The Medicaid 1115 waiver program allows states to apply for and receive permission from the Center for Medicare and Medicaid Services (CMS) to waive certain federal guidelines for Medicaid. Almost every state has a 1115 waiver for something. They are most commonly known as the alternative pathway for Medicaid Expansion for Red states.
CMS just released a letter last night indicating that it has new guidance and new desired boundaries for 1115 waivers that it will now approve. CMS is looking for more punitive waiver applications as well as indicating that it is willing to take Indiana HIP 2.0 HSA based Medicaid expansion to a national scale.
Deprioritizing etc — Really — your administration wants to cut $880 billion from Medicaid over a decade for upper income tax cuts so please cut the sanctimony.
Here is the work requirement.
The Obama Administration would not tie Medicaid to work requirements. Medicaid is a medical program. There are other work search and job training programs that are optimized as such.
This is a combination of splitting the poor into the deserving and non-deserving as well as an introduction of friction to decrease enrollment. Most people on expansion are either working, looking for work, in school or a primary care giver for dependents with significant needs. There are very few lazy lay-abouts. Instead these requirements create more hurdles that people have to jump, more hoops they have to shimmy through and more opportunities for their paperwork to be messed up. It aligns with the ritualistic humiliation of drug testing requirements for unemployment and TANF benefits. It is an assertion of power.
It won’t significantly reduce costs. The Kentucky 1115 application that was submitted last summer is good proof of that.
Cancer patients will make sure they have their paper work in. The twenty four year old who just finished up their associates degree and is waiting for benefits to get started at work is the one who is more likely to not complete the paper work. That person only went to their doctor once in the past year anyways. Work requirements and more importantly the paperwork to confirm participation and eligibility will drive away healthy and inexpensive.
The next part is about aligning Medicaid with commercial insurance practices as well as encouraging continual enrollment.
Currently Medicaid allows states to retroactively pay significant bills for uncovered people if they are found to be eligible for Medicaid. This usually happens because hospitals and other providers are allowed to presumptively enroll individuals into a state Medicaid program if they have good reason to believe the patient who is otherwise uninsured is eligible for Medicaid. Hospitals like this because it significantly reduces their bad debt and charity care expenses. This is good for patients because it gets them the care that they need. And that looks like it will go away in some states.
The enthusiasm for HSA like accounts is predictable.
That is what Adminstrator’s Verma’s previous consulting business was built on. She designed the Indiana HIP 2.0 Medicaid Expansion with its system of HSA, wellness incentives and hoops to jump through. That model will now be encouraged to go national even as the evidence base for its success is thin..
So what are the distributional impacts?
For states that have already expanded Medicaid, these changes would make current beneficiaries significantly worse off.
It is more complicated for states that have not expanded Medicaid. If these changes (plus the fact that the President is not Obama) are the necessary and finally sufficient impetus to get the some hold-out states to expand Medicaid, then they are enrolling into a worse program then people in current Expansions but they are in a better position after a bad expansion than no expansion. I have a hard time saying that the working poor in Texas or Alabama or North Carolina should wait for a better program instead of getting needed care and needed financial stability now in a sub-optimal program design. I have pragmatic objectives that overwhelm ideological objectives.
Its the combination of self-righteousness with the poor bashing that shows the talk radio origin of all current radical Republican policy. We are grounding your face into the dirt with our booted foot for your own “good and dignity.”
So the plan is: If you’re poor, don’t get sick; and if you do get sick, die quickly.
I can’t believe they left out the pee-in-a-cup gambit. Why do I want my tax dollars going to mental health treatment for some damn druggie?
Since Republican voters think Obamacare is like Obamaphones but with doctors, i.e. black and brown people getting stuff for free, I’m actually somewhat surprised that this hasn’t been the single most prominent aspect of their crusade against the law as it currently exists.
God, I hate these people. The modern Republican philosophy in a nutshell:
First Collector: At this festive time of year, Mr. Scrooge, it is more than usually desirable that we should make some slight provision for the poor and destitute.
Ebenezer: Are there no prisons?
First Collector: Plenty of prisons.
Ebenezer: And the union workhouses – are they still in operation?
First Collector: They are. I wish I could say they were not.
Ebenezer: Oh, from what you said at first I was afraid that something had happened to stop them in their useful course. I’m very glad to hear it.
First Collector: I don’t think you quite understand us, sir. A few of us are endeavoring to buy the poor some meat and drink, and means of warmth.
First Collector: Because it is at Christmastime that want is most keenly felt, and abundance rejoices. Now what can I put you down for?
Ebenezer: Huh! Nothing!
Second Collector: You wish to be anonymous?
Ebenezer: [firmly, but calmly] I wish to be left alone. Since you ask me what I wish sir, that is my answer. I help to support the establishments I have named; those who are badly off must go there.
First Collector: Many can’t go there.
Second Collector: And some would rather die.
@SenyorDave: Scrooge is MORE generous than the contemporary right wing, though, because at least he thinks his taxes pay for public institutions he approves of, like prisons and workhouses. He’s balking at giving an extra private contribution. The right wing today balks at the taxes too.
of course they will
@FlipYrWhig: You are correct. I owe Scrooge an apology for comparing him to people like Trump, Ryan and McConnell.
I know one thing for certain: If a SNAP-like work requirement was instituted for Medicaid, I’d die waiting for the paperwork to clear.
For SNAP, if you’re classed able-bodied, you have to do one of two things: Travel (up to 50 miles each way) to a job search center and search for work at least 30 hours a work, or prove you work at least 30 hours making minimum wage. For a self-employed person like myself, it completely hoses me; my income is not 30/minwage stable, and as long as I am doing any sort of self-employment, they won’t classify me as ‘disabled’ because I’m working! If I stop working and file for disability, it can take years to clear through the state system. And if you DO meet their requirements, they slash or eliminate your benefits because you’re making too much! Nice Catch-22 the Republicans of the 90s set up.
They do the same to Medicaid, it will be like demographc exclusions on steroids: A way to make sure that very few people actually can get into the program. They’ll pair it with very rigid income and asset tests, I guarantee that, so that nobody working anything more then 10 hours a week can qualify, and nobody working UNDER 10 hours a week can qualify, either.
This is a nightmare. The Republicans do not want to know why their constituents are poor and need Medicaid. All of these punitive policies are intended to solve problems created by Republican biases and lack of empathy.
People need Medicaid because they are elderly without savings or assets and need nursing home care. People need Medicaid because they have disabilities. People need Medicaid because they can’t find jobs that pay enough to support their basic needs.
There was something utterly sadistic, too, about the Nine’s decision to specifically target the Medicaid expansion and make it optional (thus rendering half the country’s poor ineligible). You ended up in the surreal situation where you had to first have a certain amount of money before the government would concede that you needed money, and help you with your health bills. Those who had any less than that amount, i.e. the very people who needed the help the most, were the same ones judged unworthy of the help.
No one’ll ever convince me that it wasn’t deliberately done with that outcome in mind. Social Darwinism and loathing for the poor is too deeply ingrained on the right, and I’ve seen too many variations from too many people, to believe otherwise. They wanted something that was specifically targeted to make the most vulnerable people in society suffer and, if need be, die.
This, of course, is entirely what we expected. That doesn’t make it any less horrible, though.
That presumptive eligibility and retroactivity piece is a big deal for people who need time-sensitive care and the hospitals that don’t want to be on the hook for uncompensated care. If Joe Uninsured shows up at the ER with a broken arm, they have to treat him, so a lack of retroactivity doesn’t encourage him to be continuously covered. It just means the hospital has to try to collect from him instead of Medicaid, which effectively means they don’t get paid. And if a woman shows up at the doctor’s 8 weeks pregnant, but she can’t be presumed eligible, she’ll have to wait 45 days while they process her application. She’d be in her second trimester before getting any prenatal care, past the point of preventing neural tube defects.
Who among the newly Medicaid eligible since ACA isn’t already working? I mean, this is just completely illogical. The millions who were signed up for Medicaid when they applied on the exchanges to buy insurance weren’t intentionally applying for a means-tested program.
Combining the exchanges, which automatically put anyone whose income is ‘too low’ to pay for insurance, with a punitive tactic to make those people prove they are ‘deserving poor’ when they don’t agree they are poor in the first place (‘never applied for Medicaid, tried to buy insurance’ is a pretty good proxy for working poor with no W-2s but some income) is a disaster which will knock down coverage by millions of insured bodies…hey, wait, I think I found the ‘why’!
These new Medicaid covered are freelancers in our post-employment economy. Your Uber driver’s family gets their insurance card through Medicaid, for example. But it’s also covering a large population of self-employed families with no time for paper-pushing bullshit who can take the option of going bare until the feces hits the ventilation and then taking a 3 month penalty for enrollment.
Our teen was pulled into SCHIP the year following the income year of my cancer DX followed by my mom’s cancer DX–I billed 34% of the hours I had during the previous tax year, understandably, and I was grateful to have a flexible setup for income that let me bill anything at all. But if the alternative to keeping her on our policy on the exchange had been complying with ‘work rules’, we’d have paid cash for her prescriptions and doctor visits. Because I can’t bill a client while I’m standing in the welfare office, so that would be a form of social support my family couldn’t afford.
David, this is a bigger deal than I think you’re giving it credit for, because state-level human services directors know everything I just said. They’re going to do a magic trick of slicing enrollment in Medicaid by making it a program for the poor and sick! But unless they also change guidelines for exchange enrollment, that means there is no way for those families to buy insurance at all, meaning that population is shifted from covered in between to uncovered until they have a baby with a heart defect.
The floggings will continue until the tax cuts improve.
If all these red state denizens could get off their lazy asses to vote ONCE EVERY OTHER YEAR and/or stop voting for republicans, they’d have a better government. Walk into the booth, vote a Dem ticket, walk out. At this point, they get the government they vote (or don’t) for, over and over again.
If you want to have nice things, *get off your lazy asses and vote*.
We offered them subsidized health care, along with huge amounts of money flowing from blue states to red economic backwaters, and they gave us the middle finger.
Hope they enjoy the untreated diabetes.
@Earl: Kansas is sick of the Brownback Republican, and got out to vote in moderates and Democrats in November. I’ve heard some hopeful sounds of Medicaid expansion coming from Topeka. Too late for some of the rural hospitals that closed for lack of funds, but better late than never. I’m watching the race for Mike Pompeo’s seat in Wichita. The Democrat is a civil rights lawyer and veteran who is fighting hard and calling his Brownback ally a coward for bailing on 3 debates so far. Check him out: http://www.votejamesthompson.com