CMS fails to verify benefits of waivered Medicaid demonstration projects

As Trump Pushes Medicaid Testing, the Grading Falls Short

By Robert Pear
The New York Times, March 4, 2018

The Trump administration is hoping to transform Medicaid by allowing states to test work requirements, premiums and other conservative policies, but a new government report says federal and state officials do not properly evaluate whether such experiments improve patient care or reduce costs.

Evaluations “generally lacked rigor,” and the findings were often kept secret for years, so they were of little use to policymakers, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in the report issued last month.

Under federal law, the secretary of health and human services can waive certain Medicaid requirements so states can use federal money for the program in ways that would not ordinarily be allowed — for example, to cover people and services that would not otherwise be covered.

These waivers have been used for demonstration projects testing innovative ideas and involving millions of people and tens of billions of federal dollars. The Government Accountability Office said the number and scope of Medicaid waivers had grown in recent years, with demonstration projects now accounting for one-third of all federal Medicaid spending — and more than 75 percent in 10 states, including Texas.

The main purpose of the waivers, according to the report, is to test and evaluate new ways of providing coverage and care to people with modest incomes. But, it said, waivers have become a vehicle for wholesale changes in Medicaid, and neither federal nor state officials adequately assess the results. The evaluations have been plagued by “significant methodological weaknesses” and often leave critical questions unanswered, the report said.

The Trump administration has been flooded with requests from states seeking Medicaid waivers. They want to impose work requirements, charge premiums, suspend coverage for people who fail to pay premiums, and restrict eligibility or benefits in other ways. A few states would like to impose time limits on Medicaid coverage for some beneficiaries.

The Government Accountability Office found particular problems in the evaluation of a Medicaid waiver granted to Indiana. The state expanded Medicaid, as permitted under the Affordable Care Act, but obtained a federal waiver for policies emphasizing “personal responsibility,” including monthly premiums and incentives for healthy behavior.

The federal government wanted to know how Medicaid beneficiaries were affected by those changes, but it could not get the data it needed from the state, so its evaluation was severely limited, the Government Accountability Office said.

Conservatives see Indiana’s Medicaid program as a model, and other states are following suit. The architects of the Indiana plan include Vice President Mike Pence, who was the governor of Indiana from 2013 to January 2017, and Seema Verma, a consultant to the state who is now the administrator of the federal Centers for Medicare and Medicaid Services.

Government Accountability Office; Medicaid Demonstrations:


Success of Pence's Medicaid expansion far from settled

By Virgil Dickson
Modern Healthcare, July 25, 2016

The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump's pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.

A new analysis funded by the state shows both positive and concerning elements to Indiana's alternative Medicaid expansion.

The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence's Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.


Trump approves Arkansas Medicaid work requirements

By Nathaniel Weixel
The Hill, March 5, 2018

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.



By Don McCanne, M.D.

Section 1115 Medicaid waivers allow states, with the approval of CMS, to establish demonstration projects that waive certain requirements of the Medicaid program as long as the objectives of the program are met. At the end of the waiver period, the results are to be formally evaluated. The GAO report shows us that these evaluations "lack rigor" and have not been released to provide important research results to the policy community.

Particularly important was the evaluation of the Indiana Medicaid waiver since it put into effect the conservative ideological preferences of Gov. Mike Pence (now vice-president) and Medicaid consultant Seema Verma (now CMS administrator). They contracted for a private study by the Lewin Group while fighting off a CMS evaluation. That is important because they both have touted the great advantages of their patient-empowerment Medicaid program when there is virtually no objective public data to show benefit - only the biased (and not all that impressive) report purchased from the Lewin Group.

Today, Arkansas followed Kentucky and Indiana to become the third state to be granted work requirements for Medicaid beneficiaries - a policy move based on conservative ideology rather than on patient benefit. We can anticipate a further expansion of anti-welfare warfare by the current administration.

When health care coverage is eventually expanded to cover everyone, it will be important to avoid segregating low-income individuals and families into an isolated welfare program. Such a program would always be vulnerable to attacks from anti-government political ideologues. Instead we need a universal egalitarian program that treats everyone fairly - a national single payer improved Medicare for all.

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