Ronnie Stewart spent years as a state social worker. Given his experience in government bureaucracy, Sewart said he understands why Gov. Matt Bevin is going to make many of Kentucky’s Medicaid recipients pay monthly premiums and regularly report their work and income status.

“He’s just trying to set up roadblocks so he can trip people up and then knock them off Medicaid to save money. That’s all there is to it,” said Stewart, 62, a Lexington retiree who credits Medicaid with paying for the cataracts surgery that restored his eyesight three years ago.

“When you charge a premium, some people can’t pay it, so off they go. When you make people file a report every month, some people aren’t going to make the deadline, so off they go,” Stewart said. “It’s all about putting up roadblocks.”

Stewart is one of 15 Kentucky Medicaid recipients who sued the Trump administration in federal court Jan. 24. They are asking U.S. District Judge James E. Boasberg to overturn the federal government’s approval of Bevin’s waiver that would require able-bodied adults up to age 64 to complete 80 hours a month of “community engagement” to keep their Medicaid coverage. That could mean a job, school, vocational training or unpaid community service.

While the controversy has focused on Bevin’s work requirement, the lawsuit also draws attention to the new hurdles that Medicaid recipients will have to jump in order to keep their coverage. They include monthly premiums, initially from $1 to $15, although they eventually will top out at $37.50; monthly check-ins to report employment and income status; annual re-enrollments; and ongoing verification of extra tasks people must complete if they want to win back the vision and dental coverage they previously had as part of their basic coverage but are about to lose.

Missing a payment or notification could trigger a six-month lockout on basic health coverage. Missing the enrollment window could mean waiting nine more months for the next opportunity.

The lawsuit, which was organized by three nonprofit groups, claims the waiver violates the 1965 law establishing Medicaid because it will result in the reduction of health care to poor people who need it. The Bevin administration estimates 95,000 people will lose their coverage over the next five years out of the more than 400,000 Kentuckians just above the poverty line who are currently enrolled in expanded Medicaid.

“Members may have health coverage temporarily suspended for not meeting the community engagement and employment initiative requirements, failing to pay required monthly premiums or failing to report a change in circumstances,” the Bevin administration told the U.S. Centers for Medicare and Medicaid Services last year in its waiver application.

Health policy experts say Kentuckians are likely to fall off the Medicaid rolls because of the paperwork obstacle course. Someone juggling a low-wage job, children and the usual turmoil associated with poverty is unlikely to have time for regular check-ins with Medicaid officials, even assuming they have reliable Internet access or transportation to a state office building in their community, the experts say.

“When you’re considering assistance programs, the research shows that each time you require a point of contact between the state and the enrollee — each time you require an active choice — you lose people,” said Laura Dague, an economist who studies changes in Medicaid policy at Texas A&M University.

“What’s interesting is that even small premiums discourage enrollment,” Dague said. “You would think the value of the program would outweigh the cost of paying $10 a month. It’s sort of unexpected that small premiums have such a large effect. They have almost the same effect as large premiums. The implication is that part of the effect of premiums is to basically increase the filing and paperwork demands on the enrollee, and that itself is what is having an effect.”

Other states have seen such results. In Indiana, the state implemented monthly premiums of $1 to $27 in its Medicaid expansion in 2015 under then-Gov. Mike Pence, who is now vice president. About 25,000 adults were kicked off the rolls over the next two years for failure to make their payments, according to Kaiser Health News.

The Bevin administration told the Herald-Leader this week that it will make the monthly check-ins “streamlined and automated,” both for people using the web and those visiting a state office. It’s assumed that about 80 percent of Medicaid recipients have a smart phone, said Adam Meier, Bevin’s deputy chief of staff for policy.

“The premiums are not intended to be a barrier and will be in lieu of the co-payment system in the current Medicaid state plan,” Meier said, referring to the fees, often $3 or $4, that some Medicaid recipients now pay for some services. “In other words, as long as a beneficiary is making monthly premium payments, there will be no additional out-of-pocket expenses. Premiums are easier to plan for and allow members to be engaged in their health outcomes.”

In Indiana, data shows that Medicaid recipients in the monthly premium plan are more likely to obtain preventive health care, stick to their prescription drug regimes and avoid the emergency rooms for unnecessary visits than Medicaid recipients in the traditional plan that charges co-payments, Meier said.

“By increasing personal involvement in health care decisions, members gain skills for long-term success and are empowered to take an active role in their day-to-day health care decisions,” Meier said.

But Kentucky’s new requirements look like a barrier to Shawna McComas, 34, another one of the Kentucky Medicaid recipients who is suing the Trump administration.

McComas is raising four children in an apartment in Lexington’s Winburn neighborhood. She usually works around 40 hours a week as a housekeeper at the University of Kentucky, a bus ride across town, for an average annual income of $28,800. However, her hours can vary from week to week, which means her pay does as well. Under the new Medicaid rules, she will need to keep the state of Kentucky regularly updated on her fluctuating income.

McComas said she doesn’t object to the work requirement; she has worked her entire life. But she fears losing Medicaid if she misses a payment or check-in. And she needs vision and dental coverage, she said, which means more time spent performing extra tasks, such as taking a “health-risk assessment,” and then verifying the completion of those tasks with state officials so she has the proper credit awarded to her new special incentives account.

“It’s aggravating to me. I feel like I’m being punished for doing the right thing,” McComas said. “If they start sending me bills, then I’m going to have to juggle which other bill I won’t be able to pay that month. Will it be my rent I’m going to short, or something else? Because I don’t have extra money lying around.”

Her co-plaintiff in the lawsuit, Ronnie Stewart, lives on $10,092 a year in Social Security checks. Stewart said he was forced to quit his job last year as a sterilization technician at UK Chandler Hospital because diabetes and arthritis made it too difficult for him to match the hospital’s demanding pace.

At age 62, Stewart said, he resents being made to “jump through hoops” after a lifetime of work, but he figures he won’t have to jump through them for long.

“I just have to make it to 65, and then I’m eligible for Medicare,” Stewart said, standing outside his small apartment off Winchester Road. “What I’m going to do is, I’ll go back to school and I’ll do one of those ‘Work Ready’ programs the governor keeps talking about. He wants us to be work ready, I’m gonna get myself work ready!”

He laughed.

“That’ll do me for a year or two. And then I’ll find something else until I make it to 65. I’ll find something. I’ll make it,” Stewart said. “I’ll fare better than a lot of the clients I worked with — people who were mentally ill, people who didn’t graduate from high school. I’ve got no idea what they’re going to do. There’s nothing for them. You tell them to go out and get a job and pay a premium or else we’ll take away your health care, and they’ll just disappear into the streets.”

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Are Bevin’s new Medicaid rules ‘all about putting up roadblocks’ for poor people?