States' Medicaid demonstrations require robust evaluation

Medicaid demonstration waivers can inform game-changing federal policies, making it imperative to "comprehensively and impartially" evaluate their impact on patient care, providers and health plans, according to an issue brief from The Commonwealth Fund.

No two Section 1115 waivers under the Affordable Care Act are alike, but a central theme is increasing beneficiaries' financial responsibility for their Medicaid coverage. Such policies are attractive to states whose leaders have been reluctant to embrace traditional Medicaid expansion.

Arkansas, Indiana, Iowa, Michigan and Montana all have secured permission increase beneficiaries' financial obligations. Arizona and Ohio propose to do the same, New Hampshire's legislature is considering such a policy and Louisiana and Kentucky have indicated they may request permission to alter normal Medicaid rules to require enrollment fees and additional cost-sharing on the part of beneficiaries.


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Four of six demonstration states also seek to test methods that tie beneficiaries' financial responsibility to behavioral changes in health and wellness--either through reduced cost-sharing, reduced or waived enrollment fees, or a combination of those factors.

Penalty-related policies, meanwhile, vary among the participating states. Indiana is the most stringent, as it imposes penalties for nonpayment of enrollment fees, disenrolls beneficiaries for nonpayment of premiums and mandates a six-month lockout before allowing them to reenroll. Montana, on the other hand, conditions reenrollment on repayment of sums owed or debt collection by the state.

As all of these demonstrations are tested, it will be critical to evaluate their effects--especially those that could result in the reduction or elimination of some Medicaid beneficiaries' coverage, the brief says. Plus, the federal government has said it may grant demonstration renewals, meaning the Medicaid coverage landscape could end up permanently altered.

Yet despite legal requirements to measure these programs' effects, it is unclear how the Centers for Medicare & Medicaid Services will capture certain aspects of some of the proposals, and states' self-assessments have the potential for a conflict of interest--suggesting the need for a nationwide, impartial evaluation, the brief argues.

To learn more:
- read the issue brief

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