As Health and Human Services Commissioner Mary Mayhew exits her post following six years during which the state cut health care services for low-income people and resisted a mostly federally funded coverage expansion, she’ll leave a handful of coverage-slashing initiatives unresolved.
One of them needs only on an OK from President Donald Trump’s administration.
It’s a proposal from Maine DHHS to start imposing work requirements on low-income, non-disabled adults in order for them to receive health coverage through Medicaid. If they don’t comply, they could qualify for coverage for only three months in every three-year period.
The LePage administration is also proposing to charge a group of people earning poverty-level incomes monthly premiums, and to charge them when they use the emergency room for what DHHS determines to be non-emergencies. If Medicaid enrollees don’t pay their monthly premiums, they would lose their coverage after a 60-day grace period. They wouldn’t be able to regain it until they’ve paid all of their missed premiums.
The LePage administration proposes all of these provisions in an application it’s prepared for the federal Centers for Medicare and Medicaid Services in hopes of securing a waiver from federal Medicaid law. It’s similar to pending requests from other Republican-led states, including Wisconsin, Arizona, Kentucky, Indiana and Arkansas.
The federal government has wide latitude when it comes to granting such waivers, but the authority isn’t unlimited. Federal law provides for waivers in order to allow “experimental, pilot, or demonstration” projects that are “likely to assist in promoting the objectives” of Medicaid.
With that legal basis in mind, the Centers for Medicare and Medicaid Services has generally granted state waiver requests for pilot projects that meet particular criteria spelled out on the agency’s website.
Based on those criteria, how should the LePage administration’s request stack up when Trump administration officials consider whether it’s waiver-worthy?
Does the proposal “increase and strengthen overall coverage of low-income individuals in the state?”
The LePage administration’s application is straightforward: This isn’t an initiative about expanding access to health coverage. The application makes clear that if the waiver is granted, fewer people will have coverage.
Does the proposal “increase access to, stabilize, and strengthen providers and provider networks available to serve Medicaid and low-income populations in the state?”
We have a hard time believing that it’s a good thing for health care providers when fewer people have the ability to pay doctors for their care. One can look to the experience of states that expanded Medicaid under the Affordable Care Act compared with those that didn’t.
Research published last year in the Journal of the American Medical Association showed that hospitals in states with expanded Medicaid saw the amount of uncompensated care they provided drop by $2 million on average between 2013 and 2014 — respectively, the year before expansion and expansion’s first year.
Does the waiver proposal “improve health outcomes for Medicaid and other low-income populations in the state?”
The LePage administration is seeking permission to charge premiums that exceed the threshold generally allowed under federal Medicaid law. This means that people with poverty-level incomes would be expected to pay up to 5 percent of their income on Medicaid premiums.
The available research on requiring Medicaid beneficiaries to pay monthly premiums shows that the premiums act as a barrier to coverage. The most likely effect is that premiums discourage people from enrolling in Medicaid, causing them to go without health coverage. Charges at the doctor’s office have the effect, according to the research, of discouraging people from seeking care.
Lastly, would the waiver “increase the efficiency and quality of care for Medicaid and other low-income populations through initiatives to transform service delivery networks?”
Since the LePage administration has made it clear that its proposal isn’t about expanding access to health care, much less improving its quality, we have a hard time seeing how the proposal meets this benchmark.
The LePage administration is standing on flimsy ground in requesting this waiver. If the Trump administration grants it, it will be showing its own disregard for the law, not to mention its disregard for low-income Americans who need access to health care.