Trump Administration Rejects Lifetime Medicaid Cap, Unpredictable on Enrollment or Benefit Cuts

NYAPRS Note: While the Trump Administration has been supportive of state proposals to tie work requirements to Medicaid, it drew the line yesterday at backing lifetime limits, a move lauded nationally by advocates for low income Americans and/or those with disabilities. It remains unclear where the Administration will be on state proposals to limit enrollment, impose a drug testing requirement, limit medication access or to prohibit reimbursement for Planned Parenthood related services.

NYAPRS is joined by national and state advocacy groups in closely tracking and opposing such proposals in close collaboration with Families USA, whose former director Ron Pollack was a featured speaker at our 2017 executive seminar. Learn more at   

Trump Officials Draw A Red Line On State Medicaid Cuts

Despite approving work-requirement plans for some states, the Trump administration rejected Kansas’s request to impose lifetime limits on Medicaid eligibility.

By Dylan Scott Vox.xom  May 7, 2018

The Trump administration has drawn a red line on Medicaid cuts. There are some proposals that the Centers for Medicare and Medicaid Services won’t approve.

In a letter on Monday, CMS Administrator Seema Verma told Kansas officials that her agency would not approve the state’s request to impose lifetime limits, which would have capped a person’s eligibility at three years, after which they could no longer be covered by the program.

Verma noted that the administration had approved proposals by other states to cut off benefits for Medicaid enrollees only if they fail to meet certain work requirements.

”In every case, these incentive structures are designed to engage beneficiaries in ways that promote positive health and well-being,” she wrote, perhaps indicating that cutting off a person’s Medicaid for nothing other than the length of time they had been covered would not meet that standard.

Verma elaborated in a speech Monday to the American Hospital Association: “We seek to create a pathway out of poverty, but we also understand that people’s circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them.”

The CMS decision to reject Kansas’s waiver is a very big deal: Lifetime limits have not gotten the same amount of attention as work requirements, but they would have signaled an equally important shift in Medicaid, away from an entitlement for all eligible Americans toward a shrinking program actively culling people from the rolls.

Even if work requirements are allowed, it matters that the administration is not going to let states to kick people off Medicaid simply because they have been on the program for a long time.

”I do think it is significant that CMS has decided to say no to one of the pending requests that cut people off of Medicaid,” Joan Alker, executive director at Georgetown University’s Center for Children and Families, told me.

Verma’s announcement also likely spells doom for similar proposals in Arizona and Utah, which sought to place a hard cap on how long people could be covered by Medicaid.

This wasn’t a given, after the administration opened the door for work requirements, which many progressives also saw as a violation of the core tenets of Medicaid.

”It’s a big deal. There was real uncertainty where the administration would come down and time limits would have a large impact on enrollment,” Eliot Fishman at Families USA, who oversaw Medicaid waivers under President Obama, said in an email.

Don’t be mistaken: The Trump administration’s willingness to permit states to impose work requirements, to end retroactive eligibility, etc., will still drive down enrollment and cut benefits. We also saw in Michigan last week how work requirements could disproportionately affect black beneficiaries, while rural white enrollees receive exemptions.

The CMS letter also did not speak to the Kansas request to institute a work requirement for parents with very low incomes — a situation that Alker has written could leave those recipients in a Catch-22.

If they don’t meet these requirements, they could lose their coverage. But if they do find work, they may end up making too much money to qualify for Medicaid in a state like Kansas, which has refused to expand Medicaid under Obamacare and therefore still only covers nonelderly, nondisabled parents who make very little money.

Nevertheless, this was a big day for Medicaid advocates. The Trump administration is not granting carte blanche for states to roll back Medicaid eligibility as much as they want. It sets an important precedent.

Red States Find Trump an Unpredictable Ally on Medicaid

By RACHANA PRADHAN  Politico  May 8, 2018

Conservatives state lawmakers aren’t getting everything they want from the Trump administration as they try to overhaul Medicaid.

Federal officials on Monday denied Kansas’ request to implement the first-ever lifetime limits on Medicaid coverage, delivering a reality check with larger implications for how far the GOP can go trimming the health program for the poor.

It marked the first time the Trump administration has categorically denied Medicaid cuts pushed by a red state. The decision — delivered in a brief letter from the Centers for Medicare and Medicaid Services without elaboration — dismayed some conservatives and frustrated state lawmakers, who say it’s virtually impossible to know what will get approved without an onerous back-and-forth with federal officials.

“They won’t tell us what they will or won't approve until we apply. We’re throwing spaghetti on the wall and seeing what sticks,” said Utah state Sen. Daniel Hemmert, whose state has asked the Department of Health and Human Services to limit certain Medicaid enrollees’ benefits in his state to five years, among other conservative changes.

“We only get one toss per year, basically,” he added. “To innovate within Medicaid, it’s frustrating and slow.”

Arizona, Utah and Wisconsin have also asked the Trump administration for similar caps on how long certain enrollees can stay in the program.

“We have heard informally from CMS that they will not approve it,” Utah state Rep. Jim Dunnigan, a Republican, said of lifetime limits in other states. A CMS spokesperson said, “CMS evaluates every demonstration proposal individually and in accordance with a set of state-specific facts.”

The Trump administration declined to act on another Kansas request: to impose a work requirement affecting roughly 12,000 low-income parents, although HHS has given four other GOP-led states permission to institute similar requirements. New Hampshire on Monday received permission to tie Medicaid benefits to employment, following similar approvals in Kentucky, Indiana and Arkansas.

Those four states, unlike Kansas, expanded Medicaid under Obamacare, growing their programs by thousands of low-income adults.

“We know that two of the best policies to move individuals from welfare to work are work requirements and time limits,” said Tarren Bragdon, president of the Foundation for Government Accountability, a conservative think tank that has opposed Obamacare’s expansion of the Medicaid program, who expressed disappointment with the decision on Kansas' request. “I am surprised."

HHS made granting work requirement requests a linchpin of its Medicaid reform strategy, pleasing conservative activists and Republican legislators. But it's being more circumspect about a long list of other controversial ideas from Republican governors.

Wisconsin’s Scott Walker wants to impose drug testing on certain Medicaid beneficiaries while Massachusetts’ Charlie Baker is seeking to limit what prescription drugs are covered under the program. Texas’ Greg Abbott, meanwhile, is pressing Trump administration officials to reinstate federal Medicaid funds for a women’s health program that excludes Planned Parenthood.

Kansas' bid for a work requirement wasn’t the first time federal health officials have punted on a major red state initiative. They were silent in March on Arkansas Gov. Asa Hutchinson's request to cap eligibility for the state's Obamacare Medicaid expansion at the federal poverty line, a move that would have trimmed enrollment in the Affordable Care Act program by roughly 60,000 people. Massachusetts has a similar proposal still under review.

“I don’t think there’s any expectation that the administration says yes to every request just because it comes from a Republican state,” said Akash Chougule, director of policy for the Koch brothers-funded Americans for Prosperity.

A spokesperson for Kansas Gov. Jeff Colyer said state officials were told in late April that CMS was unlikely to approve lifetime limits.

“While we will not be moving forward with lifetime caps, we are pleased that the administration has been supportive of our efforts to include a work requirement in the 1115 waiver,” Colyer said in a statement Monday following the rejection.

Kansas already has some of the strictest Medicaid eligibility levels in the nation for nondisabled adults, and the state had wanted to go further and limit thousands of low-income parents to three years of Medicaid benefits.

“I’m not real surprised,” said Sheldon Weisgrau, interim director of the Alliance for a Healthy Kansas, which supports Obamacare and has advocated for Kansas to expand its Medicaid program under the law. “I think ideologically they would have liked to say yes but my guess is that they found real trouble finding authority.”

Conservatives concede that there’s only so much federal officials can do through executive authority to fundamentally alter Medicaid’s trajectory without getting Congress involved. Congressional Republicans tried to enact major reforms last year — including enshrining Medicaid work requirements into federal law — but those efforts collapsed with the party’s failed bid to repeal Obamacare.

State officials in both parties have long complained that it takes protracted negotiations with HHS to change elements of their programs. Republicans say the Trump administration is being more flexible and open-minded about new ideas but they still have to jump through hoops.

“I think this sends a really important message to Congress,” said Naomi Lopez Bauman with the Goldwater Institute, a conservative think tank in Arizona that supports lifetime limits. "There are going to be things that don’t make it through."