FRANKFORT, Ky. -- In his mid-30s, Jonathan Hensley was unemployed and caring for some disabled family members. He needed to take care of himself, too, because his teeth hurt.
Historically in Kentucky, someone like Hensley -- a single, able-bodied adult with no job -- would likely not have had health insurance. But because the state expanded its Medicaid program under the Affordable Care Act in 2013, Hensley and some 400,000 other Kentuckians got taxpayer-funded medical, dental and vision coverage.
Hensley, now 37, got some needed fillings.
That routine dental coverage is now at risk, as Gov. Matt Bevin seeks to overhaul the state's Medicaid system. The Republican governor's proposal would eliminate routine dental and vision coverage for Medicaid recipients, but allow them to earn those benefits back by doing things like volunteering, undergoing a health assessment and getting a job.
Bevin administration officials say axing dental and vision coverage is a significant portion of the estimated $2.2 billion in taxpayer savings the changes to Medicaid would bring. The proposal also encourages people to take responsibility for their health, the officials say.
But health advocates say the plan would put up a barrier between the poor and access to dental care, setting up a battle in this Appalachian state where more than half of adults 18 or older have had a tooth pulled because of decay or gum disease.
"(Bevin) wants to say, 'Oh it's about providing dignity.' How is it providing dignity to sit here and say, 'You can't have vision, you can't have dental because you are a lazy bastard who is sucking on the government teat," Hensley said. "It's not because people don't want to work, people want to work. They can't get jobs and they can't get good paying jobs."
In Clay County, where Hensley lives, unemployment is at 11.1 percent, more than twice the U.S. rate of 4.9 percent. Most eastern Kentucky counties have unemployment rates in the double digits. They also have the highest populations, proportionally, of people on Medicaid. Experts say the use of dental health services across Kentucky's rural counties has been low for a variety of reasons, including a limited network of providers and a general lack of understanding of the importance of dental health. But in the first year of Kentucky's expanded Medicaid program, dental care surged by more than 100,000 people.
In Daviess County, more than 7,300 people enrolled in Medicaid after it expanded, the overwhelming majority of them adults, said Brandon Taylor, who runs the only dental clinic in the county that accepts Medicaid.
"Prior to that we frequently had patients come in with absolutely zero payer source," he said.
The Bevin administration says the current Medicaid program will cost taxpayers an extra $1.5 billion over five years, an untenable cost given the state's estimated public pension debt of more than $30 billion. Of the estimated $2.2 billion in savings generated from Bevin's proposed changes, about $300 million of it would be state tax dollars that the government wouldn't have to spend on Medicaid as currently structured.
Administration officials note that the proposed changes would not eliminate dental benefits for children, pregnant women, the medically frail and low income adults eligible for the traditional Medicaid program. Emergency dental coverage, like an abscessed tooth, would still be covered.
Routine coverage, including cleanings and fillings, would not be covered. But administration officials say adults who fulfill certain requirements, such as getting a health assessment, volunteering or taking a college class, will earn credit in a "My Rewards" account that can be used to pay for services, including dental and vision care or a gym membership. These adults would pay for services at the Medicaid rate, meaning it will be much cheaper than if they were paying out of pocket or with most commercial insurance plans.
Raynor Mullins, a retired professor at the University of Kentucky's College of Dentistry, said he fears people won't participate in the reward program and end up in the emergency room for routine dental coverage.
"If Gov. Bevin expects to solve the Medicaid cost issue by cutting the dental benefit, he's using reverse logic. I mean, it's going to cost him more," he said.
Scott Brinkman, Bevin's secretary of the Executive Cabinet, said officials do not expect participation in My Rewards to be problematic.
"We hope that's not the case because the whole purpose of My Rewards is people doing these kind of proactive, constructive activities," he said.
Brinkman said the proposed changes will include an extensive public relations plan that will encourage people to get their dental and vision exams before the changes go into effect. The state will then educate providers to encourage their patients to participate in the My Rewards plan "to make sure there is no diminution of service."
Bevin administration officials have held three public hearings on the proposal. Nearly all of the people who commented opposed the changes, including a parade of dentists and optometrists who warned of the dangers of ending routine coverage. Bevin has not yet formally submitted the proposal to the federal government, and he could still make changes.
"We take the comment period very seriously," Brinkman said, adding that Bevin would have to approve any changes before the plan is submitted.
Hensley said he likely could earn credit in the My Rewards account, but said he worried for others like him without access to transportation.
"Basic stuff like vision and dental, I mean, that should be included without having to pay extra," he said. "It can stop so many problems before they start."