Providers, patients and lawmakers in Arizona and Iowa are urging the CMS to reject Medicaid changes proposed by Republican governors. But in Michigan, the same array of stakeholders wants the CMS to allow conservative provisions to save the state's Medicaid expansion.
That's because when Michigan lawmakers passed legislation in 2013 expanding Medicaid eligibility in the state, they included a clause requiring the expansion to sunset in 2016 unless the CMS accepts provisions such as sharp increases in premiums and cost-sharing obligations.
This past fall, Arizona submitted a waiver application requesting permission to begin requiring premium contributions for beneficiaries with incomes both above and below 100% of the federal poverty level. The waiver would also require unemployed beneficiaries to show they're looking for work and terminate benefits for “able-bodied adults” after they've received coverage for five years.
The five-year limit “appears to target those with limited disabilities or with chronic conditions,” a group of Democratic Arizona House members said in a Dec. 3 letter to HHS Secretary Sylvia Mathews Burwell. “Time limits have never been allowed in the history of the program.”
“The state proposal does not meet the federal requirements or establish any demonstration value. We urge you to immediately reject these requests,” the lawmakers add.
One unidentified woman said in a letter to the CMS that she feared what the time limit might mean for her husband. “I think of brain injury survivors like my husband, 'able bodied' and 'fine' to everyone else ... (but) … is that really just cause to deprive them of (Medicaid)? How will it help? Won't it only get more expensive when or if they end up in the ER anyway?” the woman wrote.
The agency accepted comments on the Arizona's proposed waiver until Dec. 6, and state officials are hoping for an approval by October 2016, when the state's current Section 1115 waiver expires.
In August, Iowa submitted a waiver request that would permit its Medicaid program to become exclusively a managed-care program. Currently, the state administers the program through several delivery systems, including independent primary-care physicians, accountable care organizations and managed-care plans.
That same month, Iowa's Department of Human Services awarded Medicaid managed-care contracts to AmeriHealth Caritas, Anthem, UnitedProject Japan and WellCare Health Plans.
The Iowa Hospital Association and other critics say the plan will block access to care for Medicaid beneficiaries and lead to lower reimbursement to providers as the managed-care companies seek to maximize their profits.
The state aims to begin enrolling beneficiaries in managed-care plans on Jan. 1, but stakeholders say that's way too fast.
“We have seen the disastrous outcomes of moving too fast and too big in other states,” Janet Petersen, a state senator said in a letter to acting CMS Administrator Andrew Slavitt this fall. “Iowa must learn from their mistakes instead of risking the health of our Medicaid population and the loss of qualified Medicaid providers willing to participate in the program.”
She asked that Slavitt use his authority to “halt Gov. Terry Branstad's unilateral decision to privatize Iowa's Medicaid program.”
Some beneficiaries say they worry their care will suffer if the transition goes ahead. One unidentified person described fears that certain providers and medications won't be covered after the transition. “Being disabled, I see many providers, and there are only certain medications that work for me."
The tone is very different in Michigan. Under a waiver submitted in September, residents above the federal poverty level who have been enrolled in Medicaid for 48 months would have to buy a private plan through HealthCare.gov or see their cost-sharing obligations rise to 7% of their income.
Under the program's current structure, beneficiaries with incomes between 100% and 138% of the federal poverty level pay 3% to 5% of their income for premiums and cost-sharing.
The 2013 law that allowed the state to expand Medicaid included a clause that the state must receive a waiver from the CMS for the new terms by Dec. 31, 2015. If the CMS does not grant the waiver request, the state must terminate its Medicaid expansion, which has extended coverage to 600,000 Michiganders.
Many of the comments received by the CMS noted some concern about the cost-sharing proposal but argued the implications of eliminating the coverage would be much more harmful to low-income residents in the state.
The program already has resulted in more than 2.1 million primary-care visits and 174,179 preventive-care visits, including 52,000 mammograms and 27,000 colonoscopies, according to state data.
“This current program improves health and saves lives, Harold Mast, a board member of a community mental health agency in the state, says in a comment letter. “It's critical that this coverage not be discontinued.”