To Seema Verma, Medicaid is more like two programs than just one. The administrator of the Centers for Medicare and Medicaid Services – who leads the agency overseeing the federal government’s big health insurance programs – described the way she views two different populations who rely on Medicaid in an interview this week with The Post.
There are the Americans with disabilities or chronic medical conditions who aren’t able to work, she said. And then there are healthy adults able to maintain a job. Verma said she envisions Medicaid as responding differently to each population based on their needs.
“When I look at the Medicaid program, I think of it almost in terms of two Medicaid programs,” Verma told me. “There’s the program that serves the most fragile, vulnerable populations in our society. These could be people that are living on ventilators or quadriplegics. That’s a very different program than looking at the program for the able-bodied individuals.”
Verma has displayed her views on Medicaid through several major actions by CMS to allow states to impose more requirements in order to register. She often talks about her intent to give states more flexibility in running their programs, particularly when it comes to measures that might result in smaller Medicaid rolls and reduced spending.
“It is a success for us when somebody is able to rise out of poverty and no longer needs the program for those able-bodied individuals,” she said. “If they are able to get a job that provides health insurance and create that independence, I consider that a success.”
Allowing states to try out new Medicaid approaches is a major way Verma can put her stamp on the program for low-income Americans that covers about 70 million Americans. Here are three big, pending questions she and the agency she runs are considering:
Are work requirements permissible in states that didn’t expand Medicaid under the Affordable Care Act? All four of the states where the administration has said “yes” to work requirements expanded their Medicaid programs under the ACA. If recipients in Indiana, Arkansas, New Hampshire or Kentucky get a job, they don’t risk losing their benefits until they earn more than 138 percent of the federal poverty level – and at that point, they can get subsidized coverage on the marketplaces.
But Americans in states without Medicaid expansion could face a difficult, Catch-22 scenario. Verma herself has admitted this possibility.
That’s because Medicaid’s qualification bar is a lot lower in places like Alabama, Kansas, Maine, Mississippi, North Carolina and Wisconsin – states that have also requested work requirements.
For example, Alabamians must earn no more than 18 percent of the poverty level (about $312 a month) to qualify. In North Carolina, the bar is set at 45 percent of the federal poverty level. Non-disabled adults without children aren’t eligible for Medicaid in either state, no matter how little they earn.
So if Medicaid enrollees in these states got jobs to retain their coverage, they could easily exceed the earnings threshold – and get kicked out of the program. It would probably be hard for them to then afford coverage on their own, since the marketplace subsidies aren’t available to those earning less than 138 percent of the federal poverty level.
Verma hasn’t ruled out approving work requirements in non-expansion states, but she did express concerns about this kind of “subsidy cliff” in public remarks this month.
“Because there is no tax credit for them to move on to the exchanges, what happens to those individuals?” she asked at a May 1 news briefing. “We need to figure out a pathway, a bridge to self-sufficiency.”
Will states be allowed to expand Medicaid only partially? This is an approach the Obama administration repeatedly rejected, but the Trump administration hasn’t officially weighed in. Verma didn’t give us any real hints Tuesday, instead saying that CMS will evaluate these requests from states based on the impact on the federal budget, whether it’s permissible under the ACA and whether it’s consistent with Medicaid’s objectives.
“We’re continuing to look at that issue,” she said. “If they’re doing partial expansion, that means they’re coming to the exchanges, and so we’re trying to understand all of the implications and the scenarios and what the impact would be.”
Massachusetts and Arkansas have submitted waiver requests to CMS to scale back their programs to just 100 percent of the federal poverty level. Utah is moving in that direction, too, passing a bill in March proposing only partial expansion.
There are legal questions around whether the ACA even permits this move. Under President Barack Obama, the Department of Health and Human Services told states they had to either take or leave Medicaid expansion, insisting the law doesn’t allow for a halfway approach.
Can states require Medicaid enrollees to undergo drug testing? The Trump administration has given a thumbs-up to work requirements but a thumbs-down to capping Medicaid benefits over an enrollee’s lifetime. But how will CMS handle a third move by some states to require recipients to undergo drug testing? This type of waiver request could be the next major one the agency responds to.
It’s been nearly a year since Wisconsin asked the agency for the go-ahead on making applicants undergo a drug test if they’re suspected of substance abuse. Those testing positive would have to undergo treatment to sign up for Medicaid under the state’s proposal.
When I asked Verma about drug testing, she suggested it could be one way to address the country’s opioid abuse epidemic, which Trump has declared a public health emergency.
“For a lot of states, what they’re looking at is they want to be able to identify individuals that need help, and we’ve got to figure out what’s the best way to identify those individuals and then help link them to the services that are going to be most appropriate,” she said.