Clay’s Weekly Medicaid RoundUp: Week of January 15th 2018

Soundtrack for today’s RoundUp pessimist readers-  (what an amazing song, nay – album!)


For optimist readers-


LET’S TALK SHOP AT MEDICAID INNOVATIONS 2018 – I will be in Florida again (7th year for me, I think) for the Medicaid Innovations Conference. If you are going, let’s plan on meeting up. Jan 31-Feb 2, 2018. Check it out here-


WORKIN’ FOR THE WEEKEND- The big buzz this week was KY getting its Medicaid work requirements waiver approved by CMS. This will have big implications for the dozen or so other states waiting on approval for their own waivers. This is an important change for the Medicaid program, so let’s spend this week’s roundup considering perspectives on it.


FIRST THE FACTS, MAM – KY is the first state to get approval for a slew of “conservative” features to modify its Medicaid program. Features include a work requirement (that doesn’t apply to pregnant women, children, the elderly, the physically disabled or the developmentally disabled), bennies will pay premiums up to 4% of their income, and bennies can be locked-out of coverage if they don’t prove their eligibility as required / scheduled. For the work requirements (also called “community engagement”), bennies that must meet these have to put in 80 hours a month starting in July (giving them 6 months to find a part-time job if they want to keep their Medicaid benefits). Overall about 350,000 bennies have to meet this requirement, and about 175,000 of them already meet it. One last thing on the “work” requirement – under new CMS guidelines on the next-gen waivers, if a benny has an addiction, getting treatment can count towards your hours.


Now let’s look at some point / counter-point for each camp.



  • It is in violation of the federal statute because it does not meet the objectives of the program, and lawsuits will stop it

Counterpoints: Litigation (with or without a belief in its merit even by the plaintiff) is a proven method of resistance. One can just as easily argue that it makes the program more efficient and thus frees up more money to better meet the objectives of the program.

  • It overcomplicates eligibility / will be too hard to enforce / creates more costs to enforce than it saves

Counterpoints:  Maybe. It could be very simple if states work with the right vendors. This is a whole new area for technology solution providers, and they could build off of existing systems like the unemployment data sets.

  • It is mean / cruel

Counterpoints: Not really. States have made sure to target who this applies to so that those that cannot be expected to work are not under the requirement. But I am sure this attack will be repeated over and over anyway. Emotional (regardless of veracity) appeals work.

  • People will die because of these changes

Counterpoints: Unproveable, but high value to throw out the bombastic claim (with no cost of making it)

  • Sick people cannot hold down a job

Counterpoints: If they are that sick, then do they meet the disability requirements?

  • Few will be under these requirements because most on Medicaid can’t work –

Counterpoints: What about the 50% of those under new requirements in KY that already are working? Or the study in JAMA showing about half of Medicaid bennies in Michigan working? This is just “making it official” for half of those impacted, and putting the other half on notice.

  • This is unproven

Counterpoints: So are all new ideas at first (especially in Medicaid). And most 1115 demo waivers remain demos forever and never really get evaluated anyway (see recent OIG criticism on this). If we slapped buzzwords like “population health” or “big data” on it, would you like it then? Or maybe a job could be one of those “social determinants of health”?

  • This will hurt hospitals / providers because there will be less “coverage”

Counterpoints: Maybe. Or maybe DSH never really went away, and maybe uncompensated care costs are an unproven black box useful for strong-arm budget tactics.


  • We are tired of Medicaid destroying our budgets and this is a fair way to deal with this

Counterpoints: For the most part I agree. The tricky part is this is healthcare, and you have to think through how to deal with catastrophic coverage. And the idea that healthcare is a human right has gained a lot of ground in recent years.

  • People who can work should (if they want public benefits)

Counterpoints: See above

  • This will help people rise out of poverty / brings them dignity in work

Counterpoints: I also agree. I personally know several people who were homeless / near homeless and a job and the commitment to it changed their life. But- Making this work will require an overall strategy in your state tied to jobs / your local economy. You can’t just get this waiver approved and expect various issues to magically be resolved.

  • This will allow for more money to be spent on the disabled / most vulnerable

Counterpoints: Makes total sense. Now if we could also deal with all the cash lost to fraud. I have some ideas on that. Call me.

  • People who don’t make the effort to work probably won’t make the effort to improve their own health

Counterpoints: Big Duh, here. Big question is where line is drawn investing limited dollars on those who won’t get engaged (at the cost of not spending it on those who will). Or just pretend there is unlimited dollars for Medicaid and all is fine and we can go back to the fairy tale of the way Medicaid was funded before Evil Trump came along.

  • Its about time the federal-state nature of Medicaid wasn’t a one-way street. States should have more control of their programs and not just have to do whatever the feds force them to do (with ridiculous, coercive funding incentives that create no real choice for states).

Counterpoints: I think you can guess by now I agree with this one. Here, Hear!

WHAT’S NEXT – There’s a cue forming for these types of waivers. Last I looked it was 10 states — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin.  Combine the KY approval with CMS guidance recently released, and we will watch most of these get approved before summer. And more will follow.

CMS head Veerma is not playing around. She continues describe opponents of these ideas as holding onto “the soft bigotry of low expectations.” Whether the general blogosphere / MSM will ignore that volley, or attack it directly (many do), I am not sure. But she is claiming moral high ground from a conservative vantage point. And to do that in Medicaid is perhaps unprecedented. Or at least its been so long since we’ve seen it maybe we don’t recognize it. It may just be that fiscal hawks have had enough of being bullied by the doves, and have found their voice in a lady named Seema.

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (at least to put salt on your steps) and keep running the race (you know who you are).

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