By Phil Galewitz November 12,
2019
Seema
Verma, the Trump administration’s top Medicaid official, Tuesday sharply
attacked critics of her plan to force some Medicaid enrollees to work, a policy
that led to thousands of people losing coverage in Arkansas.
“We
cannot allow those who prefer the status quo to weaponize the legal system
against state innovation,” the administrator of the Centers for Medicare &
Medicaid Services said in a fiery speech to the
nation’s 56 state and territorial Medicaid directors in Washington, D.C.
A federal judge shut down
the short-lived work requirement initiative in Arkansas and stopped it from
launching in Kentucky last spring. Several states, including Indiana, Arizona
and New Hampshire, that had won federal approval have put their implementation
plans on hold pending an appellate court ruling.
Advocates
for the poor argue work requirement policies are illegal and unfairly add
hurdles to people who qualify for coverage in the federal-state health program.
But
those opponents are seeking “to manipulate Medicaid into the prototype of a
single-minded, single-payer nirvana — a utopia of open-ended government-run
health care,” Verma said. “Part of my mission is to fight such underhanded
tactics and preserve the right of states to shape your programs in ways that
are consistent with the needs of your residents, your cultures and your values.
Anything less stifles innovation.”
That
would be “a disservice to the millions of people on Medicaid today and those
who will need it in the years and decades to come,” she added.
The
federal government has approved work requirement plans in 10 states and
requests are pending from 10 others. Most of those initiatives are directed at
the low-income adults who gained coverage through the Medicaid expansion
initiated by the Affordable Care Act.
Verma
first announced plans to open the door to work requirements in a speech to Medicaid
directors in 2017.
Medicaid
— like Medicare — is an open-ended entitlement program, which means federal
funding increases as costs and enrollment rise.
In
addition to doubling down on the controversial work requirements, Verma renewed
her interest in letting states get Medicaid funding through a block grant
system. Block grants would give states more flexibility to limit enrollment and
enforce eligibility rules, she added.
Critics
have said such a change would cut Medicaid funding, limit coverage, hurt
beneficiaries and lead to lawsuits.
But
Verma said CMS would soon publish guidance to states to allow them to get block
grant funding for “certain optional adult populations.”
“Many
states have expressed a willingness to be held accountable for improving
outcomes in exchange for greater flexibility and budget certainty,” Verma said.
“Block grants and per capita cap proposals are two such alternative financing
approaches.”
Also
Tuesday, CMS issued a proposed rule that
would overhaul so-called supplemental payments that many states receive to help
their hospitals, nursing homes and doctors get extra funding beyond those
received when caring for Medicaid enrollees.
The
federal government spent about $48.5 billion on such supplemental payments in
2016 for states.
The
payments — as a share of total Medicaid fee-for-service expenditures for health
providers — ranged from 1% in North Dakota to 65% in Tennessee, according to a Congressional Research Service report.
CMS and
congressional investigators have said the payments allow states to game the
system to help bring in additional revenue for these providers without showing how they spend the money.
“I
recognize that these schemes often have their roots in self-interested
providers, egged on by opportunistic consultants seeking to leverage regulatory
loopholes or hide behind a lack of transparency,” Verma said. “I know that most
state leaders want to make sure every dollar is supporting value and improving
care for Medicaid beneficiaries, and those of you that are doing the right
thing have nothing to worry about. We have your back.”
The
supplemental Medicaid payment system has come under criticism for many years
because of the lack of transparency at
the state level. However, efforts to curtail the spending has faced pushback
from states and providers fearful of losing dollars.
Matt
Salo, executive director of the National Association of Medicaid Directors,
said state officials are open to efforts to bring more transparency but they
will be cautious about anything that severely reduces their funding.
“The
challenge is, how do you do this in a thoughtful, real-world way?” Salo said.
“We have to do it in a way that is achievable but that does not jeopardize
patient care in the process.”
Verma
acknowledged that the uninsured rate among children has grown in the past two
years despite the strong economy. She said the solution is to lower health
costs to make it easier for their parents to afford private coverage.
Patient
advocates have blamed states’ efforts to tighten Medicaid eligibility as a
leading factor in the drop in coverage.
Nonetheless,
Verma said she would push states to further limit eligibility to make sure only
those eligible are getting benefits.
“Lax
eligibility practices jeopardize the sustainability of the program,” she said.
CMS
will “ensure that states conduct timely redeterminations and make use of
appropriate data sources to verify ongoing income eligibility.”
Salo
said state Medicaid directors agree with the need for appropriate safeguards to
make sure ineligible people are not getting assistance. But, he added, forcing
enrollees to go through more steps to get and retain coverage will come at a
cost of losing people who truly deserve help.
“You
want government to work for people and want to create a system that if you are eligible
it should be easy to get on,” he said. “And if you set barriers and hurdles,
you will lose a lot of people who are eligible but could not deal with the
paperwork.”
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