The 4 biggest Medicaid controversies in 2018

Medicaid
Work requirements, lifetime limits, the public charge rule, and new expansions brought Medicaid to the front and center of political discourse in 2018. (Getty/designer491)

As its leadership will tell you, the Centers for Medicare & Medicaid Services (CMS) releases thousands of pages of regulations every year—11,000, give or take a few. Most of the American public has no idea what most of these regulations do or mean, and understandably so: Even to seasoned healthcare experts, they can seem distant, dry, and confusing.

But this year, several new Medicaid policies sent shock waves across the country. Though few in number, the impact of these policies has been, or could be, long-lasting and wide-reaching.

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In general, the response to them has fallen along party lines. On one hand, conservatives and libertarians say Medicaid spending is unsustainable, and cutting costs to the nearly $400 billion program is a must. Liberals and progressives, however, say it’s wrong to put the poorest Americans’ health in jeopardy.

That said, there have been some twists and turns. In this time of deep partisanship, 2018 showed us you can’t always predict someone’s opinion based on his or her voter registration card—even if that person is a high-ranking federal official. Perhaps that is the most shocking lesson of all.

The good, the bad, and the ugly—whatever you consider good, bad, and ugly—from the Medicaid program this year is below.

Work requirements

The most controversial topic of the year came right at the beginning: On Jan. 11, CMS told state Medicaid directors it would begin considering work requirement demonstrations through §1115 waivers. This was a first: Work requirements have not been permitted at any other point in Medicaid’s 53-year-long history.

Since then, these waiver submissions have been approved in five states—Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin—though Kentucky’s was challenged in court, and only Arkansas’ has gone into effect so far. Ten additional states have work requirement waivers pending.

While the exact conditions of each waiver vary by state, they contain some common themes. Almost all of them require beneficiaries to work a certain number of hours per week (most commonly 20) or month (most commonly 80). All exempt caregivers, individuals over a certain age, ranging from 50 to 65, and students (or count school as working).

Some states exempt other groups too, such as those being treated for substance use disorder. Several expansion states that have submitted waivers only require their expansion population to work.

All eyes have been on Arkansas since its waiver went into effect in June. The state boots beneficiaries off the program after 3 months of noncompliance; nearly 17,000 people have lost coverage since September. Some suspect many of these individuals are satisfying the requirement but seem like they’re not due to problems with the reporting system. As a PBS NewsHour segment illustrated, the reporting requirements confuse many beneficiaries, and to make matters more difficult, the reporting system shuts down each night at 9 PM.

CMS Administrator Seema Verma recently said Arkansas’ demonstration is going to give the agency “a lot of lessons learned.”

Lifetime limits

Despite the administration’s push toward stricter Medicaid requirements, it rejected Kansas’ proposal to impose lifetime limits on beneficiaries in May. Administrator Verma announced this decision in a speech to the American Hospital Association in May.

“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,” she said. In a letter (PDF) to Kansas’ acting Medicaid director, she said CMS was willing to help the state come up with another approach to meeting its goals.  

Under Kansas’ original proposal, beneficiaries subject to work requirements could receive a maximum of 36 months of coverage. The Sunflower State’s work requirement is one of the broadest proposed, exempting only caregivers, seniors, and individuals with specific medical conditions. Similarly, Arizona intended to limit those subject to its proposed work requirement to five years of coverage but revised.

Public charge

Two of the country’s top political controversies—healthcare and immigration—meshed when the administration announced the so-called public charge rule. This proposal would allow the Department of Homeland Security to consider whether someone is likely to use public services when deciding whether he or she should be granted permanent residency status.

America’s Health Insurance Plans (AHIP), the nation’s largest association of health insurers, and two hospital groups, America’s Essential Hospitals and the American Hospital Association, warned that the rule will not only hurt immigrants’ health but also raise healthcare costs, as those who lose coverage would then seek uncompensated care. According to the Kaiser Family Foundation, between 2 million and 5 million people could disenroll from Medicaid as a result of the rule.

Medicaid expansion

Major Medicaid expansion developments took place in five states this year; some involved more turmoil than others.

In Maine, pro-expansion advocates continued their legal battle against Republican Governor Paul LePage’s administration, which has sought to block the expansion since it passed by referendum in November 2017, citing funding issues. In August, the Maine Supreme Court ordered LePage to implement the expansion. Despite his continued resistance, the issue is now likely moot. Governor-elect Janet Mills, a Democrat, has said expansion is her top priority, and the Bangor Daily News recently reported that the state has the money to pay for it.

Other states’ expansions were less controversial. When voters in Idaho, Nebraska, and Utah decided to expand Medicaid, they were met with little resistance. In fact, some Republican leaders in those states indicated, if not openly voiced, support for the expansion. Idaho Governor Butch Otter, who tried to maneuver around the ACA in January, endorsed his state’s expansion one week before Election Day.

In its neighbor to the south, Utah Governor Gary Herbert signed a partial expansion into law in March. Meanwhile, Nebraska’s executive and legislative branches are actively deciding how to implement their expansion, according to the state’s public radio station.

Virginia passed a Medicaid expansion bill this year as well, but with conditions. Republicans in the legislature made a deal with Democrats to submit a work requirement waiver for the expansion population in exchange for their “yea” votes on the expansion bill. Although the expansion is set to go into effect on Jan. 1, that waiver has not been submitted yet, and after it is, CMS will need additional time to decide whether to approve it.

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