dental health and cancer treatments often make matters worse.
“We’ve been treating a 29-year-old metastatic breast cancer patient for about a year and a half,” Hayes said. “She needs a treatment called Zometa, but she has really poor oral health. Patients with poor oral health who take Zometa are at a higher risk of osteonecrosis of their jaw, which is just a fancy way of saying their tissue is generally going to die. And this also means you’re at a higher risk of infection after the chemo as well.”
The subcommittee heard from representatives of the Kentucky Primary Care Association, the Kentucky Oral Health Coalition and those on the front lines of care, including a primary care dentist who works primarily with Medicaid patients in his private practice.
They also heard from deans of dental schools at the University of Pikeville, University of Louisville and the University of Kentucky, who spoke about what they see in clinics as well as costs and issues of training the next generation of providers.
Beauregard and others noted while the new services filled an urgent need, more would be needed to address the concerns of patients and providers.
“We strongly support both the regulations before you today,” Beauregard said. “But we also support the need for a legislative solution that would permanently increase access to comprehensive dental, vision and hearing services.”
Cost and returns on investment
The federal government covers 90% of the cost of the program, according to the governor’s office. In May, the federal share of the program was listed as $31 million, and the state share amounted to $5.6 million. Kentucky spends about $14.5 billion overall on its Medicaid programs.
Cara Stewart, director of policy and advocacy for Kentucky Voices for Health, said the additional preventive care would bring a valuable return on investment, not only in terms of better health care for participants, but also in bolstering the workforce, increasing public safety and cutting costs for emergency care.
“We know that Kentucky was spending nearly $10 million a year the last three years on emergency department visits for tooth pain,” Stewart said.
That number was $9.9 million in 2021.
“I looked at some of the data requested and found via the Foundation for Healthy Kentucky Health Issues poll that nearly a third of low income Kentuckians said that their mouth and teeth affected their interviews to get a job, which if you think about it, makes perfect sense,” Stewart said. “I mean, think about our own biases, if you had two people sitting in front of you applying for a job and one of them has a full smile, they are probably going to be a lot more confident in that interview than someone missing their front tooth.”
Stewart also noted the emotional toll on victims of domestic violence, who have had a tooth knocked out. It is a constant reminder of that trauma, she said. She went on to say the impacts of new glasses and hearing aids and how much safer all Kentuckians are when people’s basic needs for vision and hearing are met.
“The return on investment, like Emily was saying, it’s nearly instant,” she said.
Objections center on how benefits were added
While no one has disputed that the new benefits provide relief for many recipients and their families, continuing these benefits next year is in jeopardy.
In March, the Republican-controlled legislature voted to reject the administrative regulations pertaining to the new Medicaid services, deeming them “deficient.”
At the time of the vote, Sen. Stephen West (R-Paris) co-chair of the Administrative Regulation Review Subcommittee, said funding for the program came from $38 million in savings from a recent change to how pharmacy benefits are managed under Medicaid. He said that move was an appropriation of funds that is the purview of lawmakers, not the governor.
“Co-chair West, myself and the Kentucky General Assembly have made it abundantly clear multiple times that we cannot afford to expand services provided under the Medicaid program,” subcommittee member and Sen. Damon Thayer (R-Georgetown) said when asked about the decision. “Currently, we cannot adequately cover the costs of services of the existing program.”
Substantially different regulations were required to be submitted for reconsideration. Medicaid regulations come as both “emergency” and “ordinary.” Both sets of regulations provide for the same benefits (hearing, vision and dental), but they are voted upon separately.
In May, after the legislature had adjourned, the Cabinet for Health and Family Services submitted revised new regulations to the subcommittee for review. Despite changes in reimbursement rates and services, the subcommittee voted on the emergency regulations and deemed them deficient. In June, the subcommittee was to have a public hearing, but this was pushed back to July and then to the August meeting.
At the August meeting, Rep. Randy Bridges (R-Paducah), a member of the subcommittee, reiterated the legislators’ concerns.
“These (regulations) were not found deficient because we do not want to provide the services to the constituents of Kentucky,” Bridges said. “They were found deficient because of the improper way in which this has been expanded. This is a revenues issue and should be taken to budget review of Health and Family Services for appropriations.”
Bridges concluded by saying that subcommittee members are not the keepers of the purse.
“We filed these initially sometime back last year,” Duke responded. “Senate Bill 65 was filed [nullifying the administrative regulations as deficient], and it was passed. The language of that bill gave us the opportunity to refile these bills if they were substantially different. It is my interpretation that these new these regulations filed…were substantially different and complied with Senate Bill 65. And that’s how we got here today.
“These have had a massive effect already on the health of the people in the commonwealth of Kentucky,” Duke continued. “We can argue about where we go from here down the road, but this was based on an appropriation that had already occurred….and properly followed that process.”
Where to go from here
Subcommittee member Sen. David Yates (D-Louisville) noted the state’s poor health rankings and the potential for new benefits to help turn that around.
“I think that we’ve seen massive effects with these numbers,” Yates said. “Forget the partisan politics and political games. Something has to be done; these appropriations have to be made.”
Yates said that it can be done and it will get passed if they want it to.
“Not only is the compassionate thing, the right thing, you’re getting people back to work,” he said. “We all have the same goal as a healthier, better, stronger, more stable Kentucky, and it starts by investing in the people.”
Committee Co-Chair Rep. Derek Lewis noted the current discussion was primarily about the emergency regulations and further discussion about the ordinary regulations would happen at a future meeting.
“I do think what matters is we go forward. I represent Leslie, Clay and Laurel counties,” Lewis said. “I have a very large Medicaid population. I’m in favor, mostly of what you are trying to do. I do have some questions on some of the more costlier procedures…I just think there needs to be conversation.”
He said he would make a personal commitment to sit down with all involved to make something happen, adding that he did not want the issue to become a political football.
“We need to get to the table and be ready for next session,” Lewis said.
The meeting ended with no action taken, so the initial vote on the emergency versions of the dental, vision and hearing regulations would stand for now.
Going forward, the two groups of regulations – emergency and ordinary – will be handled separately. On Sept. 6, the leadership will decide what interim joint committee would review the emergency regulations next. That committee would have 90 days to decide whether to meet to hear the regulations.
As for the ordinary regulations, they could be added to the Administrative Regulation Review Subcommittee’s agenda for their next meeting Sept. 12.