Medicaid Chief Nixes Idea of Lifetime Coverage Caps

The Trump administration will continue to champion policies that tighten Medicaid eligibility—but won’t allow states to impose lifetime caps on the coverage, Medicaid’s top official said May 15.

CMS Administrator Seema Verma said the agency had made it “pretty clear” it would not approve the time limits, because they don’t include a pathway back to health insurance for Medicaid beneficiaries who’ve been booted from the rolls. The program covers vulnerable people who might be able to temporarily move into work and stability, only for their circumstances to change later on.

“We always want to make sure the program serves as a safety net, and they have a place when they need it,” she said at a Washington Post Live discussion on the future of health care.

The Centers for Medicare & Medicaid Services rejected Kansas’s request earlier this month to limit coverage to a total of three years, but questions had remained over Medicaid time limits in four other states—Arizona, Utah, Maine, and Wisconsin. The decision sets a boundary on how far GOP leadership is willing to go in its quest to overhaul the nation’s largest health insurance program.

The Trump administration has sought to give states more control over their Medicaid programs through streamlined Section 1115 waivers and to use them to push a host of new limitations focused on personal responsibility. They include work requirements, approved for the first time in four states.

Verma’s Vision

Medicaid has grown dramatically to cover 74.8 million people in 2017, according to PricewaterhouseCoopers.

That includes the original populations it served such as the very poor, disabled, pregnant women, and children. But it also includes the more than 11 million people who signed up for the benefits in the 32 states and the District of Columbia that expanded the program under Obamacare.

Verma sees Medicaid for these groups as two separate health-care programs.

“It’s a different type of program, and we need a different response” for expansion enrollees, she said.

For those working-age, able-bodied adults, Medicaid should be just a temporary stopgap and hand up, according to Verma. And it should serve a “much higher” purpose: “not only to provide health-care coverage but helping them with a pathway out of poverty,” she said.

GOP lawmakers and officials have spent much of the past year warning that the $550 billion-and-growing program is costly and unsustainable, with Medicaid expansion enrollees crowding out the most needy within the ranks.

Verma echoed that she wants the program’s spending to become sustainable over the long term during her time at its helm.

Evaluating Restrictions

The CMS has approved waivers in Arkansas, Indiana, Kentucky, and New Hampshire that tie Medicaid eligibility to community engagement: employment, education, volunteering, job training, or a job search. Around 20 others are either actively pursuing or considering such requirements.

The Trump administration touts work requirements as a way to spur beneficiaries into self-sufficiency, linked to better health. Critics say those who can work already do and caution that the new rules would only make it harder for the most vulnerable in the ranks to keep up with coverage.

How will the agency determine whether they’re a success or not?

Verma said the waivers will have “strong evaluations” that consider improvement in health outcomes, as well as how many people find work and become independent from Medicaid under the requirements.

Patient advocates including Families USA and doctors’ groups have called into question the Trump administration’s use of Medicaid Section 1115 waivers for such sweeping changes in light of concerns over the effectiveness of monitoring.

A Government Accountability Office report earlier this year found that a lack of transparent evaluations meant officials don’t truly know whether Medicaid experiments are working or not.

“In the absence of federal evaluations that are meaningful, independent, and public, policies that remake the Medicaid program via waiver simply cannot be implemented in what is in essence a blindfolded manner,” the health-care groups said in a May 9 sign-on letter to Health and Human Services Secretary Alex Azar.

About one-third of Medicaid’s spending goes to the waiver demonstration projects, according to the GAO.

Other Waivers

Verma said May 15 that the CMS is mulling several other state proposals to change their Medicaid programs.

Among them is Wisconsin’s request to require drug testing.

Verma said the agency is looking at the waiver requests in light of the state’s goals: “They want to be able to identify individuals that need help” amid an opioid epidemic, Verma suggested.

The next step then is “to figure out what’s the best way to identify then help link them to services that would be most appropriate,” such as with comprehensive health assessments, she added.

She added that the agency is also looking at Utah’s proposal to allow a partial Medicaid expansion, only for adults living on incomes of up to 100 percent of the federal poverty level rather than 138 percent. The Obama administration rejected that idea with an all-or-nothing interpretation of the law.