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The Biden HHS is now de-authorizing individual components it doesn’t like from waivers that were approved years ago.
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— CMS has told four states their 1115 waivers no longer apply
WASHINGTON — The Biden administration’s decision to repeal Medicaid work requirement waivers in four states is getting mixed reviews from the health policy community.
Work requirements “definitely can be a barrier to access, and that is something that we definitely have to avoid at all costs,” said Ada Stewart, MD, president of the American Academy of Family Physicians, in a phone interview. “They could end up doing harm to patients who are at most need of Medicaid.”
Nina Schaefer, senior research fellow in health policy at the Heritage Foundation, a right-leaning think tank here, disagreed. “The whole purpose of a waiver is for states to experiment with different approaches on how they want to administer the Medicaid program,” she said in a phone interview. “There has been a lot done with work requirements on other welfare programs, so why not Medicaid? … The idea of welfare is not to have a life of permanent welfare, but as a ladder to move out of the welfare hole. Working and getting higher income — those types of things should be rewarded, not be seen as a negative.”
Last week, CMS officials notified Medicaid directors in Arizona and Indiana that they were withdrawing approval for Medicaid work requirements in those states. The administration also took similar action in New Hampshire and Arkansas in March, although those states are both appealing that action in a case now before the Supreme Court, according to Bloomberg Law.
The waivers, which were granted by the Trump administration under the 1115 waiver program, generally mandate that Medicaid enrollees show that they are participating in “community engagement” activities, which could include employment (at least 80 hours per month), job training, school enrollment, or volunteer work. The policies also come with exemptions — in Arkansas, for example, the requirement exempted students, the disabled, persons responsible for full-time care of a child or other family member, and pregnant women.
In her June 24 letter to Arizona Medicaid director Jami Snyder, CMS administrator Chiquita Brooks-LaSure noted that per federal law and regulations, “CMS may withdraw waivers or expenditure authorities if it ‘find[s] that [a] demonstration project is not likely to achieve the statutory purposes.'”
After noting the effects that the pandemic has had on the Medicaid program — including the increased unemployment and lack of economic opportunities as well as the long-term effects of COVID infection that require ongoing medical care — she continued, “At a minimum, in light of the significant risks and uncertainties described above about the adverse effects of the pandemic and its aftermath, the information available to CMS does not provide an adequate basis to support an affirmative judgment that the community engagement requirement is likely to assist in promoting the objectives of Medicaid.”
“Accordingly, CMS is hereby withdrawing its approval of that portion of the January 18, 2019 amendment that permits the state to require work and community engagement as a condition of eligibility under the [Medicaid] demonstration.”
The CMS letter to Indiana Medicaid director Allison Taylor contained similar sentiments. “We do not have evidence before us that suggests that the state has measures in place that are likely to reduce the risks of Indiana’s demonstration project resulting in substantial coverage losses at a time when losing access to healthcare coverage would cause significant harm to beneficiaries,” Brooks-LaSure wrote.
“CMS has determined that, on balance, the authorities that conditionally permit Indiana to require community engagement as a condition of continued eligibility are not likely to promote the objectives of the Medicaid statute. Therefore, we are withdrawing the community engagement authorities that were conditionally approved in the October 26, 2020, extension approval of the HIP [Healthy Indiana Plan] demonstration.”
This withdrawal of permission occurring after the waiver has already been approved opens a real Pandora’s box, according to Schaefer. “What is a precedent is that the government would now reopen what was an agreed-to contract between the federal government and the state regarding the provision of the waivers,” she said. “Is this a way that waivers are going to move in future administrations, where new administrations now reopen the Biden administration’s waivers and say, ‘OK, we don’t agree with these policies and we’re going to stop them again?’ That will have a real chilling effect on innovation at the state level.”
But Gary Rosenfield disagreed. “It could open a Pandora’s box, but when it’s bad policy, that is a Pandora’s box that needs to be opened,” said Rosenfield, senior vice president at ConsejoSano, a healthcare technology company specializing in culturally-aligned outreach to Medicaid plan members. “It’s targeting people who don’t necessarily have voices, and it’s taking the wrong approach … The whole notion that someone is sitting around saying, ‘I want to be on Medicaid so I’m not going to work’ is, in my opinion, a ridiculous thing. Statistics show that people who aren’t aged, blind, or disabled — the vast majority of them are working.”
“As long as the Biden administration makes it clear why they’re reversing the policy, and why it was bad policy to begin with, and sells it and justifies why they’re doing it … they could do it in a way that would make it defensible,” Rosenfield said, speaking during a phone interview at which a public relations person was present.
Thomas Johnson, executive director of the Population Health Alliance, a trade organization for groups interested in population health management, said in an email that although his organization has not taken a position on work requirements, “I haven’t seen any evidence from any state that has resulted in any goals being reached from supporters of such requirements.” In addition, “I think there were a number of challenges for enrollees around the country. In Arkansas, the state was solely reliant upon an online system for enrollees entering required information, and that state has the largest gap for access to the internet in the country.”
Joyce Frieden oversees MedPage Today’s Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow