Trump HHS Indicates Openness to Using 1115 Waivers to Undermine Consumer Protections in Medicaid
On top of the uncertainty surrounding Medicaid expansion and Medicaid funding stemming from GOP Affordable Care Act (ACA) repeal efforts, HHS Secretary Tom Price and CMS Chief Seema Verma’s recent letter to governors adds another layer of change and uneasiness. This letter affirms the new administration’s intent to use Section 1115 Medicaid waivers to cut key consumer protections that have made Medicaid a vital, comprehensive source of health and financial security to millions of low-income Americans.
Concerning Waiver Directions
Strong evidence demonstrates that Medicaid is efficient and cost-effective – and that the ACA’s coverage expansion has had a positive effect on state budgets and enrollees’ health. Nevertheless, the Price-Verma letter gives states the green light to move towards Medicaid policy provisions that could lead to loss of coverage and access to care, and potentially hurt state budgets, such as:
- Cost-sharing requirements. Studies show Medicaid beneficiaries lose coverage and experience barriers to care when states impose premiums and copayments. An evaluation of Indiana’s most recent waiver suggests beneficiaries who are subject to copayments likely have higher use of the emergency department (ED) as a result. Collecting premiums and copayments has shown to be inefficient and costly.
- Eliminating non-emergency medical transportation (NEMT). Medicaid beneficiaries are more likely than those privately insured to have health care access barriers and NEMT helps bridge that gap. NEMT helps Medicaid expansion enrollees access critical care and treatment including behavioral health services, preventive health services and substance use treatment.
- Copayments for non-emergent use of the ED. Copayments do not reduce unnecessary use of the ED, financially burden Medicaid consumers and fail to address larger systemic health care access issues.
- Waiving presumptive eligibility and retroactive coverage. These provisions facilitate access to care and important protections for both enrollees and the providers that serve them, especially when there are delays in the application and enrollment process.
- Support for work requirements. The letter stops short of explicitly saying it will approve work requirements, but includes language that strongly encourages states to impose training or work programs. Work requirements would be onerous on beneficiaries (most of whom are already in working families) and costly for states to administer.
We are troubled by a few other aspects of the letter. First, HHS’ intention to expedite waiver approvals and extensions may roll back important public input and evaluation requirements that have supported a fair and transparent waiver approval process. Second, a willingness to approve state waiver requests that replicate approvals in other states is troubling, since 1115 waivers are meant to be temporary demonstrations to test different approaches to providing Medicaid services. HHS should assess the impact of a waiver provision on access to care for beneficiaries in a single state, before approving it across the board.
Finally, the letter expresses an incorrect view that childless adults are not “vulnerable” and do not fit in with the mission of the Medicaid program. In fact, these low-income adults have experienced a historic lack of access to affordable health care, fluctuating income and language and cultural barriers, and thus, are appropriately served by Medicaid. Covering more adults under Medicaid has benefitted state budgets, consumer health and hospitals. Rolling back these gains would be detrimental.
Trump HHS Commits to Combatting Opioid Epidemic, But There’s a Catch
Medicaid is a critical source of coverage for adults with substance use disorders (SUD). For instance, almost 500,000 individuals (most who were previously uninsured) in Ohio have received treatment for mental illness or substance misuse under the state’s expansion of Medicaid. HHS’ letter commits to continuing the important work begun in the Obama administration to enhance Medicaid services for SUD and improve access to comprehensive substance abuse treatment. For instance, HHS plans to continue the Medicaid Innovation Accelerator Program that provides technical assistance to states in enhancing SUD services. We hope that HHS continues the previous administration’s explicit support of waivers that contained a specific set of evidence-based measures including Screening, Brief Intervention and Referral to Treatment (SBIRT), integration with primary care, recovery support services, and medication-assisted treatment. Of course, the proof of HHS’ commitment will be in what state proposals they eventually support.
However, HHS Secretary Price’s support of ACA repeal and cutting federal Medicaid payments is at odds with the letter’s promise to address opioid addiction. The latest ACA repeal bill would jeopardize an estimated 1.3 million Americans with substance use disorders or mental illness who have received treatment through Medicaid expansion.
Allowing States to Assess Their Own Compliance on Home and Community-Based Services
The letter also says the administration will give states more time and say in implementing regulations ensuring that long-term services and supports are appropriately provided to people in their homes or communities. Allowing individual states to assess their own compliance could open the door to services that are less responsive to consumer needs and preferences.
Keeping an Eye on Medicaid
The upside to this letter is that none of the harmful waiver provisions listed can take place unless the states themselves choose to pursue such avenues. However, we do anticipate that this is just the first of many regulations and guidances HHS will produce that could undermine consumer protections in Medicaid. We intend to track these developments and provide more resources that equip advocates to push back. Stay tuned!