Medicaid Buy-In and Section 1332 State Innovation Waivers

As a new Medicare-for-all bill was introduced in the House recently, a number of state-level legislative projects are generating parallel excitement about Medicaid buy-in plans.

In his recent Bill of Health post, Rahul Nayak explained how Medicaid Buy-In would allow states to introduce a public option to their insurance marketplaces. Rahul points to some major questions about how buy-in plans might be implemented. Some of these questions relate to how these plans will operate within the federal statutory system that governs health care marketplaces and Medicaid. In a December Ohio State Law Journal article, for example, Professor Lindsay Wiley explored how Medicaid buy-in plans could be enacted within the waiver systems that shape state implementation of marketplaces and the availability of premium tax credits. Most recently, Emma Sandoe, in an interview for this blog, discussed the ways states are innovating in this space.

Specifically, states seeking to implement buy-in plans will navigate questions about how to leverage the Section 1332 waiver provision of the ACA. Section 1332 of the ACA allows states to apply for waivers of certain marketplace requirements. Through these waivers, states are empowered to provide insurance options that don’t meet all QHP standards and may receive premium tax credits to directly fund insurance products. How states choose to approach this waiver system will dictate what type of funds are available to subsidize coverage, the design of buy-in offerings, and the level of coverage buy-in plans will offer.

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Protesters hold up signs that read "everyone deserves healthcare"

The Future of Health Care? How States are Trailblazing Medicaid Buy-In Programs

States can be laboratories of health reform.

Massachusetts and Oregon expanded insurance coverage during previous periods of federal inaction, and with solutions unlikely to come from a politically divided Washington D.C., how will states tackle the problem of health insurance becoming increasingly unaffordable and unattainable for many families?

Is there a role for the government to play a greater role in making health insurance affordable and accessible? As public support for action on health care grows, what options are available to states now?

I spoke to former Petrie-Flom Student Fellow and Medicaid policy scholar Emma Sandoe about states that have begun to explore Medicaid Buy-In policies, which allow people to purchase government backed health insurance or Medicaid-like plans. Read More

a row of paper dolls holding hands

Administration’s Guidance on State Innovation Waivers under the ACA Violates the Act’s Statutory Guardrails

By Joel McElvain

This post was originally published on Take Care. 

The Affordable Care Act reformed the individual health insurance market to protect persons with pre-existing conditions. Insurers who participate in this market must sell plans with a standard set of comprehensive benefits, and may not deny coverage to, or impose higher premiums on, persons with pre-existing conditions.

Through legislative, regulatory, and litigation efforts, the Trump Administration has sought to depart from the ACA’s regime to allow the sale of plans that are medically-underwritten, offer more limited health benefits, or both.

The Administration’s latest such effort comes in the form of guidance by the Departments of Treasury and Health and Human Services that adopts a broader reading of the Act’s provision for state innovation waivers. Read More

Public Charge and the Expressive Effects of Immigration Law

In early October, the Department of Homeland Security published a proposed redefinition of the Immigrant and Nationality Act’s “public charge” provision, stirring serious concern among health-care and immigrant advocacy groups.

The “public charge” provision of the INA currently allows immigration officers to deny green cards to legal immigrants who are likely to become “primarily dependent on the government for subsistence.”

DHS’s proposed rule would widen the scope of “public charge” to include any legal immigrant who uses cash or non-cash government benefits. In expanding the scope of the public charge inadmissibility determinations, DHS would empower immigration officers to consider immigrants’ current or prior use of programs like Medicaid and SNAP in evaluating applications. Read More

Some takeaways from Montana’s Medicaid expansion ballot initiative

As Nicholas Terry wrote in his recent blog post, the 2018 midterm elections produced some big wins for Medicaid. Voters in Idaho, Nebraska and Utah decided to expand Medicaid coverage under the ACA. These states followed the lead of Maine, where Medicaid was expanded by ballot initiative in November of 2017.

One exception to this trend is Montana. On November 6, Montanans rejected I-185, a ballot initiative proposing to fund the state’s Medicaid expansion through a tobacco tax. The ballot initiative would have removed a sunset provision that automatically terminates funding for the expansion in 2019. The outcome of the initiative has not necessarily killed Montana’s expanded program. The Republican legislature may still act to appropriate funding for the program, and—given that the expansion was originally passed with bipartisan support in the state legislature—this route to securing financing is not foreclosed. In August, the oversight committee in charge of the expansion bill recommended that the state fund the program regardless of the outcome of the ballot initiative.

However, even if the future of the Montana expansion remains unclear, there are still some important immediate takeaways from the result of I-185. Read More

"I voted" sticker on a finger.

Election Round Up: Medicaid Expansion is an Electoral Winner

With the midterm elections now behind us, I thought it was time to revisit a prior blog post where I discussed the prospects of state Medicaid expansion ballot propositions in Idaho, Utah, and Nebraska. I had predicted that despite the conservative nature of these states, Medicaid expansion would have a good chance of passing due to the program’s popularity.

Indeed, voters in all three states endorsed Medicaid expansion. It received 60 percent support in Idaho and 53 percent in both Utah and Nebraska.

The latter two results were closer than what I was expecting.

In the case of Utah this may because a funding mechanism was explicitly included as part of the ballot proposal. Regardless, this means that roughly 300,000 people will be newly eligible for Medicaid. Not only do may patients stand to benefit, but this could be a huge boon for struggle rural and safety-net hospitals. Read More

Congress’s opioids package and the politics of the IMD exclusion

At the end of September, the Senate passed a final version of an expansive legislative package designed to tackle the United States opioid epidemic. The package contains a broad range of policy approaches to the crisis, including enhanced tracking of fentanyl in the U.S. mail system, improved access to Medication Assisted Treatment and addiction specialists, and lifted restrictions on telemedicine and inpatient addiction treatment. The package, which now sits on President Trump’s desk, is widely expected to be signed into law.

The legislative effort has been lauded as a rare act of bipartisanship in an otherwise-polarized Washington.

The Washington Post called the set of bills “one of the only major pieces of legislation Congress is expected to pass this year.” A Time headline declared that “Opioid Bill Shows Congress Can Still Work Together.” Praise of this across-the-aisle effort is merited: the Senate voted for the set of bills 98-1, and the House voted for it 393-8.

While critics have rightfully pointed out that the package does not provide for enough increased spending to address the crisis, with more than 72,000 people dying from drug overdoses in 2017, the time is ripe for a collaborative approach to the opioid crisis, and any effort helps.

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Mary Mayhew: The New Anti-Medicaid Head of Medicaid

Mary Mayhew, a fierce opponent of Medicaid Expansion under the Affordable Care Act, was announced on October 15 as the new Deputy Administrator and Director of the U.S. Center for Medicaid and CHIP [Children’s Health Insurance Program] Services. As the House Ways and Means Committee Democrats put it in a recent tweet, the Trump Administration’s choice “is like hiring an arsonist to be a city’s fire chief.”

Mayhew spent years as commissioner of Maine’s Department of Health and Human Services under outgoing Governor Paul LePage. She stepped down in May 2017. After her time as commissioner, Mayhew pursued an unsuccessful race for Governor of Maine, coming in third in the Republican Primary this past June.

The Maine Department of Health and Human Services’ approach to Medicaid under Mayhew’s leadership does not exactly suggest she will take an expansive approach to Medicaid in her new role. According to the ACLU of Maine, enrollment in MaineCare, Maine’s Medicaid program, decreased by 37 percent during her time in office, eliminating coverage for about 80,000 people.

The state also dropped from 10th to 22nd in national health rankings.

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image showing a line of voting booths, with legs showing

Medicaid Expansion Goes to the Polls

With the 2018 midterm elections fast approaching, there are key some voter propositions with important health implications.

Most notably, this November, voters in three conservative states — Idaho (Proposition 2), Utah (Proposition 3), and Nebraska (Initiative 427) — will be deciding on whether to expand Medicaid. In addition, voters in Montana will decide whether to permanently extend their state’s Medicaid expansion. This is coming at the heels of the closely watched November 2017 referendum where Mainers decisively supported Medicaid expansion 59 percent  to 41 percent.

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waiting in line

A status update on the Medicaid work requirement landscape

Earlier this week, Michigan submitted a proposal to the Trump administration requesting approval to impose work requirements on Medicaid expansion beneficiaries. Michigan’s proposal was submitted through the Medicaid Act’s section 1115 waiver program, which allows states to introduce experimental projects that “further the objectives” of the Act. (For a more in-depth discussion of the function of section 1115 waivers in the Medicaid scheme, see Carmel Shachar’s Bill of Health post from earlier this summer.)

Work requirement waivers garnered a rush of attention after the Trump administration issued guidance indicating that it would begin approving such requests. Michigan is now one of twelve states that have submitted a work requirement proposal, with four of those states having successfully received approval from HHS.

This recent development in Michigan provides an opportunity to take stock of the Medicaid work requirement landscape since the Trump administration began approving the waivers. Read More