Responding to COVID-19: Time for Real State-Federal Partnerships

The Washington Healthcare Authority (HCA) knows what it has to do.

As the agency responsible for Washington’s Medicaid program, the health benefits of 2.5 million state, county, local, and school employees, and Washington’s Department of Public Health, the HCA is ground zero for the coronavirus outbreak in the state with the highest number of coronavirus deaths. It is learning how it can use its authority to cover and pay for services to help make sure the virus is contained and people with the virus are treated.

But it can’t use that authority without help from the federal government. Now that President Trump has declared the coronavirus outbreak a national emergency, it’s time for the federal government to quickly grant the HCA—and agencies in other hard-hit states like California and New York— new authorities under their Medicaid programs.

Under the National Emergencies Act, if the President declares a national emergency and then the Secretary of U.S. Health and Human Services declares a public health emergency, state Medicaid agencies may apply for Section 1135 waivers for permission to waive certain federal requirements that work well in normal circumstances. But these are not normal times.

So what would these waivers allow the HCA and its peer Medicaid agencies in other affected states to do?

• They could pay overworked and underfunded local public health agencies for COVID-19 testing and treatment, infection control and surveillance, and public education—services that will reduce the burden on the health care system and the number of people infected.
• They could make it easier for those eligible to enroll in Medicaid, and for them to retain their eligibility. Now is not the time to limit access to health care services, rely upon face-to-face encounters to prove eligibility, or occupy state workers with administrative activities.
• They could reduce demands on traditional health care providers and make it easier for people who self-quarantine to receive needed services in their homes—with new kinds of health providers like community health workers and community-based organizations—for new kinds of services like meals and medication delivery.
• They could make sure there are enough health care providers to treat people by increasing the scope of allowable telehealth services, allowing treatment to occur in non-traditional settings, and by relaxing certification renewal requirements for facilities, and licensing requirements for out-of-state providers. The waivers also need to make it easier for providers to bill and get paid for services, so they can continue to focus on providing care and be assured of adequate revenues.

The need for all these actions grows with the number of cases. The problem is that none of them are currently permissible. But all of them are possible, if the federal government takes swift action.

There is bipartisan precedent for the approval of Section 1135 waivers  following declarations of national emergencies with public health implications . As the result of the national emergency declared by President Bush in the wake of September 11, 2001, terrorist attacks, Section 1135 waivers were granted to New York’s Medicaid program. In 2009, during the H1N1 virus crisis, President Obama also declared a national emergency and a nationwide 1135 waiver was issued by the U.S. Secretary of Health and Human Services.

The waivers are not blank checks: they are state specific and time limited, with terms and conditions that must be negotiated and agreed upon.

This is not a time for the Center for Medicaid and Medicaid Services, which grants the waivers, to be narrow or legalistic in its review of state requests. Waivers were designed for extraordinary circumstances such as this.   “As the trajectory of the outbreak continues, many people in the U.S. will at some point, either this year or next, get exposed to this virus,” Nancy Messonnier of the Centers for Disease Control and Prevention said last week. “And there’s a good chance many will become sick.”

This Administration has made a priority of promoting state policymaking authority and flexibility in general and for Medicaid in particular. Recently, the Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said, “The Trump Administration has sought at every turn to grant states flexibility in shaping their Medicaid programs. When actually given the opportunity, states have real solutions to offer. Medicaid is stronger for that sort of robust federal–state cooperation.”

She is absolutely right about what federal–state collaboration can achieve. Public health departments and their colleague Medicaid agencies in Washington State and other states are developing real solutions to a real crisis. The state–federal cooperation that undergirds Medicaid needs to be demonstrated with swift approval of Section 1135 waivers so that states can innovate.