Even the experts seem to have more questions than answers when it comes to the federal health-care reform law

By Tara Kaprowy
Kentucky Health News

LEXINGTON, Ky. -- Confusion, primary care doctors overwhelmed by an influx of new patients, and employers opting to pay fines rather than health insurance are among the fears experts have about the federal health-care reform law. The experts discussed the issues this week in Lexington at the fall meeting of the Friedell Committee for Health System Transformation, a non-partisan, non-profit group formed several years ago to improve health in Kentucky.

Under the Patient Protection and Affordable Care Act, 30 million more people will become eligible for health insurance by 2014. People who have an income 133 percent above the federal poverty level — now $14,404 for individuals or $29,326 for a family of four — will qualify for Medicaid starting in 2014. Additionally, the federal government will give subsidies to help Americans whose income is up to 400 percent above the poverty level. With them, they must buy private coverage through state insurance exchanges.

The experts see problems arising from both options. "If you look at the overall population, it's very clear that the majority of these patients are going to be in the Medicaid program," said Elizabeth Cobb, vice president of health policy at the Kentucky Hospital Association. "Since Medicaid only pays hospitals at 85 percent of cost, that's a real concern" for providers. Cobb estimated that Kentucky hospitals will lose nearly $1 billion in revenue in the next 10 years because of the Medicaid expansion, along with cuts to other federal programs.

While hospitals will feel the stretch, so will doctors, with Kentucky lacking the primary-care infrastructure it needs to support the influx of new patients, said Dr. Steve Davis, acting commissioner for the state Department of Public Health. Davis said the average age of a practicing dentist in Kentucky is 58 years, and "in a few years," the state will have 3,000 fewer primary-care doctors.

"We don't have enough clinicians to meet those needs and that's a real problem," added Kevin Shuer, assistant professor at the University of Kentucky's College of Health Sciences.

Kentucky has taken no firm steps toward creating a state insurance exchange, a marketplace in which people will have to choose from a variety of plans. That will likely have to be done in the 2012 legislative session if the state opts to run its own exchange.

One reason for the delay is a lack of information, said Cris Miller, a partner in the Louisville accounting firm of Mountjoy Chilton Medley. "We know there will be four plans," each paying 60, 70, 80 or 90 percent of the covered benefit, she said. "We know the bronze plan is going to pay 60 percent of the covered benefit, but what is the covered benefit?"

Despite the unanswered questions, Julia Costich, chair of the Department of Health Services Management at UK's College of Public Health, believes Kentucky will set up a state-specific health insurance exchange, rather than let the federal government handle it, and will do so alone rather than partner with other states, since "the logistics to make that happen would be very complicated."

Costich's research shows about 400,000 Kentuckians will be eligible for federal subsidies as part of the exchange. Medicaid will eventually be included in the exchange and, after coverage expansion, the program's numbers could grow from its current 830,000 participants to 1.1 million in Kentucky. The federal government would cover the initial cost, but the state would gradually pick up a share, just as it does for current Medicaid patients.

The area of the state with the highest uninsured population is between Somerset and Bowling Green, according to Costich's research. There, one in four people under the age of 65 don't have any form of insurance. County-specific estimates show Franklin, Fayette and Jefferson counties have the lowest percentage of people without any form of insurance (4 to 8 percent) and Edmonson, Todd and Elliott have the highest (38 to 45 percent).

In 2014, employers with more than 50 employees who don't provide health coverage will be required to pay a penalty. The experts said paying the fines may be cheaper than offering insurance. According to global consulting firm Towers Watson, 3 in 10 American corporations are considering ending employee health coverage when the exchanges begin.

Though about 58 percent of Kentuckians have insurance through their employer, that's down from about 70 percent a decade ago, said Mark Lamberth, president-elect of the Kentucky Association of Health Underwriters. Lamberth said the drop is not surprising. "We've built a system that is really strapped on the back, for premium purposes, on employers," he said.

Another unknown is how accountable care organizations will work in Kentucky. Starting in 2012, providers that are part of an ACO — in which providers and hospitals team up to take care of a specific population in a coordinated way — will start receiving increased reimbursements from Medicare and Medicaid.

So far, there are no ACOs in Kentucky, which Miller said is not surprising. "If you know anything at all about ACOs, you know they're driven by volume," she said. "We're going to have a few in Louisville, probably as many as three in Lexington. Maybe have one in Bowling Green, one in Paducah. But I can promise you we will not have one in Pikeville, we will not have one in Somerset. There's not enough population."

With pieces of the law still undergoing legal scrutiny — the Supreme Court seems likely to decide by July whether Americans can be required to buy health insurance — and with many wondering what will remain of the law after the 2012 presidential and congressional elections, it's unclear what answers, if any, consumers might get before the end of the year. For now, "mass confusion" is what the experts are witnessing, Lamberth said. Miller agreed. "The biggest things we are hearing from our customers is fear."