Health care providers in eastern Kentucky fear potential cuts to Medicaid in a bill that passed the U.S. House could have devastating effects on the health of its people and deal another blow to the impoverished Appalachian region.
Tawnya Brock worked as a nurse in the region for decades and now serves on the board of groups representing rural health care providers across the state and country.
Brock and other providers fear cuts would close clinics and severely restrict access to health services in a rural region that desperately needs them and is largely dependent on Medicaid.
“I've never seen as much concern and turmoil in health care as what I'm seeing now. And I've been doing this since 1978,” Brock said.
The Congressional Budget Office estimates the House version of President Donald Trump’s “One Big Beautiful Bill” would cut federal taxes by $3.7 billion over the next decade, along with $1.3 trillion of spending cuts.
The largest target of the proposed cuts is Medicaid, with spending estimated to decrease roughly $800 billion by 2034, and nearly 8 million people projected to be dropped from Medicaid coverage.
The nonpartisan budget office indicates that most of the loss in coverage is due to the bill’s new work reporting requirements for enrollees, as well as more frequent eligibility checks. The Kaiser Family Foundation estimates Kentucky would lose $2 billion of federal Medicaid spending annually over the next decade, with enrollment in the state dropping by 277,000.
Four Republicans in Kentucky’s House delegation voted for the bill in May, receiving thanks from an advocacy organization of Kentucky hospitals. These supporters say the bill actually “preserves” Medicaid — rejecting other options on the table to completely gut it — and merely safeguards against “waste, fraud and abuse” by denying coverage to those who choose not to work.
But to Brock, it feels like the country is stepping back in time. Over the last decade, Kentucky’s Medicaid expansion, allowing coverage for adults with incomes up to 138% of the poverty level, has grown the region’s health care industry, increasing clinics and providers to treat patients managing acute and chronic conditions including diabetes and substance abuse.
“My fear is you will see hospitals close, you will see clinics close, and we'll lose those service lines that we have for these patients,” Brock said. “And so it's not good. I have a great concern.”
Kentucky Public Radio spoke to 10 Appalachian providers who are pleading that unless the Medicaid cuts are reversed, the region will face yet another hurdle. With high rates of chronic conditions like heart disease, diabetes and substance abuse disorder, providers say Medicaid cuts could put the region’s wellbeing and the rural health care infrastructure at risk.
From Kmart to clinic
Cars steadily trickled in and out of a packed parking lot on the side of a mountain in Hazard, where Primary Care Centers of Eastern Kentucky operates its main facility. It’s one of the larger primary care facilities in the region, combining eye care, dental, diabetes management, substance abuse treatment and a pharmacy in one building.
Leslie Deaton, a nurse practitioner with the center for 13 years, said she grew up just down the road, back when the massive center was a Kmart. Now, the patients Deaton cares for out of the former big box store are largely patients who can’t afford private insurance.
The vast majority are on Medicaid and Medicare, and she says if enough of those dollars go away, so will the clinic.
“That's mainly what my reimbursement for my services come from,” Deaton said. “If you take those monies away, then you're going to have to cut providers. You're going to have to cut nursing staff. It's going to trickle all the way down to registration staff.”
Coal mining, which long defined the community, has steadily declined over decades. Coal mining jobs have largely evaporated in the region, and the population has steadily declined since the 1980s.
Deaton said that health care filled in the hole left by coal’s absence, especially since former Gov. Beshear — the father of the current governor, Andy Beshear — expanded Medicaid in 2014.
The center began getting patients who had no records and hadn’t seen a doctor in years, she said.
“They didn't have primary care providers. They hadn't had blood work. They didn't know if they were diabetic. Some of these people had (chronic obstructive pulmonary disease) that was unmanaged,” Deaton said. “We saw an influx of people for a certain amount of time, who had not accessed health care in a long time.”
Medicaid enrollment subsequently boomed in Kentucky, with a third of the state — 1.4 million people — now covered.
And that influx of patients, many of whom struggled with chronic illnesses and unmanaged conditions, now had insurance. This led to where Perry County is now, a health care hub in the region. The county now ranks near the top in the state in health care providers and Medicaid spending, per capita.
Work requirements at center of Medicaid cuts
The House bill now under consideration in the Senate seeks to cut hundreds of billions in spending on Medicaid by introducing mandatory work reporting requirements, shortening the enrollment period and implementing more frequent eligibility checks. Under the work requirements, which would go into effect by the end of next year, able-bodied adults would have to prove they had worked at least 80 hours in the previous month to maintain coverage.
In 2018, Arkansas was one of the only states to institute work requirements for the able-bodied Medicaid expansion population, which resulted in a quarter of eligible working people losing coverage for not reporting properly in the less than one year period the requirement was in effect.
In a hearing this month, Kentucky state officials said all but a small percentage of eligible, able-bodied Medicaid recipients are already working in low-wage jobs. Census data in previous years showed a majority of adults on Medicaid in Kentucky were working. Most of the rest indicated they did not work because they were either disabled, caring for a dependent, retired, attending school or actively looking for work, with only 2% not identifying a reason.
Deaton said some of her patients at the Hazard primary care clinic might fit into that small percentage of Kentuckians on Medicaid, technically able-bodied and not working. She said some of that circles back to the decline of coal.
“A lot of these people were coal miners who lost jobs, and they're not educated,” Deaton said. “They're displaced. And then, if they're going to have to try to find work, where are they going to find it?”
Other patients of hers struggle to find jobs without computer access, or are stranded without transportation. She worries others would fail to complete the paperwork properly without assistance and get booted off Medicaid, even if they are working.
Focusing on ‘waste, fraud and abuse’
GOP Rep. Brett Guthrie, who represents a portion of western Kentucky, played a key role in the Medicaid changes in the bill as chairman of the House Energy and Commerce Committee. He and other Republican supporters say the bill snuffs out “waste, fraud and abuse” in the Medicaid system.
In a cable news appearance this month Guthrie said most of those losing Medicaid coverage in the bill are adults who are not disabled, instead just “absolutely choosing not to work.” He cited a study by a conservative think tank — disputed by some experts — saying it showed this same group of Medicaid enrollees “spend over six hours a day on video games and socializing. That’s just not fair.”
Four of Kentucky’s GOP House members voted for the bill, including Congressman Hal Rogers, who has represented much of eastern Kentucky for more than four decades. The only Republican voting against it was Rep. Thomas Massie of northern Kentucky — who said he only did so because it didn’t cut enough.
The Republicans voting for it have indicated they did so because it actually preserves Medicaid — which is the same public stance of the Kentucky Hospital Association, the advocacy group for the state’s hospitals. In response to a Democrat saying in a committee hearing that the bill would devastate Kentucky hospitals, Guthrie replied by reading a statement of support from the KHA.
“It says ‘Chairman Guthrie’s mark will ensure our hospitals can continue to provide care to our patients where they are and when they need it.’ So I would like to know where you got those numbers because it doesn’t seem to match up with the Kentucky Hospital Association,” Guthrie said.
Neither Guthrie, Rogers nor the Kentucky Hospital Association agreed to an interview about the bill.
Kentucky hospitals disagree with national groups
In contrast to the Kentucky Hospital Association, many other medical and hospital associations have taken strong opposition to the Medicaid changes of the bill, including the National Rural Health Association, the American Hospital Association, and the Federation of American Hospitals. Each organization has said the Medicaid cuts would drop people from coverage and increase the amount of uncompensated care providers must provide to patients, causing facilities to close and people to get sicker.
Republicans in Congress did consider even deeper cuts to Medicaid than the final House version. Some wanted to end Medicaid expansion entirely, but they also looked at changing the matching and reimbursement rates for expansion states — a tactic that could have ballooned state budgets and meant lower payments to providers.
In expansion states, the federal government picks up 90% of the Medicaid costs for those in the expanded population, with states covering 10%. One option considered but not acted on in the House would have lowered this to 70% — the percent now picked up at the federal level for the traditional Medicaid population.
The final House bill did include a provision specifically beneficial to hospitals, but not other primary care providers, delaying for three years $24 billion of cuts to hospitals especially reliant on uncompensated care.
Though the KHA and several local hospitals in eastern Kentucky did not make anyone available for an interview, an executive of a hospital in a different region said the industry group’s support for the bill is because “it could have been much, much worse.”
“Unless I am interpreting something wrong, I think we will be okay,” said David Absher, chief strategy officer at Harrison Memorial Hospital, located in north central Kentucky. “Of course, then it may come back (from the Senate) with a totally different version, who knows?”
Absher says he went to Washington D.C. last month with KHA officials to speak about the bill. He’s glad the House opted to keep Medicaid expansion and grandfather in the higher reimbursement rates they now take advantage of in expansion states like Kentucky.
He’s concerned about increased eligibility checks and the narrowing of retroactive eligibility from 90 days to just a month.
“That could be a huge detriment, especially to those who have recurring patients, such as your recovery centers down in eastern Kentucky,” Absher said. “I certainly see their viewpoint.”
The reconciliation bill is now in the Senate, with Trump requesting they pass it by July 4, though Republican leadership has expressed skepticism that it could happen that soon. Due to the procedural nature of the bill, it only has to pass with a simple majority and cannot be held up by the 60-vote filibuster threshold.
The Republican majority may attempt to limit the cuts in the House version of the bill, but this would decrease the odds of certain deficit hawks in the party voting for it. This includes Kentucky Sen. Rand Paul, who says he does not support the House version because it does not cut enough wasteful government spending and creates “another $5 trillion in debt” over the next decade.
‘It’s offensive to me’
Brock of the Kentucky Rural Health Association and the National Association of Rural Health Clinics said clinics like the one she spoke from in London are barely scraping by as it is, let alone being wasteful with federal tax dollars.
She says while there likely is waste, fraud and abuse in the system, “but you can't take that statement and apply it as a blanket statement to health care and to the health care community. It's offensive to me.”
If a similar or more austere version of the bill comes back to the House from the Senate, Brock is hopeful that Rogers — the longtime congressman for eastern Kentucky — will hear the pleas of health care providers like her who are sounding the alarm and vote against it.
“I think meeting with our representatives in Congress and the Senate, it is an education process there,” Brock said. “We need to share our stories.”
Leanna Newsome is a community health worker at Big Sandy Health Care in Martin County, a few counties east of Hazard, which is notorious for having one of the worst water systems in the state. She said some of her patients are the “most needy” of the region, describing several chronic health conditions she sees on a regular basis.
“I have had some patients that started out with absolutely nothing,” Newsome said. “My very first patient, actually, when I first met her, lived in the basement and had a wood burning stove, and that's how she kept warm. And it was in January.”
Newsome says almost all of the people she assists are on Medicaid and managing chronic illnesses. Some haven’t been connected to utilities or internet. Some are entirely isolated, living in rural areas with no transportation.
“Those are the patients that are going to be left behind, the ones that don't even have the basic needs,” Newsome said. “Everybody automatically assumes that people have internet, they have access to email, they don't.”
Newsome said she helps patients access benefits and it’ll be up to workers like her to help people keep up with eligibility checks and reporting their work hours.
The current reconciliation bill incentivizes states to add red tape that could result in eligible children and people with disabilities losing their health coverage in order to avoid financial penalties, according to a Georgetown University Center for Children and Families report.
Although parents, guardians and those with certain disabilities are technically exempted from work requirements under the bill, states aren’t required to automatically exempt them from additional reporting requirements. That could mean people who are supposed to be protected under the bill could still lose coverage because they fail to file the right paperwork under the new requirements, according to the report.
Addiction recovery at risk
Greg Burke with Beacons of Hope, a substance abuse rehab center with outpatient and residential facilities, walked through the Hazard inpatient center. Appalachia was ground zero for the opioid epidemic of the past few decades and still has some of the highest rates of overdose deaths in the country.
Burke says his program is almost entirely funded by Medicaid, and it’s the “only reason” they are able to operate. He pointed out three Mommy and Me beds, allowing mothers to keep their babies through treatment.
“We have a 5-month-old baby that's here, and the mother's getting treatment,” Burke said. “Take Medicaid away. Where's that 5-month-old baby at? Where's that mother at?”
Like primary care, substance abuse treatment has expanded rapidly in the area to meet high demands. A key part of Burke’s program is partnering with local businesses to help people who complete the program to find employment. It also and gives them training and education while they’re in rehabilitation to be successful.
“This is our future workforce, and when people identify the work ethic and the grit, the grind that they got here, we just need to start trying to entice some of some economic development in our area, we're gonna have the workforce as long as they leave their Medicaid alone,” Burke said.
But for many people recovering from substance abuse disorder, finding employment can be difficult, especially for those with a criminal record. A study published in Health Affairs found that millions of people with substance abuse disorder could be bumped off treatment with Medicaid work reporting requirements, running “counter to ongoing efforts to respond to the opioid epidemic” and endanger ongoing treatment.
‘Nothing but dust’
The city of Hazard’s downtown coordinator Bailey Richards said she’s not sure how the Medicaid changes would affect them yet. However, she said expanded Medicaid has been a boon for the region and an economic driver for Hazard.
“We have almost all [healthcare options] here, which is pretty incredible for a community our size,” Richards said. “In the health care field, we're hitting well above our weight.”
Richards said having access to all that care not only brings thousands of people to the area every day, but means attracting more businesses to the area too.
“You gotta have the community in a place that can accept and offer the things that those people need,” Richards said. “Having a really great hospital, having cardiac care, having cancer care, having all of those things available here is huge.”
Medicaid spending makes up a large part of the economy for the entire region, according to the left-leaning Kentucky Center for Economic Policy. In Rep. Rogers’ district, $2.84 billion was spent on care through Medicaid last year, which is more than 13% the size of the district’s real GDP.
Food benefits too are in danger under the legislation, with the Supplemental Nutrition Assistance Program facing its own litany of cuts that could leave the state to pick up roughly $250 million annually. The center said that puts the benefits of more than half a million low-income Kentuckians at risk. Those benefits too play into the economics of the area, funding local farmers and grocery stores.
Burke with Beacons of Hope said he worries that the hits would contribute to the region’s decline.
“I'm gonna tell you right now, you take Medicaid away from this area, and it's nothing but dust,” Burke said. “You're gonna be left with basically abandoned little towns and probably some very, very sick people.”
Deaton, the primary care nurse in Hazard, took particular issue with Congressman Rogers’ vote for the bill.
“He's been a part of so many good things in Eastern Kentucky that it really blows my mind that he's going that way,” she said.
Deaton hopes Rogers changes his vote when the bill comes back from the Senate, “because I think we're going to see a downfall of care. And not just even that, just people's livelihoods in general, just how they live, it's going to affect everything.”
State government and politics reporting is supported in part by the Corporation for Public Broadcasting.
