By Robert Pear
The New York Times, January 11, 2018
In a speech to state Medicaid officials in November, (CMS Administrator Seema) Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.
“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”
CMS letter to Medicaid Directors; “Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries” (10 pages):
State Waivers As A National Policy Lever: The Trump Administration, Work Requirements, And Other Potential Reforms In Medicaid
By Billy Wynne and Taylor Cowey
Health Affairs Blog, February 6, 2018
Despite repeat campaign promises from then presidential candidate Donald Trump that he had no interest in altering Medicaid and other entitlements, it was evident from the start of his administration that there would be big plans in the works for the low-income insurance program. This was evident, most notably, in his appointment of health policy consultant Seema Verma—architect of the uniquely conservative Medicaid expansion waiver in Indiana—to run the Centers for Medicare and Medicaid Services (CMS). Now, one year into the Trump presidency, after Congress’s attempts to cut and restructure Medicaid through legislation have proved unsuccessful, the administration has begun in earnest to pursue a regulatory pathway to state-by-state Medicaid reform grounded in Verma’s approach to Section 1115 Medicaid waiver design.
Alignment with the program’s purpose—defined in statute (42 US Code Section1396) as “to furnish medical assistance on behalf of families … and … individuals … whose income and resources are insufficient to meet the cost of necessary medical services”—is a key requirement for waiver approval. CMS’s newly stated criteria no longer places an emphasis on coverage levels. Instead, it focuses on Medicaid’s sustainability over the long term, upward mobility, greater independence and beneficiary engagement, incentive structures and “responsible decision-making,” and commercial health insurance design features to “facilitate smoother beneficiary transition” off of Medicaid.
At the outset of the administration’s second year, CMS has unveiled highly anticipated guidance on how states can implement work, education, and job training requirements through Section 1115 waivers. Shortly after, HHS announced the approval of the first work requirement demonstrations in Kentucky and Indiana.
Pending Waivers to Watch
Besides Kentucky and Indiana, eight other states—Arkansas, Arizona, Kansas, Maine, Mississippi, New Hampshire, Utah, and Wisconsin—have waivers pending at CMS that would impose a work requirement on Medicaid expansion or traditional adult Medicaid populations. As a feature of their proposed work requirements, some of these states are seeking to impose specific time limits on how long beneficiaries may stay enrolled in Medicaid coverage if they fail to meet engagement requirements.
Several states, including Arizona, Kansas, and Utah, have gone a step beyond time limits tied to work and have proposed lifetime limits on Medicaid coverage for able-bodied adults, ranging from three to five years. If approved in Medicaid, it would constitute another monumental shift of the program design away from being a vehicle for health care and toward being treated as a conditional welfare program.
Time-limited periods of Medicaid ineligibility, or “lockouts,” resulting from nonpayment of premiums were previously approved by the Obama administration for certain expansion adults in only a small number of states. However, with approval of the Kentucky HEALTH waiver, premiums and lockouts may now apply to the traditional population as well. These policies present an additional administrative burden for states and create a yearly hurdle for enrollees to retain their coverage, which could lead to increased disenrollment and churn.
Hospital Presumptive Eligibility
Under the ACA, hospitals gained the option to make presumptive eligibility determinations for patients in need of immediate care. The policy provides greater access to Medicaid benefits for low-income individuals and protects participating hospitals from a percentage of uncompensated care costs. Where some states have previously been allowed to waive presumptive eligibility enrollment and retroactive coverage for pregnant women and children, it has not yet allowed a state to eliminate presumptive eligibility conducted by hospitals, as Maine and Utah are currently proposing to do.
Arkansas, which expanded its Medicaid program in 2014, has proposed to reduce eligibility for its expansion population down from the 138 percent of federal poverty level dictated by the ACA to 100 percent of poverty, while still maintaining the enhanced expansion funding for those who remain. Massachusetts later included a similar provision in its own pending waiver. Critics worry that approval of this “partial expansion” would set a precedent with budgetary and coverage consequences for low-income individuals in other states.
Exclusion Of Planned Parenthood
Separately from its actions on 1115 waivers, CMS recently issued a letter to state Medicaid directors rescinding previous guidance issued by the Obama administration regarding the “Free Choice of Provider” requirement in Medicaid, particularly in relation to providers of family planning and abortion services. The guidance had clarified that states may not exclude family planning providers from Medicaid reimbursement “solely because they separately provide family planning services or the full range of legally permissible gynecological and obstetric care, including abortion services.” This was widely understood to be in response to certain states seeking to prevent Medicaid dollars from going to Planned Parenthood. Citing “legal issues under the Administrative Procedure Act,” CMS has removed this guidance and opened the door to states that were previously seeking to exclude the organization.
Medicaid Drug Formularies
In response to the rising cost of prescription drugs, Massachusetts has proposed adopting a closed formulary for its Medicaid population. This would involve a waiver of the statute that otherwise requires Medicaid coverage of Food and Drug Administration-approved outpatient drugs provided the manufacturer participates in the Medicaid Drug Rebate Program.
From a state perspective, the Medicaid landscape has grown ever more complex as the program is increasingly found at the nexus of partisan debate and made the subject of major reform efforts that swing with the party controlling the White House or Congress.
With its solicitation of work requirement proposals and the other waiver reforms implemented in 2017, Verma and the Trump administration have decidedly swung the pendulum once more. Many states are responding in kind and ushering in an era of profound change for the decades-old program. But it remains to be seen if we will truly see work requirements and related reforms tested in the states as the legal and regulatory framework upon which this new paradigm is built is called into question in the courts. At the heart of the matter, as always, will be the question of how our nation views the core objectives of the Medicaid program—as health care or welfare for the nearly 70 million Americans enrolled.
After approving Medicaid work requirements, Trump’s HHS aims for lifetime coverage limits
By Tony Pugh
Lexington Herald-Leader, February 5, 2018
After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.
The move would continue the Trump administration’s push to inject conservative policies into the Medicaid program through the use of federal waivers, which allow states more flexibility to create policies designed to promote personal and financial responsibility among enrollees.
“I think you have to be very thoughtful here in a way that’s quite different from cash assistance,” said Gail Wilensky, a senior fellow at Project HOPE who ran the Medicaid program from 1990 to 1992 under President George H.W. Bush. “It depends on what the safeguards and defaults are in a program like this. Otherwise it does not make a lot of sense and seems to be cruel and inappropriate.”
By Don McCanne, M.D.
CMS Administrator Seema Verma is critical of the Obama Administration because it used the Medicaid program to help low-income people receive the health care that they needed, just as the law requires. Referring to this as the “soft bigotry of low expectations,” Verma is encouraging states to apply for waivers that would use the deprivation of Medicaid benefits as a whip to move individuals out of poverty and into jobs. Instead of looking at Medicaid as a health care program that should be expanded to all who need it, she looks upon it as a welfare program that needs to be ratcheted down (presumably to reduce taxes for the benefit of the rich).
It is not only the work requirements that would reduce access to care for Medicaid eligible individuals; Verma is also considering other policies that would further reduce access. As the article by Billy Wynne and Taylor Cowey indicates, CMS also encourages lifetime caps that would arbitrarily throw individuals off of the program based simply on a time limit rather than on need; they would require premiums which could be a hardship for these vulnerable individuals; they would use lockouts perhaps as punishment for failure to comply with all details of the application process; they would eliminate presumptive eligibility prohibiting individuals from receiving coverage in an emergency even though obviously eligible; they would allow states to reduce their Medicaid expansion programs, keeping otherwise eligible individuals out of the program; they would allow states to exclude family planning and preventive services provided by Planned Parenthood, and they would allow closed drug formularies preventing individuals from obtaining excluded medications.
Obstructing the path to health care results in financial hardship, physical suffering, and sometimes even death.
Not even all of the conservatives can stomach this. Gail Wilensky, head of HCFA (precursor of CMS) under President George H.W. Bush, recognizes the difference between capping “cash assistance” welfare and capping a program designed to help people get the health care they need. As she says, a program capping health care “does not make a lot of sense and seems to be cruel and inappropriate.”
It’s true. Either actively or passively denying health care to anyone does not make a lot of sense and seems to be cruel and inappropriate. We need a well designed single payer national health program that takes care of everyone.
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