Helgerson Assails "Reprehensible" CMS Medicaid Work Requirements Plan, Rosenbaum Finds Plan will Hurt Poorest, Most Vulnerable Americans

NYAPRS Note: NYS Medicaid Director Jason Helgerson blasted CMS Administrator Seema Verma’s support for work requirements for Medicaid beneficiaries, adding that “it was absurd for her to suggest that she was ushering in a new day for Medicaid by taking it away from millions of people.”Former CMS Director Cindy Mann found the proposal “disturbing”, adding that the Affordable Care Act gave states the “flexibility and financing” to cover that population in diverse ways, without seeking a federal waiver.”
And health policy expert law professor Sara Rosenbaum’s reaction: “It tells me that the agency is preparing to disavow a central objective of federal law and instead will attempt to accomplish exactly what the law does not countenance, namely, a reduction in the level of assistance available to the poorest and most medically vulnerable Americans.”
Finally, former NYAPRS Board co-President Steve Coe asked “if states reduce their roles through means testing where are people going for health care? He advocated for a Scorecard that looks at “the cost of uninsured individuals and the ways states highlight social determinates of health and steps taken to engage individuals in preventive care, social supports, training.”

Trump Administration Will Support Work Requirements for Medicaid
By Robert Pear November 7, 2017 New York Times

WASHINGTON — The Trump administration announced on Tuesday what it called “a new day for Medicaid,” telling state health officials that the federal government would be more receptive to work requirements and other conservative policy ideas to reshape the main government health program for low-income people.

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said the administration would approve proposals from states to require work or community engagement for people who want to receive Medicaid. The Obama administration had turned down such proposals, saying they would not further the purposes of Medicaid, which are to promote health coverage and access to care.

But in a half-hour speech to the National Association of Medicaid Directors, which represents state officials, Ms. Verma said on Tuesday that Medicaid had a higher purpose: to help people “rise out of poverty and government dependence.”

Many people on Medicaid, including many who became eligible as a result of the Affordable Care Act, are able-bodied adults of working age, Ms. Verma said.

“These are individuals who are physically capable of being actively engaged in their communities, whether it be through working, volunteering, going to school or obtaining job training,” Ms. Verma said. “Let me be clear to everyone in this room: We will approve proposals that promote community engagement activities.”

She heaped criticism on the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”

Jason A. Helgerson, the Medicaid director in New York State, said on Twitter that Ms. Verma’s comments were “absolutely awful.” It was absurd for her to suggest that she was ushering in a new day for Medicaid by taking it away from millions of people, he said.

Ms. Verma worked for years as a consultant to state Medicaid officials. With her guidance, her home state of Indiana expanded Medicaid eligibility under the governor at the time, Mike Pence, while emphasizing “personal responsibility” by requiring beneficiaries to pay premiums and contribute to health savings accounts.

In her remarks on Tuesday, Ms. Verma did not renew Republican calls for repealing the Affordable Care Act. But she criticized the law’s expansion of Medicaid, an option that has been taken up by 31 states.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults does not make sense,” Ms. Verma said.

Average monthly enrollment in Medicaid, according to the Congressional Budget Office, has climbed by nearly one-third, to 77 million people, since President Barack Obama signed the Affordable Care Act in 2010.

The Kaiser Family Foundation reports that at least six states — Arkansas, Indiana, Kentucky, Maine, Utah and Wisconsin — have pending waiver requests that would require work as a condition of eligibility for some Medicaid beneficiaries. New Hampshire submitted its own proposal last week.

“Community engagement” is a broad term that states define in various ways. It can include not only paid employment, but also volunteer activities, going to school, job training, searching for jobs, caring for elderly relatives and even treatment for drug or alcohol abuse.

Donna Checkett, a former Medicaid director in Missouri, said Ms. Verma’s position on requiring such activities was “180 degrees different from that of the previous administration.”

Cindy Mann, who was the top federal Medicaid official under Mr. Obama, said Ms. Verma’s objections to Medicaid coverage of working age, able-bodied adults were “upsetting and disturbing.”

The Affordable Care Act gave states the “flexibility and financing” to cover that population in diverse ways, without seeking a federal waiver, Ms. Mann said.

And she noted that the expansion of Medicaid had been defended by Republican governors including Chris Christie of New Jersey, John R. Kasich of Ohio, Rick Snyder of Michigan, Chris Sununu of New Hampshire and Brian Sandoval of Nevada.

Ms. Verma also announced changes to speed the review of state requests for waivers of the federal Medicaid law. She said the Trump administration could approve some waivers for 10 years. Waivers have typically been approved for five years, with the possibility of an extension for three years.

In addition, Ms. Verma said, “if we approve an idea in one state and another state wants to do the same thing, we will expedite those approvals.”

She said the Trump administration would issue a scorecard measuring and comparing states’ performance in improving the health of people on Medicaid. The federal government and the states together spend more than $550 billion a year on Medicaid, and people deserve to know if the money is “producing positive results,” she said.

Matt D. Salo, the executive director of the National Association of Medicaid Directors, said state officials agreed with Ms. Verma that they should focus on Medicaid beneficiaries and the outcomes of the care provided.

But, Mr. Salo said, “we have a lot of disagreement” with the contention that Medicaid should not be serving able-bodied adults of working age. State officials said that many Medicaid beneficiaries had low-wage jobs that did not provide health insurance for them or their family members.

Ms. Verma insisted that the Affordable Care Act had given states perverse financial incentives, paying a higher share of Medicaid costs for newly eligible beneficiaries.

“The A.C.A.,’’ she said, “moved millions of working-age, nondisabled adults into a program that was created to care for seniors in need, pregnant mothers, children and people with disabilities, stretching the safety net for some of our most fragile populations, many of whom are still on waiting lists for critical home-care services while states enroll millions of newly eligible able-bodied adults.’’


States Will Be Allowed To Impose Medicaid Work Requirements, Top Federal Official Says
By Paige Winfield Cunningham November 7, 2017 Washington Post

The government will give states broader leeway in running their Medicaid programs and allow themto imposework requirements on enrollees, a top federal health official said Tuesday in outlining how the Trump administration plans to put its mark on the insurance program for low-income Americans.

Seema Verma, who heads the Health and Human Services Department’s Centers for Medicare and Medicaid Services, did not spare criticisms of the Obama administration and called its opposition to work requirements “soft bigotry.”

“Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Verma said in a sweeping address to the National Association of Medicaid Directors. “Those days are over.”

The speech was Verma’s most detailed public explanation of how she plans to approach Medicaid in a highly politicized era in which Republicans still hope to roll back its expansion under the Affordable Care Act as well as enact future spending cuts through their various health-care bills.

The program’s chief problems, according to Verma, include the expansion to add able-bodied adults and overall costs, which now comprise 29 percent of total state spending. She also faulted the federal government for requiring too much reporting from states and for delaying approval of states’ waiver requests to run their programs in alternative ways.

Multiple times throughout her half-hour speech, she used the phrase “card without care” to make her point that simply enrolling people in Medicaid isn’t effective if they can’t find a doctor who will accept them — an ongoing problem with the program because its reimbursements are lower than for Medicare or private coverage.

“We fail to live up to that promise when Medicaid merely provides a card without care,” she said. “And that’s why we’re ushering in a new era for Medicaid at CMS.”

Verma stressed that she and President Trump are “deeply committed” to the program, while accusing the prior administration of quashing state innovation and undermining Medicaid’s traditional partnership between the federal and state governments.

She listed a number of ways that CMS will change its approach, by expediting state waiver requests that mirror past approvals, allowing some waivers for up to a decade and starting a “report card” that grades state programs.

Waivers are a major way the Trump administration can reshape Medicaid. A half-dozen states have applied or soon will apply to require program enrolleesto get a job or do some kind of community volunteering as a condition of their coverage.

Verma has long supported such requirements, which the Obama administration uniformly rejected, but Tuesday was the first time she explicitly promised that her agency would approve this type of waiver request.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense,” she said.

Some officials from states currently asking to implement work or community engagement requirements were pleased at Verma’s declaration of support, including Kentucky Medicaid commissioner Stephen Miller.

“You heard what was said today, and we’re right in sync with that,” Miller said. He said he’s expecting notification “soon” from CMS that Kentucky’s waiver request has been approved. The state is hoping to set its new requirements in motion starting the middle of 2018.

But New York Medicaid director Jason Helgerson said it was “completely reprehensible” for Verma to use the phrase “soft bigotry” to describe Medicaid programs that don’t impose extra requirements on low-income people seeking coverage.

“Where should I start? Helgerson said, when asked to respond to Verma’s address. “Shocked, appalled would be the two primary reactions I have.”


Medicaid Chief Says Feds Are Willing To Approve Work Requirements
By Phil Galewitz November 7, 2017 Kaiser Health News |

The Trump administration signaled Tuesday that it would allow states to impose work requirements on some adult Medicaid enrollees, a long-sought goal for conservatives that is strongly opposed by Democrats and advocates for the poor.

“Let me be clear to everyone in this room: We will approve proposals that promote” employment or volunteer work, Seema Verma, the head of the Centers of Medicare & Medicaid Services (CMS) said in a speech to the nation’s state Medicaid directors.

Such a decision would be a major departure from federal policy, and critics said it would lead to a court fight. President Barack Obama’s administration ruled repeatedly that work requirements were inconsistent with Medicaid’s mission of providing medical assistance to low-income people.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve the working-age, able-bodied adults does not make sense, but the prior administration fought state-led reforms that would’ve allowed the Medicaid program to evolve,” Verma said.

“For people living with disabilities, CMS has long believed that meaningful work is essential to their economic self-sufficiency, self-esteem, well-being and improving their health,” she added. “Why would we not believe that the same is true for working-age, able-bodied Medicaid enrollees?”

Verma also blasted the Affordable Care Act, saying the health law’s efforts to give coverage to so-called able-bodied adults was a mistake because it resulted in “stretching the safety net for some of our most fragile populations,” such as children, pregnant women and people with disabilities. It also has added to the problems for Medicaid enrollees getting access to care, she said.

The speech got a cool reception from the state directors. None of her comments brought immediate clapping from the nearly 1,000-person audience, but there was polite applause at the end.

Eight states — Arizona, Arkansas, Indiana, Kentucky, Maine, New Hampshire, Utah and Wisconsin — have submitted requests to CMS seeking to require nondisabled Medicaid enrollees to either work or provide community service.

The proposed work requirement rules vary by state. Arizona calls for enrollees to be working, seeking work or attending school or job training for at least 20 hours a week.

New Hampshire would require enrollees to work, engage in job training or acquire education for more hours the longer they are in Medicaid. For example, they would put in 20 hours a week the first year they were enrolled, 25 hours the second year and at least 30 hours in their third year.

Verma did not say when she would rule on the pending applications, but one CMS official said it would likely be before the end of the year.

The Medicaid chief said she wants to give states more flexibility as CMS officials “reset the federal-state relationship, and restore the partnership,” so that Medicaid “is sound and solvent and helps all beneficiaries reach their highest potential.”

Kentucky expects to get a green light from CMS and plans to implement the mandate by July, said Stephen Miller, the state’s Medicaid director. “We were in sync with what she had to say” about work requirements, he said.

He said that even though the state’s Medicaid rolls have soared to cover 33 percent of residents, Kentucky still has high rates of cancer, smoking and obesity. “We have to try something else,” he said. “We need to do more than just help people access health care.” The move would also help the state save money, he added.

Allison Taylor, Indiana’s Medicaid director, said a work requirement would help the state find the nearly 1 million workers it is estimated to need by 2025.

Studies show the vast majority of Medicaid enrollees are already working, looking for work, going to school or caring for a relative.

About 59 percent of nondisabled adults on Medicaid who are under 65do have jobs, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Verma said the Obama administration was wrong when it denied states’ requests to implement work requirements, also known as community engagement mandates. “Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said. “Those days are over.”

New York Medicaid Director Jason Helgerson said the speech created an “us vs. them” scenario. “To suggest that the work we do is some form of bigotry is disgusting,” he said.

While he welcomed more flexibility from CMS toward states, Helgerson said the ACA has been a boon to New York and there is no evidence of people having longer waits for care since the expansion.

Verma decried the Obama administration’s emphasis on Medicaid enrollment. “While many responded to this expansion with celebration, we shouldn’t just celebrate an increase in the rolls, or more Medicaid cards handed out,” she said. “For this population, for able-bodied adults, we should celebrate helping people move up, move on and move out.”

Several Medicaid directors said they were upset that Verma suggested they care only about adding people to Medicaid rolls. “We do so much more than that,” said one Medicaid director, who refused to be named because of concerns about working with CMS.

More than16 million peoplehave been added to Medicaid since 2013, mostly as a result of 31 states and the District of Columbia expanding eligibility under the federal health law.

States and the federal government split the costs of the$576 billion Medicaid program,which covers 74 million people. States are allowed to set benefits and eligibility rules within broad federal guidelines.

Since the 1990s, the federal government has increasingly allowed states to temporarily waive Medicaid rules to give states the ability to experiment with how they administer the program. States have used those options for efforts such as adding monthly premiums or customizing their expansion of Medicaid under the 2010 Affordable Care Act.

Two long-term requirements of such waivers are that they do not increase federal costs and they improve health coverage of the poor.

CMS said Tuesday that expanding access is no longer a key purpose of federal Medicaid waivers. That would be a philosophical change in the program that would open the door to approve work requirements, which states acknowledge would reduce the number of people enrolled.

“It tells me that the agency is preparing to disavow a central objective of federal law and instead will attempt to accomplish exactly what the law does not countenance, namely, a reduction in the level of assistance available to the poorest and most medically vulnerable Americans,” said Sara Rosenbaum, a health policy and law professor at George Washington University in Washington, D.C.

Verma’s decision had been widely expected. Before being appointed to CMS, she was a health care consultant, and she helped the Indiana and Kentucky Medicaid programs draw up their waiver requests, including work requirements. To avoid a conflict, CMS said Verma will not be involved in decisions on those two states.

A decision to support work requirements would likely end up in a court battle, said Jane Perkins, legal director of the National Health Law Program, an advocacy group. Perkins said CMS has power to allow states to experiment with the Medicaid program but not by curtailing eligibility.

“This is really a change in the complexion of the Medicaid program, where CMS is saying to states, ‘Come tell us what you want to do and if you want to cut back the program, we will give you the go ahead,’” Perkins said. “That is inconsistent with congressional intent” of Medicaid waivers.

Verma’s address to the National Association of Medicaid Directors meeting in Arlington, Va., marks one of her few public appearances since taking office. Despite overseeing both Medicaid and Medicare — programs that affect more than 120 million Americans — she has given few interviews or public speeches.

She has frequently been mentioned as a possible replacement for Health and Human Services Secretary Tom Price, who resigned in September following allegations of wasteful travel spending.

Verma’s speech came afteran announcement by CMSon Monday that it would streamline the often-arduous process to get Medicaid waivers. It offered to fast-track some requests and said it would allow states to get waivers for up to 10 years — five more years than currently allowed.

Verma also said the federal government would release scorecards showing Medicaid outcomes, but she gave no details on what measures would be evaluated. Some state officials fear CMS will use the new grading measure to lower their federal funding.

Most Medicaid enrollees are in private managed care plans, which get evaluated each year by states, looking at everything from vaccination rates for children to cancer screening rates for adults.