Louisvillian William Devoe Sr. hasn’t had health insurance in 15 years.
But this past spring, Devoe, a janitor who works at the Nia Center on Broadway, discovered during a health fair there that he qualified for Medicaid. A state worker who assists people with health insurance explained to him there would be no monthly premium for the insurance.
Cost was always the main reason he’d gone without health insurance.
“I just couldn’t afford it. I even looked into certain places, certain insurance companies: Aetna, Cigna. Just trying to get health care. It just cost,” Devoe said.
So he enrolled in Medicaid, ending years of being “super-cautious” of injury and illness.
“I just tried not to get hurt or go to the doctor very much, ’cause I didn’t have no health insurance,” he said. “Not until this Kynect thing came along.”
Since 2013, half a million Kentuckians have gained health insurance through Kynect, the state health insurance exchange set up as part of the Affordable Care Act. Like Devoe, most of those enrollees qualify through the expansion of Medicaid that came under the federal law.
Largely because of its estimated $1.1 billion cost to Kentucky over the next six years, the Medicaid expansion led by Gov. Steve Beshear has had its share of opponents. The state was one of only two in the South to expand the program under the ACA. Kentucky’s Medicaid Expansion Report, which was commissioned by Beshear’s administration, estimates the net economic benefit of the expansion at $30.1 billion over eight years. By expanding, the state may have avoided a $99.5 million negative impact on Kentucky, that report found.
The concept of holding states responsible for providing quality and affordable care to their residents is nothing new. The 1985 Heckler Report recommended it.
The groundbreaking report by the U.S. Department of Health and Human Services was the first to examine the health status of African-Americans, Hispanics, Asians and Native Americans at once. It recommended the private and public sectors do more to improve minorities’ access to health care, as those populations are more likely to be low-income, uninsured, and rely on Medicaid and charity care.
''I just tried not to get hurt or go to the doctor very much, ’cause I didn’t have no health insurance. Not until this Kynect thing came along.'' William Devoe Sr.
Local and state governments have tried a number of programs to do this. Metro government established the Center for Health Equity in 2006 in an effort to do more outreach to minority communities. And state government’s Office of Health Equity, which is funded in part by federal grants, came online in 2008 with a similar mission.
Dr. Stephanie Mayfield, commissioner of the Kentucky Department of Public Health, said Kynect is the state’s way of applying the Heckler Report’s recommendation. And while state government doesn’t have reliable figures on enrollment of minorities through the exchange, nearly 19 percent of African-Americans in Kentucky were uninsured before the first enrollment period began in October 2013. Officials estimate 86,000 African-Americans in the commonwealth are enrolled in Medicaid today.
“Here are some things that have changed: We have significantly decreased the number without insurance, and we know people are accessing health care,” Mayfield said.
But there can be other hurdles after someone gets health insurance.
Some people may not have reliable transportation. Others may need child care during a doctor’s visit. Some may not be able to get time off from work to see a physician. Mayfield said complications such as these affect African-Americans and Kentuckians living in Appalachia disproportionately.
A veteran, Devoe typically gets emergency care through the VA. But in the past, getting to the VA Medical Center on Zorn Avenue was a hassle because he relied on public transportation. He said it took him 40 minutes to get from his downtown home to the VA. In a car, it takes 12 minutes.
Although he was grateful to at least have the option to go to the VA hospital, Devoe said it wasn’t the same as having health insurance and access to his own primary care provider.
The Affordable Care Act highlighted the importance of the screenings that primary care physicians can provide — HIV, diabetes and colorectal cancer — by requiring doctors to offer them free of charge. But without health insurance and a primary care provider, many never get what could be lifesaving tests.
“Preventative care and primary care really do kind of go together,” said Dr. Brent Duncan of Shawnee Christian Health Care Center in Louisville.
When the center opened in 2011, more than half of its patients were uninsured, Duncan said. Now, most are on Medicaid via Kynect.
He said as a result, the center’s small group of doctors has been able to get more people in for preventive screenings, which has led to ongoing care and better management of conditions such as diabetes and hypertension.
Duncan describes the relationship between patient, primary care physician and specialists as a bicycle wheel. The primary care physician is at the center.
“You’ve got the center that kind of really spins and takes care of everything, and then we’ll need to send you, say, to a specialist to have a surgery,” he said. “So that’s going out one spoke. You go get that taken care of, you come back, and we continue to take care of you.”
But that doesn’t typically happen without insurance.
Sick & Tired is a four-part web and radio series examining health disparities among racial minorities in Kentucky. It's part of the Next Louisville: Community Health project, a partnership between WFPL News, the Foundation for a Healthy Kentucky and the Community Foundation of Louisville.
For most low-income people, standard health care is just too expensive. For instance, the average price of a new uninsured patient appointment is about $160, according to a study by Johns Hopkins Bloomberg School of Public Health. That research also found costs were lower in high-poverty areas, and only one in five people were told they could be seen without paying the whole cost up front.
That’s why getting people their own health insurance — whether on Medicaid, through an employer or in the private market — is so important.
Devoe, a borderline diabetic with hypertension, plans to make his first appointment later this month. He has a Medicaid card now. He’ll be able to see a doctor — his own doctor — next time he feels sick, he said. He’ll be able to get health checkups, too.
“It’s a lot of people out here uninsured that can’t pay for it,” he said. “You don’t have to pay for it. You just gotta come and enroll.”