Restore Medicaid to Its Former Self Quickly

Me – Talk: Recent article on Health Affairs I tapped into and decided to present here at AB. The topic? As expressed in the title, return Medicaid to its former self and improved upon by the new Biden Administration. I also have been working on additional posts touching upon the history of the opioid epidemic by the numbers, single payer, and a comparison to the a European healthcare model.

“In Its First 100 Days, The Biden Administration Must Restore The Soul Of Medicaid, Health Affairs,” Nicole Hubereld, Paul Shafer

Some Purpose . . .

The new administration should turn things around quickly and fix the damage trump and his administration did as sponsored by Republicans and supporters. This is as vital as getting stimulus money to people.

With the pandemic and many out of work, one of the top priorities for President Biden in his first 100 days should be: repeal the changes to Medicaid over the last 4 years by Republicans driving the Trump administration – bus. Medicaid provides a safety-net covering nearly one-quarter of the population today and will also cover those who have recently lost income and insurance. Nothing could be more vital during a pandemic than people needing healthcare.

The PPACA is not perfect but with the implementation of it, the expansion of Medicaid in 38 states and Washington D.C. came to be. It was “only” Republican opposition which stymied it in the other 12 states.

The expansion gave those workers with no employer healthcare, who could not afford traditional healthcare insurance, were part-time or low-wage workers, and the underserved population such as people of color access to healthcare. The PPACA inspired Medicaid expansion also narrowed the disparity in coverage between Black and White populations from 11.0 to 5.3 percent and between Hispanic and non-Hispanic White populations from 25.4 to 16.6 percent.

With the Trump administration taking office, many of the features of Medicaid benefiting low-income people during normal times and times of crisis such as continuous eligibility, comprehensive benefits, limitations on out-of-pocket payments, and guaranteed federal matching funds to states came under attack. This Republican administration reduced many of the new benefits of Medicaid, eliminated them, or required eligibility or other novel requirements.

Instead . . .

Work requirement policies and block grants of Medicaid funds enacted were meant to stymie its growth. Other attacks included reduced coverage of non-emergency medical transportation, retroactive eligibility, and frequent eligibility redeterminations were enacted to stymie users and the program’s purpose.

Much of the impediments were implemented through the use of administrative executive orders by the Trump administration. These can be reversed by President Biden.

What Actions are needed?

Rescind Work Requirements

The initial work requirements resulting from the 2018 State Medicaid Director Letter (SMD) “Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries” should be rescinded.  Work requirements resulted from a Congress failing to repeal the ACA in 2017. The SMD letter allowed states to require work or other “community engagement” requirements such as job training or volunteer programs as a condition of Medicaid eligibility.

This requirement is a first in the history of Medicaid. Fifteen states have received HHS approval for demonstration projects that include work requirements. 0f which:

  • Three states voluntarily withdrew their demonstrations (Kentucky, Maine, and Virginia),
  • Four states have had their “1115- waivers” stayed by federal courts (Arkansas, Kentucky, Michigan, and New Hampshire),
  • An additional seven states have waivers pending at HHS to include work requirements, and
  • South Carolina had work requirements approved without Medicaid expansion. 

States implementing work requirements (Arkansas) expanded Medicaid focusing work requirements on the expansion population. Unlike work requirements in the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families, Medicaid work requirements are not required by federal law.

Political interests put them in place to stymie enrollment in the belief people on Medicaid were malingering. Health and Human Services (HHS) advancing such job requirements as necessary are contrary to the program’s purpose. In the limited time work requirements have been implemented, substantial Medicaid disenrollment resulted and were not supported by alternative employment opportunities with health benefits.

Revoke The Block Grant Initiative

 In early 2020, the Centers for Medicare and Medicaid Services issued a State Medicaid Director  (SMD) letter to clarify and communicate policies set forth in Block Grant Initiative regulations. The SMD letter gave guidance.

It invited state applications for Section 1115 waivers to convert Medicaid funding for certain populations to block grants or limits on per capita spending. The waivers allowed less federal oversight in exchange for limiting funding while also continuing to enact work requirements for the expansion population.

Whether enacted or not, Section 1115 does not give HHS the authority to waive Section 1903 of the Social Security Act. SSA Section 1903 governs the provision of the federal Medicaid’s matching funds to states. If challenged in court, the block grant policy struck down and would face a fate similar to work requirement waivers. As of yet, no court has ruled on the Healthy Adult Opportunity (HAO) initiative.

Only two states had sought to participate in the HAO initiative.

  • Oklahoma withdrew a waiver application after amending its the state constitution to support an expansion, and
  • Tennessee submitted a block grant waiver application before the implementation of HAO.

Since approval has not been given, the withdrawal is relatively easy. A new HHS secretary would clarify Medicaid policy stating the HAO waiver proposals are unacceptable.

Reverse Policies That Cut Benefits

Implementing 1115-Waivers policies allow increased Medicaid cost sharing and limits on benefits and coverage. Some state policies initiated during the Obama administration were give-aways in state negotiations to encourage expansion. Under 1115-Waivers, Medicaid retroactive costs for qualified enrollees three months prior to enrollment could be disallowed by the state. The waivers allowed states to also drop enrollees for nonpayment and also require frequent redeterminations.

Cost sharing, limits on benefits, and coverage requirements rules should not be a part of Medicaid and eliminated by the new administration.

Restore Access To Planned Parenthood Services

Under the Trump administration, HHS gave states leeway to modify Medicaid’s free-choice-of-provider requirements. Some states eliminated Planned Parenthood as a qualified provider for payment purposes. Most federal courts rejected this with the exception of the Fifth Circuit (Planned Parenthood vs. Kaufman). In its decision, beneficiaries do not have standing to challenge state decisions to eliminate providers from Medicaid. The decision restricts low-income patients’ access to mammograms, Pap smears, and other preventive care, such as screening for sexually transmitted infections. Newly elected President Biden needs to reverse this policy.

Paying Back Medicaid

I have added this particular Medicaid issue. There are many stories of people caring for other relatives, spouses, etc. who are on Medicaid. Upon the death of the relation, Medicaid billed the survivors left with the assets (house, etc.) of the deceased. Survivors liquidated those assets to payback Medicaid. The parents no longer had income or could afford healthcare, and went on Medicaid. It would seem to me a resolution could be to limit as to what can be taken very much like there is with an inheritance after death.

In The End?

Until we get better healthcare such as Single Payer, Medicaid is the fall back for most US citizens in times of unemployment or crisis.

Medicaid purpose and functions as a tool is to protect individual and public health, addressing social determinants, diminishing entrenched disparities, and improving coverage and access to care for vulnerable communities and to stabilize state budgets

The Trump administration worked to undermine the program along with the ACA.  

The Biden Administration Must Restore The Soul Of Medicaid”, Health Affairs, January 11, 2021, Nicole Hubereld, Paul Shafer