Internists Offer Recommendations to Ensure Medicaid Expansion Waivers Represent Patient Interests

(Washington, March 21, 2016)— The American College of Physicians (ACP) today released a position paper that reviews Medicaid expansion waivers and offers recommendations to influence stakeholders so that Medicaid coverage is expanded in a manner that best suits patients. Medicaid Expansion: Premium Assistance and Other Options notes that some past waiver experiments have been widely adopted by state Medicaid programs, including managed care delivery models and benchmark benefit plans.

“The Affordable Care Act (ACA) expanded Medicaid eligibility to all individuals with incomes up to 138 percent of the federal poverty level (FPL) or about $16,242 for a single adult or $33,465 for a family of four (in 2015),” said Wayne C. Riley, MD, MPH, MBA, MACP,  ACP president. “The expansion would predominantly benefit childless adults, a population historically barred from Medicaid regardless of income level, and low-income parents.”

Opponents of the law argued that the federal law was unduly coercive and challenged the expansion. In 2012, the United States Supreme Court ruled that it is unconstitutional for the federal government to coerce states into expanding Medicaid by withholding funding for their existing Medicaid programs if they did not. As a result, Medicaid expansion is now totally optional for the states.

“Several states have sought to expand Medicaid coverage in a manner that is more palatable to the conservative ideological leanings of their legislators and residents,” Dr. Riley continued. “Using the Medicaid waiver process, which permits Medicaid programs to seek approval from the federal government to forgo some traditional Medicaid rules, states have received approval from the federal government to increase cost-sharing and impose premiums, trim benefits, use Medicaid funds to purchase private insurance, and require or encourage enrollees to participate in wellness or health behavior initiatives.”

ACP’s paper offered these five recommendations:

  1. Medicaid programs must develop and widely disseminate information and provide education outreach to enrollees (and potential enrollees) that clearly explains in plain language health insurance concepts, plan rewards and penalties, provider and hospital network, and other pertinent information. Materials should meet the needs of the Medicaid population, including those with disabilities and/or limited English proficiency and literacy.
  2. At a minimum, Medicaid expansion waivers should provide coverage of the essential health benefit package, non-emergency transportation, Early and Periodic Screening and Diagnostic and Treatment benefits, mental health parity, and other benefits required of Alternative Benefit Plans.
  3. Medicaid premiums and cost-sharing should be structured in a way that does not discourage enrollment or cause enrollees to dis-enroll or delay or forgo care due to cost, especially those with chronic disease. If cost-sharing is applied it should be done in a manner that encourages enrollees to seek high-value services and health care physicians and other health care professionals. Medicaid enrollees should not be restricted from reenrolling in coverage (i.e., locked-out). Medicaid out-of-pocket costs should remain nominal and be subject to a cap (such as no higher than 5 percent of family income) for those with incomes above the poverty line.
  4. Work-related or job search activities should not be a condition of eligibility for Medicaid. Assistance in obtaining employment, such as through voluntary enrollment in skills and interview training programs, can appropriately be made available provided that it is not a requirement for Medicaid eligibility.
  5. Medicaid wellness programs should be structured in a manner that monitors health status and encourages healthy behavior through positive incentive-based programs.  Punitive approaches that penalize enrollees for not achieving better health status, or for not changing unhealthy behaviors, should be avoided.

“Because waivers are temporary,” Dr. Riley concluded, “it is important to closely monitor the effects of waiver experiments to better understand the effect of premiums on poor and/or chronically ill patients; provider accessibility and participation; whether Marketplace-based plans are preferable to existing Medicaid managed care arrangements; and the effect of waivers on administrative complexities, enrollee satisfaction, and overall cost.”

The American College of Physicians is the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 143,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.