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Medicaid Work Requirements Raise Discrimination Concerns
Medicaid Work Requirements Raise Discrimination Concerns
By Misty Williams, CQ
Health policy experts and advocates say the way some states are proposing to implement Medicaid work requirements may run afoul of civil rights laws, spurring potential legal challenges.
Several states are considering adding requirements that people who receive Medicaid work or participate in other activities, usually for at least 20 hours per week. Both Michigan and Ohio want to exempt from work mandates residents of counties with high unemployment rates — which also happen to be mostly rural and overwhelmingly white. Meanwhile, predominantly black cities, such as Flint, Mich., and Cleveland wouldn’t get the same break despite having equally high or, in some cases, higher jobless rates.
Consumer advocates say the bubbling controversy raises broader concerns about whether Medicaid work requirement proposals disproportionately impact minorities and America’s poorest citizens, black and white alike.
“If it’s a good policy, why do these folks need to be exempted?” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “Why do certain people get privileged over others? It certainly raises many, many questions.”
The Trump administration and fellow Republicans tout work requirements as a way to help improve people’s health, lift them out of poverty and reduce their dependence on government assistance. The idea is part of a larger push by conservatives to treat Medicaid more like a welfare program, instead of a health insurance system.
States hope to give people more than just an insurance card, Centers for Medicare and Medicaid Services head Seema Verma said during a talk earlier this week. It’s about a “pathway out of poverty, a bridge to independence.”
Verma noted that the administration recognizes not everyone should be required to work and that it provided guidance to states about what types of individuals should be exempt. CMS also told states to consider developing plans to address people who live in regions with limited employment opportunities, according to a Jan. 11 letter to state Medicaid directors.
CMS has so far approved work mandates in four states – Kentucky, Indiana, Arkansas and, most recently, New Hampshire. Roughly a dozen others either submitted formal requests to CMS or are considering the idea.
The plans focus on non-disabled, working-age adults who would work 20 or more hours a week or participate in other activities, such as volunteering, job searching or schooling.
Most would exempt people with disabilities, pregnant women and those in substance abuse treatment or who are medically frail. But who would be exempt from work requirements can also vary widely by state, experts say.
Waivers for Counties But Not Cities
In Michigan, a bill winding its way through the state legislature would exempt residents in certain counties – those with unemployment rates of 8.5 percent or higher – from having to meet work requirements to receive health coverage under Medicaid.
Critics argue the only counties that would meet such a benchmark are rural and predominantly white. Meanwhile, cities such as Flint and Detroit that have high unemployment rates – and largely black populations – but are within counties with overall lower rates would not receive a pass.
For instance, more than half of Flint residents are black and the city’s unemployment rate in March stood at 10.4 percent, according to the U.S. Census Bureau and state data. Yet the economically-depressed city would not qualify for an exemption because the overall unemployment rate in Genesee County where Flint is located – with a population that’s three-fourths white – is less than 6 percent.
The legislation's authors may not have intended to discriminate by race, but it’s problematic nonetheless, said Ben Sommers, a Harvard University associate professor of health policy and economics.
“The consequences of carving out high unemployment counties but not cities . . . that is really hard to justify on policy terms,” Sommers told CQ.
Whether the discrimination is intentional makes no difference from the perspective of civil rights law, two University of Michigan law experts wrote in a recent New York Times op-ed.
The law bars recipients of federal funds, including state Medicaid programs, from employing “methods of administration that appear neutral but have a discriminatory effect on individuals because of their race,” according to professors Nicholas Bagley and Eli Savit.
“There’s a deeper lesson here,” the men wrote. “If work requirements were a good idea, conservative Michigan legislators wouldn’t need to exempt their rural constituents.”
Both say if Michigan’s lawmakers approve such a plan, it ultimately could be challenged in court.
Ohio's Proposal
Experts say a similar Medicaid work requirement proposal in Ohio could also lead to civil rights and racial bias complaints, as well as litigation.
The plan targets an estimated 36,000 adults who gained health coverage when the state expanded Medicaid under the 2010 health care law (PL 111-148, PL 111-152). Thirty-two states and the District of Columbia expanded the government insurance program for low-income Americans; 18 have not.
The Ohio proposal would waive work requirements in 26 overwhelmingly white counties because of high unemployment. But largely black communities in cities such as Cleveland and other urban areas would get no exemption.
On average, the populations in the exempted counties are 95 percent white; meanwhile, many other communities have unemployment rates equal to that or higher, according to former Ohio Medicaid director John Corlett, now the executive director of The Center for Community Solutions, a nonprofit advocacy group.
“If an area has high unemployment, it should be treated the same,” Corlett said. “By not looking at smaller geographic areas, or smaller units of government, it really leaves some people at a disadvantage.”
Corlett said he believes the issue could lead to legal challenges if federal officials approve the state’s plan.
Ohio formally submitted its Medicaid work requirements proposal to CMS on April 30. Michigan’s plan passed the state Senate and is now under consideration in the House.
CMS, which has to approve states' plans before they can be implemented, did not respond to questions from CQ regarding the concerns about racial discrimination.
Challenges for Vulnerable Groups
Even if states don't specifically exempt areas with high unemployment, Medicaid work requirements will still disproportionately impact marginalized groups, advocates say.
Recent studies of work requirement proposals in Mississippi and Alabama found that African-American mothers and families living in small towns and rural areas would be hardest hit by such mandates, according to researchers at Georgetown.
Both states did not expand Medicaid and have some of the strictest income eligibility levels in the nation. Work mandates are a losing proposition for parents in those states, the university’s researchers concluded. If parents don’t get a job, they would lose their health coverage. But if they do work 20 hours a week, they would make too much money to qualify for Medicaid.
“We’re talking about the poorest, most vulnerable families in these states, and African-Americans are disproportionately represented in this population,” Alker said. “They’re already disadvantaged economically speaking and this is going to make it worse.”
In Kentucky, where the state is set to begin rolling out new work rules this summer, black residents generally have higher unemployment rates and many face barriers to work, such as a lack of transportation and few job options, said Dustin Pugel, a policy analyst at the Kentucky Center for Economic Policy.
At the same time, rural Kentucky communities that are largely white but economically-depressed, such as the eastern part of the state where the coal industry has been decimated, will be hurt, too, Pugel said.
The controversies around work requirements in Ohio, Michigan and other states highlight the complexities of policies that may be politically appealing but problematic when it comes to actually instituting them, said Sommers with Harvard.
“The policy lends itself to an appealing soundbite,” he said. “But the devil’s in the details.”
Monday, May 21, 2018
Friday, May 18, 2018
Thursday, May 17, 2018
CMS Won't Approve Medicaid Lifetime Limits for States
CMS Won't Approve Medicaid Lifetime Limits for States
By Misty Williams, CQ
The nation’s top Medicaid official on Tuesday made clear that the Trump administration would not allow states to impose lifetime limits for people on Medicaid.
The comments from Centers for Medicare and Medicaid Services Administrator Seema Verma followed her announcement last week that the agency rejected a three-year lifetime limit proposal from Kansas.
“You’re dealing with a fragile population and there are changes in their lives,” said Verma, who spoke Tuesday at a health care event at The Washington Post. “We always want to make sure that the program serves as a safety net and there’s a place for people to go when they need it.”
Verma’s statements Tuesday and CMS’ recent Kansas decision signal that the administration is only willing to go so far in giving states flexibility to radically revamp their Medicaid programs.
At least four other states – Arizona, Utah, Wisconsin and Maine – have sought to impose limits on how long people can receive benefits through the government insurance program for low-income Americans.
Consumer advocates have applauded the rejection of lifetime limits but remain worried about other fundamental changes to Medicaid, such as work requirements, that the administration does favor.
“It’s unfortunate that CMS is willing to end coverage for people who can’t meet rigid work requirements, pay premiums, and comply with increased red tape, which also undermines Medicaid’s role in ensuring millions of low-income people can get the health care they need,” said Judy Solomon, vice president of health policy at the left-leaning Center on Budget and Policy Priorities, in response to last week’s Kansas decision.
The administration and Republicans are pushing for work requirements, saying they help lift people out of poverty.
So far this year, CMS has approved plans to implement Medicaid work requirements in four states: Kentucky, Indiana, Arkansas and, most recently, New Hampshire.
But Verma has hinted in recent weeks that CMS may not necessarily approve all Medicaid work requirement proposals from states as is.
She said in a meeting with reporters earlier this month that states wanting to institute work requirements must first create a plan to help people at risk of losing coverage if they end up earning too much money.
The issue is particularly relevant in states that did not expand Medicaid under the 2010 health care law (PL 111-148, PL 111-152) and have very strict income eligibility limits.
Work requirement critics argue poor parents could be kicked off the program if they earn slightly too much money, even though many low-wage jobs don’t provide health insurance. Many affected people may also earn too little money, less than the federal poverty line, to qualify for subsidies to buy coverage on the health law’s exchanges.
Verma said earlier this month that the agency is in discussions with Mississippi, which has not expanded Medicaid, about how they can revise their work mandate proposal.
“I want to be very careful about this,” she said.
Medicaid Expansion
The CMS chief also said Tuesday that the agency is continuing to weigh whether states should be allowed to only partially expand Medicaid.
At least three states – Arkansas, Massachusetts and Utah – want to limit Medicaid expansion.
The health law required states expanding Medicaid to cover people who earn up to 138 percent of the federal poverty level, or about $16,700 for a single person in 2018. Arkansas and Massachusetts both want to roll back their expansions to people making 100 percent of poverty, while Utah wants to institute an expansion up to 95 percent of poverty.
Health policy experts say allowing partial expansions could end up costing the federal government more money since many people kicked off Medicaid would then be eligible for exchange subsidies, which are fully federally-funded. States have to pick up at least part of the cost of Medicaid expansion.
“We’re trying to understand all of the implications,” Verma said. “What’s the impact going to be on the federal budget?”
Wednesday, May 16, 2018
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Former HHS Secretary Walks Back Criticism of End to Mandate Fee
Former HHS Secretary Walks Back Criticism of End to Mandate Fee
By Andrew Siddons, CQ
Former Health and Human Services Secretary Tom Price said Wednesday that comments he made a day earlier that appeared critical of Republicans' decision to effectively repeal a mandate to buy health insurance were taken out of context.
On Tuesday, Price told attendees of the World Health Care Congress in Washington that eliminating the penalty for lacking health coverage would result in higher costs for those purchasing individual health plans.
While Price suggested that getting rid of the fee may help Americans who don’t want to purchase insurance, he quickly added: “There are many, and I’m one of them, who believes that that actually will harm the pool in the exchange market, because you’ll likely have individuals that are younger and healthier not participating in that market, and consequently that drives up the costs for other folks within that market.”
In a statement on Wednesday, Price said that “repealing the individual mandate was exactly the right thing to do.” He said his remarks at the conference were meant to convey “how repealing the mandate would affect certain populations in the absence of additional reforms, like the expansion of Association Health Plans and other measures that use market forces to drive down costs.”
“Additional reforms are vitally necessary,” he added.
During his nine months as Trump’s health secretary and for years as a Georgia congressman, Price was one of Republicans’ leading cheerleaders for the repeal of President Barack Obama’s health care law (PL 111-148, PL 111-152), which established the mandate that most people purchase health insurance. Price resigned in September after being dogged by questions about his use of private planes.
Republicans have touted the elimination of the penalty, which was in last year’s tax cut (PL 115-97), as their most significant step in fulfilling campaign promises to overturn the law.
Democrats and health care law supporters seized on Price’s conference comments. Sen. Patty Murray, D-Wash., said that Republicans who voted to repeal the mandate penalty starting next year were responsible if health insurance premiums rise.
“People across the country are unfortunately going to start seeing higher rates being filed as soon as this week, and former Secretary Price’s comments make it absolutely clear who families should hold accountable — President Trump and Congressional Republicans,” Murray said in a statement.
Mary Ellen McIntire contributed to this report.
HHS Secretary Pushes for More Transparency in Health Care
HHS Secretary Pushes for More Transparency in Health Care
May 2, 2018 – 10:21 a.m. By Misty Williams, CQ
The Trump administration’s top health official on Wednesday touted new government initiatives to drive the transition of the nation’s health care system toward value and transparency, hinting that more changes are to come.
Health and Human Services Secretary Alex Azar emphasized the need for patients to have access to their own health data, arguing that knowing prices and outcomes can allow them to find better, cheaper health care.
One way HHS is working toward that goal is overhauling Medicare’s so-called Blue Button, which allows patients to download their medical histories. A revamped version, Blue Button 2.0, will allow people to share their health data with applications created by private companies, Azar said.
“Patients ought to have access to their data, period, however you want to accomplish it,” he said. “They’ve got to have access to data on price and quality. Knowledge is power.”
Azar spoke Wednesday morning in Washington at the 2018 World Health Care Congress, which brings together health care providers, employers, insurers and government agencies to share best practices and focus on quality improvement and cost effectiveness.
The Blue Button effort is part of the agency’s broad MyHealthEData initiative, launched in conjunction with the White House Office of American Innovation, which is working to put people in charge of their own medical information.
When consumers are empowered, market forces do work, Azar said. He also noted a recent proposal by the Centers for Medicare and Medicaid Services to require hospitals to post prices online in an effort to improve transparency for patients. The suggested change is part of a recently released proposed rule seeking a broader overhaul of hospital health IT rules.
CMS also recently released more than 1,000 comments from stakeholders urging the agency to take new actions through the Center for Medicare and Medicaid Innovation, Azar said. And CMS recently requested providers' input on surprise billing, director provider contracting within Medicare and other issues, he added.
“It’s been a busy couple of weeks, and every week in the future is going to be quite busy,” he said.
The government also plays a key role in health care innovation as the steward of the world’s largest collection of health care data and the largest funder of biomedical research, Azar said.
CMS will be releasing Medicare Advantage encounter data to researchers for the first time, he noted.
The National Institutes of Health will also begin enrolling people in a $1.5 billion study on Sunday. The goal of the program, called “All of Us,” is to sign up more than 1 million participants who would then undergo a baseline physical and grant the government access to their electronic health records so their health can be tracked over time. NIH also plans to conduct genetic sequencing on their biological samples.
Azar emphasized that officials hope to build trust among populations that historically have been underrepresented in research.
“This will not be just the largest collection of this kind of data in history. It will also be by far the most diverse,” he said. “This kind of data could revolutionize how we treat a range of diseases and conditions.”
New participants will join 25,000 people who have already been part of a year-long early test of the program.
Thursday, May 3, 2018
Florida awards Medicaid contracts as expansion speculation builds - Modern Healthcare Transformation Hub - Modern Healthcare
Florida awards Medicaid contracts as expansion speculation builds - Modern Healthcare Transformation Hub - Modern Healthcare Of the Florida Medicaid HMO’s, only Tampa-based Wellcare has a contract in Georgia.
Estimate of autism prevalence goes up slightly, CDC reports | Georgia Health News
Estimate of autism prevalence goes up slightly, CDC reports | Georgia Health News The Georgia AAP has worked in partnership with the Ga. Dept. of Public Health to improve screening, detection and diagnosis of children with ASD; as well as development treatment resources, such as ABA therapy, for them.
Wednesday, May 2, 2018
Tuesday, May 1, 2018
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