WASHINGTON -- One challenge for anyone trying to predict the impact of recent Medicaid waivers is the lack of published findings around recent demonstration projects, argued a healthcare policy expert and panelist at a conference here Monday.
Medicaid expansion under the Affordable Care Act was hugely beneficial to anyone who couldn't have received coverage without it, said Sara Rosenbaum, JD, of the Milken Institute School of Public Health at George Washington University, speaking at the conference, hosted by Medicaid Health Plans of America.
Some states, however, have felt that the program's requirements needed to be modified in order to meet their particular needs. The law allows them to adjust those requirements through experimental demonstration projects.
However, some expansion waivers may also carry risks.
For example, the impact of waiver provisions allowing cost-sharing obligations for those with "negligible income," is not well-understood, Rosenbaum said. Such policies may even deter potential enrollees, she added.
While "a ton of evaluation" has been commissioned by the administration over the last 6 or 7 years, "there's very little empirical research on the effects of [Medicaid] demonstrations," she told MedPage Today.
"The evaluation components [of Medicaid waivers] are not being taken seriously," she said, and results of some completed evaluations haven't been published.
As for the "Healthy Indiana Plan," a demonstration that the current Centers for Medicaid and Medicare Services administrator, Seema Verma, helped design in her previous job in that state, Rosenbaum told MedPage Today there's "almost nothing" in terms of research.
One report that has been released, a July 2016 from the Lewin Group, "leaves fundamental questions unanswered, such as how many people were deterred from seeking coverage or prematurely lost coverage as a result of the financial responsibilities," said Rosenbaum.
She also worried that some states are overseeing their own evaluations of demonstration projects -- a clear conflict of interest. Other reviews simply aren't rigorous, and fail to "carefully frame" important questions, Rosenbaum added.
"It's been customary for states to contract with research firms, universities and other entities to conduct independent and unbiased evaluation projects. That's historically been the case across states and waiver types," said David Rogers, managing principal for Health Management Associates Medicaid Market Solutions in Lansing, Michigan, in an email.
New Trends in Waiver Design
Since efforts to repeal the Affordable Care Act, many of which also included plans to overhaul state Medicaid programs, tanked this year, some "red" states are pursuing their own revisions.
One popular trend in the current Section 1115 waivers is to impose premiums, noted the KFF report. Another re-emerging idea is the concept of a "partial expansion," limiting eligibility for Medicaid enrollment to 100% of the federal poverty level (FPL) for childless adults instead of the current 138%.
In a half-dozen states that have already expanded Medicaid, officials have suggested eliminating coverage for those above 100% of FPL, Alexander Shekhdar, vice president of State and Federal Policy for Medicaid Health Plans of America and the panel moderator, told MedPage Today.
Arkansas is one of those states. If approved, Shekhdar said, it could trigger copycat requests from many others.
Another idea cited by audience members would cut the proportion of healthcare costs for which the insurer, versus the enrollee, must be responsible.
From Rosenbaum's perspective, many recent proposed requests seem to come from a checklist of changes that would simply cut state spending.
But "the objective of Medicaid is to get medical assistance to people who need it," she said during the panel.
A earlier this year laid out the Trump administrative's attitude toward waivers. It encouraged two types of Medicaid waivers, Rosenbaum said: those that "culled the rolls" -- using work requirements, drug testing, and time limits -- and those seeking to make Medicaid operate more like commercial plans.
"I think we've reached the limits of where we can go and where as a nation we should go" in terms of waiver flexibility, she said.
"With waivers, in theory, there's benefits and risks. We're about to embark on a period of mostly risks," Rosenbaum told MedPage Today, after the panel.
Tools of State Experimentation
"I want to focus on the positive," said Catherine Anderson, vice president of healthcare policy for United Healthcare Community & State, while acknowledging that waivers have advantages and disadvantages.
Waivers have been critical for states to create programs that address their own "unique needs."
"Without waivers [Medicaid] managed care doesn't exist," Anderson added.
Having long-term care incorporated in Medicaid managed care was initially only possible in a few states, including Florida, Texas and Arizona, Anderson said: "If it weren't for those early states ... we wouldn't see the movement to bringing complex populations into a managed care environment that we do today, and waivers create that opportunity."
Rogers highlighted a recently approved waiver from West Virginia designed to help treat more people with substance use disorders.
In 2015, West Virginia had the highest overdose rate in the country, according to .
A new waiver enables West Virginia's Medicaid program to expand its ability to pay for addiction treatment, by allowing the state to skirt a regulation barring payment for treatment in facilities with more than 16 beds.
Five other states -- California, Maryland, Massachusetts, New Hampshire, and Virginia -- have received similar waivers, Governing indicated.
Examples of waivers intended purely to cut states' Medicaid expenses are already in place.
Medicaid is the largest expenditure for states -- when federal funding is included -- and frequently the second highest expenditure, when looking at state general fund spending, Rogers said. "The real challenge is that state general fund spending for Medicaid continues to grow faster than state revenue."
Medicaid crowds out other state priorities, including education, Rogers explained.
One example of a state using a waiver to deal with such challenges is Florida's request to to Medicaid -- under which states pay for catastrophic care costs incurred prior to formal enrollment -- through a so-called 1115 waiver.
Similar requests have been agreed to and implemented in more than a dozen states over the past 20 years, Rosenbaum said, but no evaluations have been forthcoming.
"How is it possible to keep getting waivers of retroactive eligibility ... and we have no idea [about] the effects on people or healthcare systems or anybody else?" Rosenbaum asked.