While the American Health Care Act was pulled from consideration a few weeks ago for now, changes could still be coming through the regulatory and administrative authority of the Center for Medicaid and Medicare Services (CMS). This is where it’s important to remember the federal and state partnerships aspects of Medicaid. The majority of changes through regulation or administration will have to be a proposal from states to the federal government. The federal government can communicate with the field about changes it would like to see (cost sharing, work requirements), but these changes can only be implemented IF states submit proposals requesting these changes. What might these changes be?
Work requirements
Various states such as AZ made work requirements requests during the Obama administration and those requirements were rejected. States might expect a different response from the current CMS. But the majority of Medicaid recipients work already and or engage in meaningful daily activity. Drew Altman from Kaiser Family Foundation has a simple analysis of the issue here.
The opportunity in all the conversations about work is that perhaps states will consider supportive education or supportive employment initiatives to assist people with disabilities to work. Many people want to work but do not have the skills or resources (transportation, child care) needed to obtain or maintain a job, including many supportive housing tenants. When states are putting forward work requirements, make sure they consider these issues as well.
Cost sharing arrangements
Cost sharing is Medicaid speak for “the person receiving the benefit pays more out of pocket”. Beneficiaries can pay more up front, in the form of a premium or more when they receive care, such as a co-pay. Research has clearly shown that cost sharing strategies commonly make coverage harder to access for people with limited incomes. So states’ don’t increase revenue much through collecting all those $1-$10 co pays. Rather persons forgo care due to these hurdles and states save money that way. Indiana’s Medicaid plan, being touted as the example due to the influence on policy of Vice President Pence requires beneficiaries to make their first payment before they are enrolled in care.
Lifetime limits on benefits
States have also proposed a lifetime limit on Medicaid benefits for people they consider “Able Bodied Adults”. Arizona proposed a total of 5 years lifetime of benefits. This was rejected by the Obama Administration CMS and is likely to be approved by the Trump Administration CMS.
Alignment with Commercial Insurance Plans
The stated goal from Secretary Price is for persons enrolled in Medicaid be ‘prepared’ to enter the work force. So alignment with commercial plans is being developed, even in some states, having Medicaid recipients participate in commercial plans with subsidies for the cost sharing requirements that most commercial plans entail.
What will you need to track more closely now that these changes would be likely be approved at the federal level?
- Your Governor’s race– Governors may now campaign on possible changes to the state Medicaid program. Be sure that those changes have a positive impact on the people you serve, the programs you manage and your community.
- How your state Medicaid Plan engages with stakeholders– All states are required to have a stakeholder group called a Medicaid Advisory Committee. The purpose of the group is to engage with Health Care stakeholders regarding both how the state’s Medicaid program is performing and any changes that might be being considered. Get involved!
- Communications from your state Medicaid Program– When your state is making changes, such as submitting a waiver or a state plan amendment, there are two required public comment periods. The first period is between the state and stakeholders and comments need to be considered in the revision that states make before the requests are submitted to the federal government, in this case, CMS. The second comment period is when CMS receives the requests and also asks for comments. These are opportunities to influence how your state plan operates and what benefits are offered to people in your community.
So while the ACA remains the law of the land for now, the details of regulations and administration can be changed at the state level to make care easier or harder to access. Providers and advocates will need to watch closely as changes are proposed to ensure the viability of their services and coverage and care for the people they serve.
