Kentucky Shows What Can Happen When a Poor, Conservative State Expands Medicaid

In a state best known for horses, bourbon, and poverty, a quiet transformation is taking place. Kentucky ranks in the bottom five for almost every health statistic imaginable. It’s also been among the most vigorous of state actors in implementing the Affordable Care Act. That combination makes it an interesting case – what happens when a poor, unhealthy state does its best to take advantage of the ACA?

The short answer is that over a half million people – in a state of only 4.4 million – sign up for healthcare. About 75 percent of those who signed up didn’t previously have health insurance, so the uninsured population has dropped by 42 percent and the uninsured rate has gone from more than 20 percent to less than 12 percent.

Although the health-care exchanges that were created by the Affordable Care Act have gotten most of the news coverage so far, it’s the expansion of Medicaid that has had the biggest impact, with about 80 percent of the newly insured in Kentucky getting coverage through Medicaid.

In the Supreme Court’s June 2012 decision upholding the constitutionality of the Affordable Care Act, the court ruled that states could opt out of the Medicaid expansion without losing any of their current Medicaid funding. Many policy analysts didn’t think the ruling would have a major impact, since the federal government is paying for the entire expansion for the first three years and gradually reducing to 90 percent in 2020. As MIT healthcare economist and Affordable Care Act architect Jonathan Gruber put it, “When the Supreme Court decision came down, I said, ‘It’s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?’”

More than a few, as it turns out.

Only 27 states and the District of Columbia have opted into Medicaid expansion.  In Kentucky’s case, it found that expansion would actually save money, delivering a $15.6 billion boost to the economy while creating almost 17,000 jobs—all while insuring its most vulnerable citizens. As Governor Steve Beshear wrote in a New York Times op-ed defending the decision, “…to those more worried about political power than Kentucky’s families, I say, ‘Get over it.’ … and get out of the way so I can help my people. Here in Kentucky, we cannot afford to waste another day or another life.”  He called the reform “the single most important decision in our lifetime for improving the health of Kentuckians” and said the state would “come out ahead in terms of both health outcomes and finances. In fact, if we don’t expand Medicaid, we will lose money.”

In contrast, as Gruber notes, the states choosing not to expand Medicaid “are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.”

The non-expansion states already have, on average, poorer health outcomes and large uninsured populations, and now they will fall even further behind healthier states. The difference is already visible in survey data, according to Gallup.


If the 23 states that haven’t expanded Medicaid were to instead opt-in, nearly 7 million additional people would likely receive coverage. These states are also passing up on more than $400 billion in federal funding.

This slow expansion of Medicaid is not unprecedented. In 1966, when federal funds for Medicaid were first available, only 26 states had programs up and running by the end of the year. By 1970, however, 48 states offered Medicaid. It wasn’t until 1982 that the last hold-out, Arizona, finally opted-in.

One of the tricks for providing healthcare in states where Obamacare is politically unpopular is—well, not too tricky: call it something else. Although ‘Obamacare’ remains unpopular in Kentucky, ‘Kynect’—the name of the state’s health insurance exchange—is popular.

The faith community is also playing a major role in pushing for expansion, arguing that it is a moral issue, and noting Jesus’ role as a healer. Rev. Raphael Warnock, the Senior Pastor of Ebenezer Baptist Church in Atlanta, reminded policymakers that the millions of people caught in the Medicaid gap “are not numbers, these are our church members and family members. So for us, this is a matter of life and death.” Towards the end of August, the Moral Monday Movement marched on 12 state capitols urging governors and legislators to expand Medicaid.

In my own church in Kentucky, I have already seen the benefits of expansion.  One of our members who works for wages that are too low to afford health insurance, but were too high to qualify for Medicaid prior to expansion, finally has access to healthcare. For the first time she stopped worrying about what would happen to her if she were to get sick before she was old enough to qualify for Medicare.

The Robert Wood Johnson Foundation and the Urban Institute have provided a state-by-state breakdown of what opting-out of Medicaid expansion is costing in both human and financial terms. Find out what your state is missing out on, and then urge your decision-makers to follow Kentucky’s lead.



Editors Note: Listed states had not expanded eligibility as of July 2014. They include Indiana, Pennsylvania. and Utah, which have pending waiver proposals to expand eligibility. Totals may not add because of rounding. Note that Pennsylvania announced last month that it will expand Medicaid.




Food Stamps, 50 Years Later: Stop Impeding, Start Improving

The Food Stamp Act of 1964 was signed into law 50 years ago, launching a food assistance program that has been a lifeline for millions of hungry Americans. Five decades later, our political leaders – national, state, and local – need to acknowledge the enduring value of the Supplemental Nutrition Assistance Program (SNAP—the modern incarnation of food stamps), stop making false arguments to justify gutting it, and focus on improving America’s most effective tool in the fight against hunger.

Because hunger is an ongoing problem in America, our nation has steadfastly supported a federal nutrition assistance program that feeds hungry families as it boosts local economies. Though some politicians disingenuously argue otherwise, it still does both of those things very well.

SNAP reduces food insecurity and, in 2012 alone, lifted more than 4 million Americans out of poverty. More than half of those individuals—2.1 million—were children, who are potentially the most devastated by hunger due to increased risk of poor health, hospitalizations, developmental delays, behavioral problems and low academic achievement. Of course, food insecurity causes harm at every age, and SNAP is effective as well for millions of seniors and working-age adults in blunting the harshest impacts of hunger and poverty.

In terms of economic benefits, SNAP creates markets, and spurs economic growth and jobs in both rural and urban communities, at grocers, farmers’ markets, military commissaries, manufacturers and farms. In addition, because SNAP beneficiaries spend 97 percent of their allotments in the month they are issued, the economy as a whole benefits. Research conducted by Moody’s Analytics and USDA estimate that there is between $1.73 to $1.79 in economic growth per $1 of SNAP benefits.

With so many proven advantages—not to mention a historically recognized moral and bipartisan responsibility to care for our nation’s most vulnerable citizens—why do so many leaders attempt to justify cutting the program, or trot out tired reform proposals we know won’t work?

Food insecurity causes harm at every age, and SNAP is effective in blunting the harshest impacts of hunger and poverty.

For example, the recent Farm Bill cut SNAP benefits and access to the program in several ways, hurting low-income, hungry people as well as our economy.

Most recently, House Budget Committee Chairman Paul Ryan doubled-down on a warmed over bad idea when he proposed to take 11 safety net programs, including SNAP, and convert them into a single block grant for states, with few minimum standards other than the kinds of harsh conditions for beneficiaries that Rep. Ryan favors.

Ironically, the weaknesses of programs converted into block grants—how they lose support over time as their goals are watered down, funds are diverted to more politically powerful constituents, and the grant become less effective and more vulnerable to attack—are highlighted by Rep. Ryan’s companion proposal. He would expand the Earned Income Tax Credit (EITC) to childless workers—a good step—but pay for it by eliminating the Title XX Social Services Block Grant, as well as other low-income programs, including the Fresh Fruit and Vegetable Program for children and the Farmers’ Market Nutrition Program.

Such proposals are a waste of policymakers’ time and focus. Our nation would be much better served by implementing thoughtful solutions to hunger that focus on expanding opportunity and reducing poverty, rather than weakening programs that support working and unemployed adults, children and seniors.

First and foremost, we need to improve economic outcomes for families in the workforce through better wages, benefits, and supports like the EITC and the refundable Child Tax Credit. We need to strengthen child nutrition programs so children have access to food both in and out of school. We also need to improve SNAP so people have more resources to purchase a healthy diet. The current, woefully inadequate monthly allotments are based on the outmoded Thrifty Food Plan (TFP), a descendant of a diet developed for emergency use in the 1930s.

A recent Institute of Medicine report found that SNAP benefits are not enough for most beneficiary households—and don’t do enough for food security and food purchasing power. Other research—including USDA’s own analysis of a recent (temporary and now eliminated) benefit increase provided through the American Recovery and Reinvestment Act—has shown the powerful effect of a healthier allotment.

Fifty years after our nation’s legislators took on the fight against hunger, today’s leaders need to put politics aside.  It’s time to acknowledge SNAP’s necessity and value; correct its shortcomings and build on its strengths; and celebrate its historic contribution to the well‐being of America and its people.





How Real Food Can Help Fight Poverty

On January 8, 1964, in his State of the Union address, President Lyndon Johnson announced the launch of the War on Poverty. While the programs implemented since then have done a tremendous amount to mitigate hardship in America—the poverty rate would be nearly twice as high without the safety net—our nation’s rate of poverty and growing income inequality are a black stain on our body politic. While the official poverty rate is 15 percent, fully four out of five Americans will experience at least one year of poverty or another form of significant economic hardship at some point during their working years.

It’s time to renew our nation’s deep commitment to ending poverty. This commitment shouldn’t be made out of mere sympathy but in the interest of our nation as a whole. But getting out of poverty starts with a healthy body and healthy mind. Let’s all agree that an adequate, nutritious diet is something each and every one of us needs—and deserves. This shouldn’t be a stretch for most of us to see and understand.

More and more we are realizing how our diets impact our physical and mental health. Lack of access to adequate, nutritious food prevents students from thriving academically and workers from performing at peak levels at their job. Healthy food is an important engine to propel students and workers out of poverty. This is not to oversimplify the problem, or to suggest that this is all that needs to be done, but it is a very important starting point. Access to real food is foundational to climbing out of poverty.

Let's all agree that an adequate, nutritious diet is something each and every one of us needs and deserves.

As someone who has played a lot of sports in my life, and even coached a little, I know that when it comes to athletics and improving and developing talent it all starts with fundamentals. This means recognizing how interconnected the issue of poverty is to many other issues like health, education, being safe, feeling cared about, and good, healthy food. A student cannot learn if he is full of sugar and processed food—or distracted by hunger pains. An adult can’t stay healthy if he or she needs to eat the cheapest, most accessible and most processed food for years at a time. The most basic thing we can do to lay the foundation for good health, and academic, social and financial success, is to eat—as Michael Pollen has put it—real food. We are what we eat, period.

When it comes to health and wellness, and solving the gut-wrenching issues of poverty and hunger, we need to get back to the fundamentals. We need to grow more of our food in or near our cities, which can drive investment into our poor neighborhoods. We need ‘edible classroom’ programs which can get more healthy food to our kids, teach our students about where food comes from and the knowledge of how to grow it. We need a garden in every school yard, a kitchen in every school where students can learn to prepare the food they grow, and a salad bar in every cafeteria. And we need to protect and strengthen investments in our bedrock federal nutrition programs such as the Supplemental Nutrition Assistance Program and Child Nutrition programs.

Our current policies make healthy food inaccessible for millions of Americans, while subsidizing and making pervasive fake foods that give us diabetes, heart disease and high blood pressure—which lead to higher healthcare costs down the line.  An ounce of prevention is worth a pound of cure—yet policymakers continue to make penny-wise and pound-foolish decisions.  Every dollar wasted on the current approach is money that can’t go to investments that bring more justice to our broken economic system.

There are leaders that are already making connections between the food we eat, our health and well-being, and the poverty we see all around us. Laurie David’s new movie, Fed Up, includes commentary from Katie Couric, First Lady Michelle Obama, and former President Bill Clinton. Dr. Mark Hyman, a thought leader in the area of food and nutrition, says the country cannot afford the cost of bad food, and the bad health that follows. In one of his recent blog posts, he said that because of bad food, “….our kids are sicker, leading to an achievement gap that limits our capacity to compete in the global marketplace, and 70 percent of our kids are too fat or unfit to fight, threatening our national security. These are not small problems.”

Pilar Gerasimo, a writer and editor, says that health is the “gateway” to power. Without optimal health and vitality, she says, everything else that we want to do gets harder. The bottom line is this: integrating healthy eating and wellness into our social safety net will energize our current programs, strengthen the mental and physical well-being of those who need them, and inspire more Americans to support a new approach that will better position families in poverty to work their way up the ladder to the American Dream.




This Labor Day, Let’s Remember Those Who Can’t Afford a Day Off

In a recent New York Times article, reporter Jodi Kantor describes the challenging lifestyle of Jannette Navarro, a 22-year-old single mother who is a Starbucks barista with an erratic work schedule. The article chronicles Jannette’s seemingly impossible balancing act of seeking childcare, pursuing an education, and providing for her family.

The workplace stress and uncertainty that Jannette faces day-to-day is also felt by low-income working families across the US. Fluctuating work hours and limited resources make the daily demands of family life and trying to get ahead in the economy a constant challenge, creating anxiety as families simply struggle to stay afloat.

Through its research, Children’s HealthWatch, a national nonpartisan network of pediatricians and public health researchers, has documented that job security isn’t just an economic and lifestyle issue – it affects our physical health as well.  In our brief published today – Steadying the Foundation: Maternal Job Stability, Safety Net Programs & Young Children’s Health – we describe how job instability (defined as maternal job loss or reduced work hours) increases the risk of poor health for mothers and their young children.

In urban hospitals across the country, we interviewed more than 14,000 low-income working mothers with children under age four.  We found that 38 percent of these women had experienced job instability in the past year. Compared to stably-employed mothers and their children, mothers with job instability were more likely to have poor mental and physical health, and their children were significantly more likely to be in poor health and have developmental delays. Our research also found that job instability is linked to higher levels of material hardships such as housing insecurity (living in overcrowded conditions or moving frequently) and family food insecurity (when families lack sufficient food for all members to lead active, healthy lives).

While financial loss due to job instability can end up harming the health and development of young children, our research suggests two of the largest federal safety net programs – the Supplemental Nutrition Assistance Program (SNAP) and Unemployment Insurance – can blunt the impact. The rate of child food insecurity – a severe level of food insecurity where children have to skip meals or go without eating for an entire day – was significantly lower for children whose mothers experienced job instability but also received SNAP, than it was for the children who did not receive SNAP.  In other words, SNAP helped to buffer children from the worst effects of job instability.

Unemployment insurance (UI) had a similar positive effect, stabilizing the housing of children whose mothers had lost a job. Families experiencing job loss who received UI were 27 percent less likely to be housing insecure than those families that did not receive UI.

No one wakes up in the morning saying, ‘I think I want to lose my job today and go apply for government assistance'

Of course, no one wants to have to rely on public assistance as they juggle the demands of raising a family and inconsistent work hours or job loss. As Tianna Gaines-Turner, a member of Witnesses to Hunger in Philadelphia, puts it, “No one wakes up in the morning saying, ‘I think I want to lose my job today and go apply for government assistance and wait weeks for my unemployment to go through.’ No one wants that. But food stamps and other government assistance programs are important to help families who, through no fault of their own, end up unemployed and need a little extra help.”  She and her husband both work to support their three children but have struggled to escape poverty.

In response to the New York Times article, Starbucks has announced it would change the way it schedules its baristas in order to improve “stability and consistency.” Shifting towards a more manageable and family-friendly work environment is a good first step. However, there are other actions that policymakers should take to promote job stability and improve the health and self-sufficiency of low-income families.

First, increase the minimum wage to at least $10.10 an hour, and index it to inflation to ensure its value does not erode in the future; also expand the Earned Income Tax Credit (EITC) and Child Tax Credit to provide a critical boost to low-wage working families’ incomes. Second, ensure that the SNAP benefit is calculated based on the real cost of a healthy diet to help eligible families put more healthful food on the table.  Right now, it’s based on a plan that doesn’t match the costs of living for today’s working families. Third, permit “good cause” as a qualified reason for leaving a job under UI regulations.  Currently, many workers are ineligible for UI even if they have an unavoidable and justifiable cause for resigning, such as health problems or child care issues.  Lastly, strengthen the Family Medical Leave Act so that qualified workers receive up to 12 weeks of paid leave each year for the birth or adoption of a new child, serious illness of a family member, or a worker’s own medical condition.

This Labor Day, we should recognize the kinds of workplace practices and policies that allow families to lead healthy, productive lives with stability for their children.  The solutions are within reach – employers and policymakers can strengthen economic security for all working families.



Bank of America Settlement and the Need for Legal Aid Lawyers

Last week, Bank of America reached a record-setting $16.65 billion settlement with the Department of Justice for selling toxic mortgage securities during the housing boom. The agreement includes $30 million for states to distribute to their legal aid programs. This is encouraging news for the 1.75 million homeowners who are still in default on their mortgages, as well as the 9.5 million borrowers who are underwater and at risk of foreclosure.  But it’s not enough.

One of the best ways to prevent unnecessary foreclosures is to provide struggling families with a legal aid lawyer.  While the state guarantees legal representation for any criminal proceeding, there is no such guarantee in civil cases. Therefore, access to fair representation depends largely on the availability of free legal aid lawyers who have a long track record of helping people with no other options—such as battered spouses, people with disabilities, parents seeking child support, homeless veterans, and others without means.

Legal aid lawyers have the necessary training to help homeowners navigate the byzantine mortgage servicing system. They can identify mortgages that were illegal or predatory, and also help families make their mortgage payments by securing resources like unpaid wages, child support, public benefits, or unemployment insurance. Legal aid programs have saved many thousands of homes since the start of the financial crisis, but recently have struggled to secure funding for their vital work.  The Bank of America settlement will hopefully be helpful in this regard  but we need to do much more.

Early in the foreclosure crisis, the Center for Responsible Lending, a national advocacy group, received a $15 million grant for an innovative grant-making enterprise called the Institute for Foreclosure Legal Assistance (IFLA).  Over the course of three years, IFLA more than doubled the number of attorneys devoted to foreclosure prevention work and created a national infrastructure of training, informational materials, and networking that served as a powerful force multiplier. The program ultimately reached tens of thousands of borrowers either through individual assistance, broadly applicable policy changes, or access to critical information and materials.

Yet funding for IFLA was only available for three years, and at the end of that period, IFLA closed its doors. Since then, resources for foreclosure prevention work have dwindled even as the significant risk of foreclosure for millions of homeowners continues. Yet the IFLA infrastructure still exists, and an infusion of funds could immediately be put toward productive use without the need to build a new program.

While the Bank of America settlements directs monies to states, there is another source of federal monies that could be used to restart IFLA’s critical work: the remaining funds from the Independent Foreclosure Review (IFR).

The IFR was initiated when financial regulators found evidence that mortgage servicers had engaged in rampant misconduct when troubled borrowers came to them for help with their mortgages. The regulators first attempted to review every case individually, but that effort foundered. Instead, they decided to compensate homeowners who were most likely to have been harmed by the servicers, setting aside $3.6 billion for this effort. Borrowers ultimately claimed roughly 86 percent of the monies set aside but approximately $500 million remains unclaimed.

Regulators are considering giving those remaining funds to states for their “unclaimed funds” accounts in case homeowners file late claims. However, under this scenario, it is unlikely that much of that money will end up in the hands of homeowners seeking compensation. In fact, according to a recent letter to federal regulators from the National Housing Resource Center—an advocate for the nonprofit housing counseling community—only 2.8 percent of unclaimed funds held by New York State, and about 6 percent held by the state of Texas, reach the rightful owners every year. These funds are much more likely to end up in a state’s general funds where they could be used for just about anything, as has occurred with proceeds from other mortgage settlements.

Instead, regulators should send the states only the amount of remaining IFR funds that are likely to be claimed by homeowners. The rest of the money should be used for other foreclosure prevention efforts—including re-funding IFLA—to reinvigorate critical civil legal aid efforts, prevent unnecessary foreclosures, and help stabilize communities that are still being left behind in the economic recovery.

With the Bank of America agreement, hundreds of billions of dollars have now been collected in settlements with lenders and servicers, and families and neighborhoods should be far better off than they are now. Adequately funding national, state and local civil legal aid programs is one of the most effective ways to ensure that these settlements provide meaningful assistance to the people and communities that have been hit the hardest by the bad behavior of financial institutions.