Kentucky's dentists and optometrists asked Gov. Matt Bevin's administration not to remove dental and vision coverage from basic Medicaid benefits. Visits to the dentist and eye doctor are often the first step in identifying more serious health conditions, including diabetes, they say.
But the Republican administration made only slight changes to its proposal to reshape Medicaid in Kentucky — allowing dental and vision benefits only for the first three months of Medicaid coverage,
After that, dental and vision benefits are optional, available only through a "rewards" program in which Medicaid members can earn points to pay for them through activities such as work or volunteering.
"We were beating our heads against the wall," said Dr. Bill Collins, a dentist and president of the Kentucky Dental Association. "Everything we said fell on deaf ears."
Doug Hogan, a spokesman for the state Cabinet for Health and Family Services, which oversees the state's Medicaid program, said Bevin's proposal was designed to mirror commercial health plans, which do not typically include dental and vision benefits.
And Medicaid does not require dental and vision benefits to be included though Kentucky currently offers them.
Hogan said Bevin's proposal offers several "easy ways" people can earn such services at no cost, such as participating in weight-loss programs or diabetes classes.
The federal government, which must approve the changes, is now reviewing Bevin's plan to scale back the Medicaid expansion enacted under the Affordable Care Act by his predecessor, former Gov. Steve Beshear, that added 440,000 people to the program.
Bevin's proposal predicts about 86,000 fewer Kentuckians will be covered by Medicaid within five years.
Bevin has said that Kentucky's Medicaid plan, which now covers nearly 1.4 million residents, is not sustainable and that the state can't afford its share of the cost although the federal government pays most of it.
He also has said he wants people to take more personal responsibility for their own care and put "skin in the game" by paying premiums, co-payments and meeting requirements that "able-bodied adults" work or volunteer at least 20 hours a week to keep Medicaid benefits.
His plan also promotes moving many people off Medicaid to commercial insurance through their employers.
Collins said the problem with the governor's plan is that many of the adults added through the expansion work at low-wage jobs that don't offer health insurance.
"I don't think they understand who they are trying to take off," Collins said. "These are the working poor. You're taking off working people who are trying to make a living."
Health advocates also worry about the overall impact of Medicaid changes on people with diabetes in a state with the nation's third-highest rate of diabetes. A 2015 state study found that 18 percent of Kentucky adult Medicaid members were diagnosed with diabetes in 2013, compared with 12 percent of Kentuckians overall with the disease.
Often, when conducting a routine eye exam, Louisville optometrist Dr. Aaron McNulty discovers that a patient has diabetes but doesn't know it.
"All the time," said McNulty, a board member of the Kentucky Optometric Association. "It's a common scenario."
Collins treats dental patients in some of Kentucky's poorest counties in eastern Kentucky with the highest rates of Medicaid coverage. He is seeing many more patients thanks to the state's 2014 Medicaid expansion.
Some patients are in such bad shape they must have all of their teeth extracted, he said.
"These people have been so many years without care and without insurance," Collins said of his new patients.
He said doubts people realized it could affect their health benefits by voting for Bevin. Rather, it was general dissatisfaction with the economy, the lack of jobs in the region and President Barack Obama, a Democrat.
"Sometimes you cut off your nose to spite your face," he said. "That's what they did."