Bevin Wants to Deal with Pension Crisis, Tax Reform Separately

Kentuckians Are Concerned About Proposed Changes to Medicaid

Kentucky officials recently asked the Centers for Medicare and Medicaid Services (CMS) to change certain parts of their original request to alter the commonwealth’s Medicaid program. These changes would move Kentucky’s health and economy further in the wrong direction by making the work requirement more difficult to comply with and instituting a six-month lock out for enrollees who fail to report relevant changes in income or employment hours within ten days.

State officials decided to open a comment period for public input on these changes. The result was that 1,273 Kentuckians from 100 counties submitted comments to the state and CMS, overwhelmingly sharing concern about the ways these additional changes would harm their communities and themselves, and supportive of the state’s Medicaid program in its current form. These comments are in addition to the 1,804 comments posted last year in response to the original waiver request, which were 9 to 1 against the waiver.

See the map below for a sample of comments on the changes submitted across Kentucky counties:

The proposed changes to Kentucky’s Medicaid program are being considered for approval by CMS now, and the final plan must take into account the results of both public comment periods. If the decision-makers in Washington take that responsibility seriously, they will not approve the request, which would roll back our health care gains rather than build on them.

How Cuts to Federal Non-Defense Discretionary Funding Would Impact Kentucky

When Congress returns from its August break, the House is expected to vote on their plan for 2018 appropriations that includes cuts to non-defense discretionary (NDD) funding, as well as deep cuts to entitlement programs. The proposed cuts to NDD programs would harm our state’s ability to improve education, support children and families, make our communities safer and healthier and develop the workforce and economy.

As noted previously, the proposed House appropriations for NDD programs would be 17 percent below what was appropriated in 2010 after adjusting for inflation and 22 percent once growth in the population is taken into account. Here are some examples highlighted in a recent Center on Budget and Policy Priorities (CBPP) report of what the effects of these funding levels would be:

Elementary and Secondary Education

Much of the $2.3 billion in proposed cuts nationally to K-12 education funding — which would make for a cumulative 20 percent cut since 2010 when accounting for inflation — come from eliminating grants to school districts that aid in recruiting, training, supporting and retaining high-quality teachers. Among other important efforts, grants fund the Kentucky Network to Transform Teaching, which aims to increase the number of highly credentialed teachers in our state.

Other cuts include reductions in funding to 21st Century Learning Centers. According to one estimate, this would mean 2,649 Kentucky students would be unable to participate in after-school programs that provide students with homework assistance and an array of activities that complement their regular academic programs. As an example, South Livingston Elementary School offers an after-school computer coding program through this federal grant. The House appropriations proposal would also eliminate funding for grants to improve literacy instruction.

While the two main basic federal grant programs for local schools would not be cut, their funding levels would be inadequate to provide needed services to students with disabilities and economically disadvantaged students. The appropriations level for Individuals with Disabilities Education Act (IDEA) grants would be increased by $200 million, but this is still short of what is needed just to keep up with inflation. The other main grant program, Title I, would receive no increase; Title I provides funding to more than half of all public schools for additional services and supports for disadvantaged students.

Mental Health

The Community Mental Health Services block grant would be cut by more than 1/4, from $563 million in 2017 to $421 million in 2018. In addition to paying for services for people without health insurance, the block grant also pays for services not covered by private insurance or Medicaid — as well as additional measures to connect people with needed care. The budget would cut this basic safety net mental health program at the same time Kentucky and the nation are suffering from a widespread opioid epidemic. Our state has been hit particularly hard and has the third highest rate of death due to drug overdose, alongside Ohio. Many with addiction problems also have some type of mental illness that needs to be treated in conjunction with their substance use disorder.

Disease Control and Prevention

The House proposal includes cuts to overall funding for the Centers for Disease Control and Prevention (CDC) — a reduction of $198 million, or 2.8 percent below 2017 funding. The CDC is responsible for detecting and controlling infectious diseases, responding to emerging crises such as Zika and monitoring public health. More than half of the budget for Kentucky’s Department for Public Health is from federal sources, including a federal grant from the CDC that funds the Kentucky Women’s Cancer Screening program.

Job Training and Employment

Federal Workforce Innovation and Opportunity Act (WIOA) funding is an important source of job training in Kentucky.  The appropriations in the House budget would cut several WIOA programs —including eliminating grants that support the expansion of apprenticeship programs and cutting by 41 percent nationally administered funding that assists workers dislocated by adverse events like plant closings and natural disasters. These cuts would have a negative impact on the Kentucky economy and could stall the state’s plans to ramp up workforce development efforts, including through apprenticeships.

Rental Assistance

Funding for Housing Choice Vouchers, which provide rental assistance to low-income seniors, people with disabilities and families with children, would be increased a little but not enough to cover the amount needed to renew all current vouchers in 2018. The proposed funding level would mean 140,000 households nationally would lose their vouchers; 1,967 vouchers are at risk in Kentucky. These cuts would worsen homelessness and make it even more difficult for low-income households struggling to make ends meet. Already three out of four eligible low-income households nationally do not receive rental aid due to funding limitations, with long waiting lists for assistance being typical. In Kentucky, there are only 57 affordable and available rental homes for every 100 extremely low-income renter households.

Child Care

Federal child care assistance funding is important to the budget of Kentucky’s popular Child Care Assistance Program (CCAP), which provides support to more than 26,000 low-income Kentucky families struggling to afford care while they work. The proposed appropriation levels for federal child care assistance would be just 0.1 percent higher than in 2017, which is considerably less than what is needed just to keep up with rising child care costs. At the same time, additional investments are needed to cover the costs of meeting federally mandated standards to strengthen the health, safety and quality of child care. As a result of federal funding coming up short, fewer children would be served.

Water Infrastructure

Kentucky already faces many environmental challenges, including pollution that degrades our drinking water and state budget cuts that have weakened environmental enforcement. The House budget proposal would make the situation worse, further diminishing federal efforts to reduce water pollution and improve access to safe drinking water — for instance, by helping to replace aging pipes, upgrading treatment systems, and correcting problems such as wastewater and stormwater draining into the same sewers and overflowing during heavy rains. The proposed appropriation levels for water infrastructure are $270 million below 2017 funding through the Environmental Protection Agency — bringing the cumulative cut to 46 percent below the 2001 level when inflation is taken into account. Agriculture Department programs that specifically address the water infrastructure needs of rural communities would also be cut — by 17 percent from 2017 levels.

If these proposed appropriations were enacted for federal NDD programs — especially on top of cuts to key entitlement programs — our state would experience a weakened education system, reduced health (including mental health), and fewer opportunities for Kentuckians to move up the economic ladder. Rather than the continued erosion of federal NDD funding, we need greater investment in critical services that help build thriving communities in Kentucky.

We’re Ready to Work with McConnell to Improve Health Care

Four Added Concerns About Kentucky’s Fiscal Outlook

The fact Kentucky has a severely underfunded pension system and that Gov. Matt Bevin plans to call a special session on the issue has been widely publicized.  So has the round after round of state budget cuts in recent years. On top of those challenges are added fiscal problems, made even clearer recently, that present a daunting picture for the commonwealth in 2018 and beyond.

Last week, the state budget director appeared before the Interim Joint Committee on Appropriations and Revenue to provide an overview of the fiscal year that ended on June 30, 2017, and a look forward at what to expect in fiscal year 2018.  The information presented is cause for concern:

1. Weakening revenues from sales and individual income taxes – The two major taxes that support the General Fund are the income tax (41.9 percent) and the sales tax (33.3 percent). Both underperformed in 2017, experiencing decelerating growth when compared to the prior two years, even though the economy grew. Over the years, the General Fund has declined as a share of the state’s economy, falling from 7.3 percent in 1991 to just 5.9 percent in 2017. This means the current tax code does not align as well as it should with how the economy and incomes are growing. Despite their underperformance, the income tax and sales tax still provided the bulk of the new revenue for the General Fund, as other revenue sources failed to pick up the slack. Overall, revenues were $138.5 million below the estimates on which the budget was based.

2. Revenues will need to be higher than the Consensus Forecast Estimate in 2018 because of 2017 shortfall – Because there was a shortfall in 2017, revenues must increase by 3.8 percent rather than the 2.4 percent estimated by the Consensus Forecasting Group to meet the levels required for the budget to balance in 2018. Revenue growth in 2017 was a lackluster 1.3 percent, so the trend is not good. In the letter accompanying the 2017 Annual Edition of the Quarterly Economic and Revenue Report, the state budget director states that this will be a “difficult hurdle to attain,” and his staff estimates growth of only 2.5 percent for the 1st 3 quarters of the 2018 fiscal year.

3. Necessary Governmental Expenses (NGEs) are growing unsustainably – NGEs were $85.3 million in 2017, which is $24.4 million more than in 2016. NGEs are expenditures that do not have a specific line item appropriation in the enacted budget. Historically NGEs have been emergency expenditures that cannot be easily predicted. Examples include fire suppression if the forest fire season is particularly bad, or amounts to cover the cost of addressing an emergency declared by the governor.

Over the past several years, however, the General Assembly has used NGEs as a technique in the budget to authorize the payment of recognized and known expenses without having to include those expenditures in the bottom line. In other words, the use of NGEs allows the General Assembly to pass a budget that actually spends more than the total enacted amount. In the 2016-2018 enacted budget, there are 21 separate expenditures authorized as NGEs rather than through appropriation of funds. The expanded use of NGEs is concerning because these expenses are not capped in any way as a normal appropriation would be and the total amount is not known until the books are closed at the end of the fiscal year. Further, the use of NGEs to pay for known expenses reduces the resources available in the Budget Reserve Trust Fund for true emergencies.

Of particular note are the increases in corrections expenditures paid as NGEs, which were $16.9 million more in fiscal year 2017 than they were in fiscal year 2016. Expenditures were higher primarily because prison populations are up, parole rates are down, medical expenses for prisoners have increased and the General Assembly reduced the amount requested by Gov. Bevin for the Department of Corrections for these expenses. Going into 2018, the state has 1,836 more prisoners than was anticipated at the time the budget was enacted. In addition, legislation passed by the General Assembly during the past two sessions enhancing penalties and sentences for drug related offenses will likely further increase the prison population beyond projections, which means that corrections-related NGEs could be higher in 2018 than they were in 2017.

4. The Budget Reserve Trust Fund may be depleted at the end of 2018 – The target for the Budget Reserve Trust Fund is that it be at least 5 percent of General Fund revenues, which would currently be $543.7 million. Going into fiscal year 2017, the budget reserve trust fund had a balance of $235.8 million.  After deducting the 2017 NGEs from the total, the balance is $150.5 million. The General Assembly appropriated $56.7 from the fund for 2018 expenditures, leaving an available balance of $93.8 million, just 0.9 percent of General Fund revenues. The current balance will not be enough to cover 2018 NGEs if they continue to increase as they have over the past three years.

The fiscal year-end information presents a very sobering and challenging picture for the commonwealth going into 2018 and beyond without even considering the pension challenge and the many areas of the budget that are deeply underfunded after years of cuts. The budget situation is likely to worsen unless the General Assembly takes responsible action to generate needed new revenue.

Continuing General Fund Erosion Is More Evidence of the Need to Clean Up Tax Code

As a share of the economy, Kentucky’s General Fund is worse off today than before the last positive effort to clean up the tax code under the Kentucky Education Reform Act (KERA) took effect – 5.9 percent in 2017 compared to 6.4 percent in 1990 (see graph below). Due to the growing number and size of tax breaks in Kentucky’s tax code, General Fund revenue eroded relative to the economy for two decades after KERA and has largely stagnated since 2010. In fact, weak revenue growth in 2017 put the General Fund back on a downward trend.

The increase in revenue in the early 1990s was a necessary response to the 1990 Supreme Court ruling that the state was failing in its duty to provide an efficient system of common schools. Through KERA the General Assembly raised significant new General Fund revenue largely from cleaning up income tax deductions that higher income people were able to claim. Unfortunately, the revenue boost – which enabled vast equity and achievement gains in education – did not last for long, harming all areas of the state budget.

Though the difference between the General Fund as a share of the economy in 1991 and 2017 is just 1.4 percentage points, that represents huge revenue losses. If the General Fund in 2017 was 7.3 percent of the economy instead of 5.9 percent, we would have had $2.6 billion more to help make up for years of underfunding the pension systems, address our addiction and child protection crises, restore funding for K-12 schools and make college and housing more affordable, for example.

State Budget Director Chilton identified erosion in the two main sources of General Fund revenue – the individual income tax (42 percent of the General Fund in 2017) and the sales and use tax (33 percent) – as contributors to the problem. In the 2017 annual edition of Kentucky’s Quarterly Economic and Revenue Report, he wrote that “when one (or both) of these revenue sources fails to keep pace with economic growth, the remaining taxes have been struggling to pick up the slack.” Corporate taxes face problems due to too many loopholes, while coal severance and cigarette taxes apply to tax bases that are declining.

Because the real problem with our revenue system is its failure to track economic growth, the real solution is cleaning up tax breaks that cause the disconnect. Asking more from those at the very top of the income scale who are taking home the lion’s share of economic growth, and tightening loopholes that allow large corporations to avoid taxation are key examples of revenue generating reforms that will allow us to sustainably invest in the building blocks of thriving communities.

On the other hand, cutting income taxes (which primarily benefits the wealthy) and shifting to greater reliance on sales taxes (which primarily asks more of low and middle income Kentuckians) would further disconnect our revenue system from where the economy is growing.  And moving away from income taxes will fail to propel economic growth as its proponents falsely claim.

Changes to Medicaid Waiver Request Move Further in the Wrong Direction

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Last August, Kentucky applied to modify its Medicaid program through a request to the federal government to waive certain requirements of the law, known as an 1115 waiver. 1 As explained in our comments at the time, the proposed changes would result in fewer Kentuckians covered and therefore decreased access to health care, which would ultimately harm health and move the state backwards. 2  While the waiver proposal is framed in terms of increased financial sustainability and reduced costs, it would likely increase costs for the state as it introduces new, expensive and complex administrative burdens, and limits access to the preventative care that improves health and keeps costs down in the long run. Rolling back Kentucky’s historic gains in health care coverage would hurt the many Kentuckians who benefit from the state’s Medicaid program in its current form and act against the goals of the Medicaid program as a whole and the 1115 waiver in particular.

With the recent modification of the original waiver request comes added barriers to getting and using Medicaid coverage. By jumping from a 12 month phase-in of the community engagement component to an immediate 20 hour per week requirement, the enrollment losses would be even more severe. And by enforcing a reporting requirement on income changes with a six-month lock out for non-compliance, the program would penalize enrollees simply based on the nature of low wage work. These changes intensify the harms of an already counterproductive waiver.

Work Requirement Is Misguided and Harmful — and Change Makes It Worse

The original waiver request required a community engagement requirement that made eligibility for Medicaid coverage conditional on 20 hours a week of some work-related activity. This minimum hourly work requirement was to be ramped-up over a period of 12 months, but the operation modification changes that to an immediate 20 hour mandate. Embedded in the work requirement is the assumption that people covered by Medicaid are not working, or would be encouraged to increase their work by the requirement, with the goal of having their incomes rise above the level that makes them eligible for Medicaid. This assumption is wrong-headed, as it ignores the reality of low-wage work and the barriers to improved employment.

Most Medicaid enrollees who can work do work

In Kentucky, the majority of Medicaid expansion enrollees currently work, and four out of five adult Medicaid expansion enrollees have worked at some point in the past five years. 3 The Kaiser Family Foundation estimates that 51 percent of Kentucky Medicaid-covered adults currently work, and 66 percent come from a family where at least one person works. 4

Of those who do not work, most are ill or disabled, taking care of a loved one, or are in school or retired. Kaiser estimates that, nationally, all but 4.5 percent of Medicaid-enrolled adults are working or meet one of those criteria. Of the 4.5 percent who either do not work or have a good reason not to, 3.3 percent are looking for work and just 1.2 percent are not.

Work requirements ignore the nature of low-income work

hours, sometimes below 20 hours per week. In fact, according to 2015 Census data, 1 in 5 non-elderly Kentucky adults whose incomes qualify them for Medicaid work less than 20 hours per week. 5 As of 2015, the three industries that employed the most Medicaid expansion-eligible adults in Kentucky were restaurants, construction and department stores, all of which often provide only part time and sometimes irregular work opportunities. 6

Estimates from the Kaiser Family Foundation mentioned above showed, nationally, 41 percent of Medicaid-covered adults work full time and 18 percent work part time. Low-income workers often are forced to work fewer hours than they would prefer. According to the Department of Labor, over 5 million Americans work part time involuntarily and would work more if their place of work offered more hours or they could find full time jobs.7

Work requirements do not promote long-term employment or reduce poverty

An established body of research shows work requirements do not reduce poverty or succeed in helping people obtain long term, permanent employment. 8 Among those who received cash assistance through the Temporary Assistance for Needy Families (TANF) since its creation in 1996, work requirements have not yielded long-term results. One review of 13 randomly assigned studies showed a work requirement resulted in a short-term increase in employment, but employment outcomes faded after 2 years and the requirement didn’t have any effect on employment 5 years afterward. In fact, the study showed most participants were not employed 75 percent or more of the time, 3 to 5 years out from their participation in TANF-required work activity. 9 The communities that have shown significant long-term employment effects through a program that required work as a condition of eligibility were in Portland, Ore., and Riverside, Ca.. In those communities program administrators offered significant work supports and training, and encouraged participants to hold out for better jobs with higher wages that offered more opportunity for advancement.

Most individuals subject to work requirements remain in poverty, and in some cases become poorer. An evaluation of 11 programs that offered cash assistance and SNAP (formerly known as food stamps) showed that the percent of TANF participants living in poverty in the observed communities didn’t change 2 years after participation, and the percent living in deep poverty (half of the poverty level or less) increased in 6 of the 11 communities. 10

Work requirements are ineffective as a condition of eligibility for public benefits because they do nothing to change either an individual’s job qualifications, ability to afford job training and education or the existence of decent job opportunities in the labor market in which he or she is trying to navigate.

Work requirements would result in decreased enrollment

In the recent request to add a work requirement nearly identical to the one Kentucky has proposed, the Indiana Family and Social Services Administration estimated that a quarter of those for whom a work requirement would apply would lose coverage due to non-compliance. 11 Assuming our state’s Medicaid population is similar, this requirement alone could lead to roughly 100,000 people losing coverage because they would not be able to meet the requirement for various reasons.

Those reasons do not have to do with a lack of motivation, or a desire to “free-load” as some have suggested, but are due to a struggling labor market. Between 2009 and 2017, 32 Kentucky counties saw the total number of jobs decline 10 to 32 percent. Roughly 3/4 of Kentucky counties saw either modest job growth of less than 10 percent or a decline in jobs during that time frame.12 A depressed labor market in much of the state, barriers to gainful employment or advancement like criminal records and poor health, and a lack of income supports and adequate wages are primarily what is holding back unemployed and underemployed Medicaid enrollees from better economic mobility. 13

Removing the ramp-up for community engagement hours would exacerbate the damage

By eliminating a 12 month ramp-up for community engagement and instead requiring an immediate 20 hour per week activity related to work, the state would be enforcing a mandate without any opportunity for participants to adjust to it. Although the waiver amendment request includes a three month delay in the requirement, primarily for first time enrollees, enrollment would decline even more substantially than under the original waiver. In the estimate provided within the public notice section of the operational modifications document, it is estimated that 9,048 more people would lose coverage than under the original waiver request. A total of 96,687 would lose coverage by the 5th year. According to the estimate, people would lose coverage “for a variety of reasons, including program non-compliance.” In other words, rather than strengthen and expand coverage for low-income individuals, as is the first of four criteria for an 1115 waiver, these changes do the opposite.

 

Locking Out Medicaid Enrollees for a Failure to Report Changes in Income Is a Penalty for the Nature of Low-Income Work

There is already a requirement that enrollees report changes in wages that bump them over the income eligibility threshold. But the proposed change penalizes a failure to report a much larger number of changes, with failure to comply resulting in a six month lockout from the program. Now changes that must be reported include changes in income that affect thresholds to pay different levels of premiums (25, 50 and 100 percent of the Federal Poverty Level), changes in an employer’s health insurance offerings and premium costs, and changes in work-related hours per week. This requirement punishes people solely on the volatile nature of low-wage work.

Medicaid workers work in industries with instable hours and income

As mentioned previously, Kentucky workers covered by Medicaid work in jobs with irregular hours and inconsistent wages. This is especially true for the three industries with the largest Medicaid populations: restaurants, construction and retail. In retail, hours change weekly or even day-of; restaurant workers depend on tips, which vary greatly, especially when shared; and construction work is seasonal and often depends on weather conditions as well as the location of construction projects.

Low-wage workers face a number of challenges that would make this reporting requirement onerous. According to the Center for Law and Social Policy, many low-income workers are employed in jobs that have:

  • Inadequate hours.
  • Highly variable hours on a weekly basis.
  • Little advance notice of shifts, including being sent home early or called in right before a shift begins because of growing use of management strategies like “just-in-time” scheduling.
  • Split shifts or on-call shifts. 14

In each of these cases, wages and hours would vary on a week-to-week basis. But the waiver modification states such changes would have to be reported to the cabinet within a 10 day period. This would be burdensome for both the enrollee and the state, and would almost certainly result in people churning on and off Medicaid and higher administrative burden.

Locking out Medicaid enrollees for a failure to report income would increase churn and disrupt care 

As already mentioned, given the highly variable work schedules and income of Medicaid-covered workers, it is very likely many Medicaid enrollees will become locked out of coverage. That results in one of two things: Either enrollees would decide to go without coverage and forgo needed care, or they would seek out a financial or health literacy class so they can re-enroll. In either case, this would be burdensome for the state and disruptive for the individual.

People already churn in and out of Medicaid in Kentucky at a high rate. Between 2012 and 2013, 19 percent of the Medicaid population changed eligibility status. 15 Each time someone’s eligibility status changes it requires administrative action. The prospect of a large number of people becoming locked out of Medicaid and then moving back on, potentially the same day, multiple times a year would dramatically increase the administrative cost and burden for the state.

In addition, disruptions in care could have very serious consequences for individuals with chronic conditions. According to a study from the Harvard School of Public Health, 72 percent of Medicaid expansion-eligible Kentuckians have 1 or more chronic conditions. 16 The study also found a substantial increase in the number of low income Kentuckians with a primary care physician and getting regular care for chronic conditions, thanks to Medicaid expansion. The waiver will cause more of these people to cycle on and off coverage, reducing health and costing the state more in the long run as conditions that might not have worsened become more expensive to treat.

Build on Kentucky’s Health Care Successes – Don’t Undermine Them

Kentucky has made historic progress in health care, primarily through our decision to expand Medicaid. Several studies have shown that multiple measures of health access and outcomes have improved since 2014:

  • The number of uninsured Kentuckians dropped by more than half.
  • Screenings for cancer, diabetes and dental issues have risen dramatically.
  • The number of people with a primary care physician and who are receiving regular care for a chronic condition have increased.
  • Preventable hospitalizations for problems like hypertension and asthma have dropped.
  • Breast cancer deaths and infant mortality have declined.
  • There is an increase in Medicaid expansion-eligible Kentuckians who report having excellent health. 17

The 1115 Medicaid waiver process exists to demonstrate innovations in health care coverage and delivery that move us forward. In spite of our unparalleled gains in health, this process could be used to make even more improvements. In fact the goals of an 1115 waiver, according to the Centers for Medicaid and Medicare Services are:

  1. Increase and strengthen overall coverage of low-income individuals in the state.
  2. Increase access to, stabilize and strengthen providers and provider networks available to serve Medicaid and low-income populations in the state.
  3. Improve health outcomes for Medicaid and other low-income populations in the state.
  4. Increase the efficiency and quality of care for Medicaid and other low-income populations through initiatives to transform service delivery networks.

But the waiver request does not meet these standards, as we described in our prior comments, and those failures are worsened by the most recent round of modifications. The new barriers to coverage, administrative complexity and reduced benefits are in direct conflict with what a demonstration waiver should do.

Forcing people off health care coverage based on the nature of their work and the current state of the labor market impedes that progress and would ultimately harm our communities. We urge the state to abandon these changes and work with stakeholders across the commonwealth to shape our Medicaid program in a way that builds on, rather than rolls back, our successes.

  1.  “Kentucky Health,” Kentucky Cabinet for Health & Family Services, August 15, 2015, http://chfs.ky.gov/NR/rdonlyres/69D38EB6-602F-4707-933C-80D5AAE907F7/0/KYHEALTHWaiverFINAL.pdf.
  2.  Dustin Pugel & Jason Bailey, “Proposed Medicaid Waiver Would Reduce Coverage and Move Kentucky Backward on Health Progress,” Kentucky Center for Economic Policy, October 7, 2016, http://kypolicy.org/dash/wp-content/uploads/2016/07/1115-Medicaid-Waiver-Federal-Comments-KCEP.pdf.
  3.  Dustin Pugel, “Many Kentucky Workers Have Gained Insurance through the Medicaid Expansion and Are Now at Risk,” Kentucky Center for Economic Policy, December 8, 2016, http://kypolicy.org/many-kentucky-workers-gained-insurance-medicaid-expansion-now-risk/.
  4.  Rachel Garfield, Robin Rudowitz & Anthony Damico, “Understanding the Intersection of Medicaid and Work,” The Henry J. Kaiser Family Foundation, February 17, 2017, http://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.
  5.  Data are from the 2015 American Community Survey one year estimates for Kentucky adults under 64 years old who earn less than 139% of the Federal Poverty Level.
  6.  Pugel, “Many Kentucky Workers Have Gained Insurance through the Medicaid Expansion and Are Now at Risk.”
  7. Data are from the Current Population Survey’s June 2017 estimate for workers in nonagricultural industries who worked part time for economic reasons. https://www.bls.gov/webapps/legacy/cpsatab8.htm.
  8. LaDonna Pavetti, “Work Requirements Don’t Cut Poverty, Evidence Shows,” Center on Budget and Policy Priorities, June 7, 2016, https://www.cbpp.org/sites/default/files/atoms/files/6-6-16pov3.pdf.
  9.  Jeffrey Grogger & Lynn A. Karoly, Welfare Reform: Effects of a Decade of Change, Harvard University Press, 2005.
  10.  Stephen Freedman et al., “National Evaluation of Welfare-to-Work Strategies: Two-year Impacts for Eleven Programs,” Manpower Development Research Corporation, June 2000, http://www.mdrc.org/publication/evaluatingalternative-welfare-work-approaches.
  11.  “Amendment Request to Healthy Indiana Plan (HIP) Section 1115 Waiver Extension Application,” Indiana Family and Social Services Administration, July 20, 2017, https://www.in.gov/fssa/hip/files/HIP%20Amendment%20(Update%207_20).pdf.
  12.  Jason Bailey, “Job Recovery for Some Kentucky Counties, Second Recession for Others,” Kentucky Center for Economic Policy, May 15, 2017, http://kypolicy.org/job-recovery-kentucky-counties-second-recession-others/.
  13.  Jason Bailey, “Address Declining Workforce through Job Creation and Work Supports,” Kentucky Center for Economic Policy, July 11, 2016, http://kypolicy.org/address-declining-workforce-job-creation-work-supports/.
  14.  Jessica Gehr, “Doubling Down: How Work Requirements in Public Benefit Programs Hurt Low-Wage Workers,” Center for Law and Social Policy, June 2017, http://www.clasp.org/resources-and-publications/publication-1/Doubling-Down-How-Work-Requirements-in-Public-Benefit-Programs-Hurt-Low-Wage-Workers.pdf.
  15.  Anita Cardwell, “Revisiting Churn: An Early Understanding of State-Level Health Coverage Transitions Under the ACA,” National Academy for State Health Policy, August 2016, http://nashp.org/wp-content/uploads/2016/08/Churn-Brief.pdf.
  16.  Benjamin D. Sommers, Bethany Maylone, Robert J. Blendon, E. John Orav & Arnold M. Epstein, “Three-Year Impacts Of The Affordable Care Act: Improved Medical Care And Health Among Low-Income Adults,” Health Affairs, May 17, 2017, http://content.healthaffairs.org/content/early/2017/05/15/hlthaff.2017.0293.
  17.  Dustin Pugel, “New Report Highlights Kentucky’s Gains in Care and Health,” Kentucky Center for Economic Policy, March 17, 2017, http://kypolicy.org/new-reports-highlight-kentuckys-gains-care-health/.

KET: Areas of Conflict and Compromise in State Tax Reform

Indivisible Group Eyes Common-Sense Tax Reform