The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
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The Center for Evidence-based Policy at Oregon Health & Science University is a national leader in evidence-based decision making and policy design.
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We publish The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to population health.
Blog: The View from Here
Nov 29, 2017 | Christopher F. Koller, President
Who should the Medicaid program serve? And who decides? These questions have been implicit through much of 2017, as we endured a remarkably uninformed “repeal and replace” debate in Congress. The November announcement by the Centers for Medicare and Medicaid Services (CMS) of new policies for section 1115 waiver consideration and review tees them up again.
The answers are subject to interpretation and turn a great deal on what one thinks of personal merit.
Federal law is of limited use in answering these questions. Congress has repeatedly changed the purpose of Medicaid since its inception in 1965 as “a medical assistance supplement for people receiving cash welfare assistance—the poorest families with dependent children, and poor aged, blind, and disabled individuals,” making it possible for states to finance care for more individuals by continually expanding the definition of populations eligible for Medicaid.
So does Congress set the guardrails for Medicaid—mainly in terms of the maximum income levels, family status, and disability status—and the states define who Medicaid serves? Not exactly. Congress has made its preferences known by creating different federal matching rates for different populations. More significantly, the fact that the Center for Medicaid and CHIP Services (CMCS) has to approve state proposals for how these populations are covered means the states and the current federal administration are forever renegotiating Medicaid’s purpose.
One way the federal government makes its views known about who Medicaid should serve, Sara Rosenbaum points out, is by how they define the objectives of the program, which were changed by the Trump administration. In announcing the new section 1115 waiver review policy, CMCS lists six objectives:
Compare these to the objectives for Medicaid as set forth by the previous administration:
Gone is the primary emphasis on coverage. Now, emphasis is on upward mobility, responsible decision making, and beneficiary transition to commercial coverage. If Medicaid is to serve more than the poorest families and the aged, blind, and disabled, it will be as a tool to get them “up”—up the economic ladder and into “independence.”
CMS Administrator Seema Verma elaborated on these changes in a speech to the National Association of Medicaid Directors (NAMD). CMS is encouraging state Medicaid programs to pay particular attention to unemployed Medicaid recipients who do not have a permanent disability. “These are individuals,” she said, “who are physically capable of being actively engaged in their communities, whether it be through working, volunteering, going to school, or obtaining job training.” She continued, “Let me be clear to everyone in this room—we will approve proposals that promote community engagement activities.”
So Medicaid is seen as a deal—you merit it as long as you are deemed trying to be a good community member. This focus on Medicaid’s purpose as a tool for promoting community engagement is notable for several reasons:
Fundamentally, however, this is a debate about how to prioritize access to a limited resource—finances for health care. Administrator Verma in her NAMD speech made a specific reference to preserving Medicaid availability for “deserving Americans,” the implication being that a non-disabled person without a job is less deserving of public financing and medical care than others. This reflects a view that access to health care treatment is not a precondition for citizenship and community engagement for low-income populations, but a reward for meritorious behavior. This view stands in contrast to how we consider public education and access to health care for the elderly, which do not have to be earned.
This is not a new policy position but is in conflict with other federal policy (notably the Emergency Medical Treatment and Labor Act, which compels hospitals to provide medical care in their emergency rooms), reflecting the conflicting views on the subject in the United States. With the passage of the Affordable Care Act and the ability of states to expand Medicaid enrollment, the Obama administration took a dim view of Medicaid’s role in promoting virtue and discouraged work requirements as a condition for Medicaid eligibility. Instead they saw Medicaid as a tool for expanding access to health care.
The Medicaid program remains, however, a state-federal partnership. The administration’s stated objectives for Medicaid are not the final word. States will continue to have authority and influence over how personal merit is determined in financing health care, who is deserving, and what it truly means to be a community.
The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience.
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