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“Rejected” Medicaid Reforms May Resurface

Partial Medicaid expansion, desired by some Republican governors but rejected by the Trump administration last year, may not be so rejected after all.

At least not according to Seema Verma, administrator of the Centers for Medicare & Medicaid Services, which oversees the federal Medicaid program.

In a recent interview, Verma said the administration is reconsidering its rejection of partial Medicaid expansion, an idea she supports and that

What I have said to states and to governors [is] “Tell me what you want to do, and it’s my job to help you get to where you want to go.”

To emphasize this point, Verma also said that

We are changing the partnership between the federal and state government.  We are trying to empower states.

The National Alliance of Safety-Net Hospitals supports Medicaid expansion everywhere.

Learn more about Verma’s recent remarks about Medicaid expansion in the Politico article “Seema Verma:  Medicaid reform rejected by Trump is ‘under review.’”

 

States Taking Different Paths to Pay for Medicaid Expansion

With the federal share of Medicaid expansion falling to 90 percent next year, states that expanded their Medicaid programs under the Affordable Care Act are now exploring new ways to raise the money to pay for the 10 percent for which they will soon by responsible.

Some are implementing hospital or insurer taxes while others are increasing existing taxes on hospitals and health insurers.  New Hampshire is directing part of the proceeds from a liquor tax for this purpose and other states have introduced cigarette taxes.  Some are charging premiums to Medicaid beneficiaries and introducing Medicaid work requirements so they can reduce overall enrollment.  Many are using money from their general revenues.

This all comes at a time when many states are finding that their budget situations have improved and are better than they have been in years.

Learn more about how states are dealing with this challenge, and whether they are finding that it is worth it, in the Washington Post article “States scramble to head off future Medicaid shortfalls.”

Election Brings Good News for Medicaid

Medicaid came out on top in elections throughout the country last week.

With the arrival of a Democratic majority in the House, attempts to repeal the Affordable Care Act, including its Medicaid expansion, appear to have come to an end – at least for now.

Voters in three states approved ballot questions to expand their states’ Medicaid programs.

And two states elected governors likely to expand their states’ Medicaid programs.

Learn more about what the mid-term elections meant to Medicaid and its future in this Washington Post story.

 

Medicaid Expansion Helping Diabetics

The Affordable Care Act’s Medicaid expansion has led to a 40 percent increase in the number of prescriptions for diabetes medicine filled in the 30 states that expanded their Medicaid programs.

Meanwhile, there was no change in the number of diabetes-related prescriptions filled in states that did not expand their Medicaid programs.

This is considered important because it suggests that many low-income people who either could not afford their diabetes medicine or whose illness was undiagnosed are now being treated for the disease – a significant development because every diabetic who is treated for the condition represents a cost savings of $6394 a year, mostly because of fewer hospitalizations.

Because diabetes is especially prevalent in the low-income communities urban safety-net hospitals serve, these hospitals have played a major role in bringing much-needed treatment to their communities, improving their health of their residents, and helping to reduce health care costs.

Learn more about how Medicaid expansion is improving the health of low-income people with diabetes and lowering health care spending in this California Healthline report or go here to see the Health Affairs study “Medicaid Eligibility Expansions May Address Gaps in Access to Diabetes Medications” on which that report is based.

Verdict: Medicaid Expansion Improved Care and Access

A new review of studies published since the Affordable Care Act’s Medicaid expansion has concluded that expansion improved care, access to care, and coverage in states that expanded their Medicaid programs.

Among the improvements cited by studies are:

  • greater use of primary care
  • more preventive health visits
  • more behavioral health care
  • shorter hospital stays
  • fewer avoidable hospital admissions
  • reduced access problems
  • reduced reliance on hospital ERs as a primary source of care
  • improved monitoring and compliance rates for patients with diabetes and hypertension
  • higher rates of screening for prostate cancer and Pap smears

In addition, hospitals provided less uncompensated care and had better margins.

Learn more in the Health Affairs study “The Effects Of Medicaid Expansion Under The ACA:  A Systematic Review,” which can be found here, or go here for a Healthcare Dive summary of the study.

Medicaid Changes: More Than Just Work Requirements Coming?

While the green light for state applications to impose work requirements on their Medicaid recipients is receiving all of the attention, the Trump administration has issued guidance that appears to pave the way for other major changes in the Medicaid program as well.

Specifically, the Centers for Medicare & Medicaid Services has issued guidance that will enable states to pursue section 1115 waivers to test different ways of serving Medicaid patients that are otherwise not permitted under federal Medicaid law, including:

  • establishing time limits on how many months or years individuals may be enrolled in Medicaid;
  • locking out for a specified period of time Medicaid recipients who have not gone through annual eligibility redetermination or have failed to pay Medicaid premiums;
  • prohibiting hospitals from making presumptive eligibility determinations when they encounter new, low-income patients who are not enrolled in Medicaid at the time;
  • tightening their eligibility requirements;
  • excluding family planning providers like Planned Parenthood; and
  • establishing closed drug formularies for their Medicaid population.

Learn more about how the foundation has been laid for such changes if states are so inclined to pursue them and the implications of such changes if they are implemented in the article “State Waivers as a National Policy Lever:  The Trump Administration, Work Requirements, and Other Potential Reforms in Medicaid, which can be found here, on the Health Affairs Blog.

A New Wave of Medicaid Expansion?

Spurred by the Trump administration’s invitation to states to apply for approval to make work requirements a part of their Medicaid program, a number of states that spurned the opportunity created for expansion under the Affordable Care Act may consider pursuing Medicaid expansion in the near future.

Currently, some elected officials in Idaho, Kansas, North Carolina, Utah, Virginia, and Wyoming appear to be considering what they once considered unthinkable:  making more of their residents eligible for Medicaid.

For the most part, expansion talk is coming from moderate Republican legislators who believe a work requirement may help soften the staunch opposition to Medicaid expansion among their more conservative Republican colleagues – and at this point it is all still just talk.

Ten states have already sought federal approval to establish a work requirement as part of their Medicaid programs and one state, Kentucky, has already had such a request approved.

Learn more about how a federal move to reduce the number of people on the nation’s Medicaid rolls may actually result in an increase in nation-wide Medicaid enrollment in this Washington Post story.

Medicaid in the Spotlight

State-option work requirements.

A cap on federal spending.

New flexibility for states to address eligibility, benefits, and provider payments.

Rolling back the Affordable Care Act’s eligibility expansion.

Medicaid is under the policy microscope in Washington these days in ways it has not been for many years as the new administration continues to work to put its stamp on the federal government’s major program to provide health care to low-income Americans.

These and other possible changes are of great interest to the nation’s private safety-net hospitals because these hospitals care for so many more Medicaid and low-income patients than the typical community hospital.

What are policy-makers considering and what are the potential implications of their efforts?  Learn more in the new Health Affairs blog article “Medicaid Program Under Siege,” which can be found here.

Medicaid Expansion Helps Save Hospitals

Hospitals in states that took advantage of the Affordable Care Act to expand their Medicaid programs are six times less likely to close than hospitals in non-expansion states.

And the impact of Medicaid expansion is even more beneficial for hospitals that serve rural communities.

These are among the new findings in a new study that examines the effect of Medicaid expansion on hospital finances and hospital closures.  Among those findings,

We found that the ACA’s Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion.

According to the study, these hospitals, as a result of Medicaid expansion, served fewer uninsured patients and provided less uncompensated care than they previously had, thereby improving their financial health.  This effect has been especially pronounced in communities with especially large numbers of uninsured patients – communities like those served by urban safety-net hospitals.

For this reason, the study’s authors conclude that

Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

 To learn more, go here, to the Health Affairs web site, to see the study “Understanding The Relationship Between Medicaid Expansions And Hospital Closures.”

MACPAC Meets

The non-partisan legislative branch agency that advises Congress, the administration, and the states on Medicaid and CHIP-related issues met recently in Washington, D.C.

The following is the Medicaid and CHIP Payment and Access Commission’s own summary of its meeting.

The December 2017 meeting of the Medicaid and CHIP Payment and Access Commission began with a brief update on the State Children’s Health Insurance Program (CHIP). Although federal funding for the CHIP expired at the end of September, legislation to renew funding was still pending in Congress. The Commission then heard from a panel discussing state tools to manage drug utilization and spending in Medicaid. Panelists included Renee Williams, director of clinical pharmacy services for TennCare; Doug Brown, Magellan Rx Management’s vice president for Medicaid drug rebate management; and John Coster, director of the Center for Medicaid and CHIP Services Division of Pharmacy at the Centers for Medicare & Medicaid Services. At the final morning session, Commissioners reviewed a draft March 2018 report chapter on streamlining Medicaid managed care authorities. The Commission voted to approve recommendations to Congress, but deferred action on a third recommendation for further discussion at its upcoming January 2018 meeting.

In the afternoon, MACPAC staff previewed highlights from the December 2017 MACStats: Medicaid and CHIP Data Book. MACStats pulls together Medicaid and CHIP data from multiple sources that often can be difficult to find. The collection is published annually and individual tables are updated throughout the year. The Commission then reviewed the draft March report chapter on telemedicine in Medicaid, and later in the day the Commission returned to the topic of prescription drugs, to explore potential recommendations on the Medicaid drug rebate program.

The final December sessions covered MACPAC’s annual analysis of disproportionate share hospital payments (a required element of its March reports), and findings from interviews with four states to better understand how they are implementing Section 1115 Medicaid-expansion waivers.

The following presentations, many with supporting documents, were offered during the MACPAC meeting:

  1. State Strategies for Managing Prescription Drug Spending
  2. Review of March Report Chapter: Streamlining Managed Care Authorities
  3. Highlights from MACStats
  4. Review of March Report Chapter: Telemedicine in Medicaid
  5. Potential Recommendations on Medicaid Outpatient Drug Rebates
  6. Review of Draft March Report Chapter: Analyzing Disproportionate Share Hospital Allotments to States
  7. Implementation of Section 1115 Medicaid Expansion Waivers: Findings from Structured Interviews in Four States