TEXAS JUDGE ORDERS THE ACA UNCONSTITUTIONAL

The future of the Affordable Care Act (ACA) is at risk after a federal district court judge ruled the law to be unconstitutional. On Friday, Judge Reed C. O'Connor (TX) sided with twenty Republican legislators and ruled the law unconstitutional after congress passed the December 2017 tax bill.

Last years tax bill removed the laws Individual Mandate that penalized taxpayers for failing to have healthcare coverage. Preceding the bill, the Supreme Court ruled in favor of the ACA due to the fact that the mandate was considered a tax and an appropriate power of the Congress. However, Judge O'Connor's position is that the law is no longer constitutional without the penalty.

According to Judge O'Connor, "The Court finds the Individual Mandate "is essential to" and inseverable from "the other provisions of" the ACA." Last week, the ruling was reached while most plans were approaching the close of open enrollment. Despite his order, enrollee's coverage should not be affected and a final decision will not likely be made until it reaches the Supreme Court. Up to this point, the Supreme Court has made two constitutional related rulings to the ACA and this will more than likely be the third.

Soon after, Attorney General Becerra and fifteen other Democrats vowed to appeal the ruling. Becerra stated, "Today's ruling is an assault on 133 million Americans with preexisting conditions, on the 20 million Americans who rely on the ACA for healthcare, and on America's faithful progress toward affordable healthcare for all Americans. The ACA has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court. Today's misguided ruling will not deter us: our coalition will continue to fight in court for the health and wellbeing of all Americans."

Senate Minority Leader Chuck Schumer commented, "The ruling seems to be based on faulty legal reasoning and hopefully it will be overturned."

According to legal experts, this effort has very little chance of standing up in court and it will most likely be denied. If the order was supported in the Supreme Court, it would seriously affect the nation's health care system given that the ACA touches nearly every aspect of it.

Read more about Medicaid and the ACA here.

CMS ACHIEVES THE LOWEST IMPROPER PAYMENT RATE IN TEN YEARS

Medicare and Medicaid accounted for $40 billion dollars in improper payments in 2017 and the Medicaid program has been on the GAO's High Risk List since 2003 because of insufficient fiscal oversight. However, last month CMS announced that the agency achieved the lowest improper payment reduction rate for the programs in 8 years. This makes 2018 the second consecutive year that the rate has been below the 10% threshold following the compliance initiatives established in the Improper Payments Elimination and Recovery Act of 2010.

Leading up to this point, CMS has made a concentrated effort to decrease improper payments by focusing on claims identification, reporting, and technology solutions that address payment error vulnerabilities.

CMS Administrator Seema Verma said, "Our accomplishments over the past year were the result of a focused effort to target root causes of improper payments. CMS also implemented a targeted review strategy that focused on provider education, assistance and burden reduction. The agency's actions emphasized prevention-oriented activities."

Defining and understanding this wasteful spending is a prime focus for effective oversight according to the administrator. She recognizes that not all improper payments are fraud but that these payments fail to "meet statutory, regulatory, administrative or other legally applicable requirements."

CMS determined that the decreased rate was a consequence of their targeted review strategy that concentrates on provider education, assistance, burden reduction, and prevention activities that simplify and clarify policy. In addition, the agency also favors the implementation of innovative solutions from the private sector that will combat improper payments and assist Medicaid and Medicare providers.

In spite of the success, the agency is aiming to reduce the rate even further. Verma states, "While we have made progress on reducing the improper payments rate, we are not satisfied and more work needs to be done to achieve increased and consistent reductions in the future by implementing already existing initiatives as well as innovative processes."

HOW IMPROPER PAYMENTS OCCUR

The vast majority of improper payments result in government-funded health care systems as a result of antiquated data systems and methodologies. Specifically, the data employed by the federal government to detect overpayments and fraud is unreliable.

In 2012, HHS Regional Inspector General Ann Maxwell declared, "... much of the data used to identify improper payments and fraud is not current, available, complete, [or] accurate."

Throughout Medicaid, the coordination of benefits and ascertaining who is responsible for a claim is complicated. It demands timely data and the use of numerous data sources. Also, eligibility data is uncoordinated between federal and state systems and it is often not accurate.

PREVENTION OF IMPROPER PAYMENTS 

On a legislative level, Congress made efforts to remedy improper payments with the introduction of the Improper Payments Elimination and Recovery Improvement Act of 2012 and the Fraud Reduction and Data Analytics Act of 2015. Nevertheless, without reliable, complete, and accurate data, Medicaid will continue to make payments in error.

Additional initiatives to combat Medicaid's improper payments are developing from the private sector. Syrtis Solutions (Syrtis) has ushered a technology-based solution to assist the program in determining third party liability (TPL) before medical and pharmacy claims are paid improperly. Our company discovered that Medicaid's traditional TPL discovery processes' are primarily retrospective and fail to capture 13.4% of individuals who have unreported primary commercial coverage. Because of this, Medicaid loses billions in improper claims payments; consequently, inefficient post-payment recovery processes are employed to recoup the improper payments. To make matters worse, these post-payment recovery initiatives only recover less than $0.20 on the dollar.

CMS's announcement in November was a notable achievement in light of the high rate of improper payments within government-funded programs. For the first time in history, improper payment reduction rates were reported for Medicare, Medicaid, and the Children's Health Insurance Program. While Congress and federal agencies are working to keep the momentum by implementing legislation and prevention activities, the private sector is also creating innovative solutions to minimize waste and help these programs operate more effectively.

Click here and learn more about Syrtis Solutions.

THE 2018 MIDTERMS FAVOR MEDICAID EXPANSION

Medicaid expansion was a key subject in this year's midterm elections. Three states - Idaho, Nebraska, and Utah - successfully passed ballot initiatives to expand their Medicaid programs, while Kansas and Maine elected pro-expansion governors. Because of this, almost 500,000 additional low-income citizens will be permitted to enroll in the government-run health program. Here is a recap of the latest expansion activity.

MEDICAID EXPANSION BALLOT INITIATIVES

IDAHO

Since voters in Idaho favored Idaho Proposition 2, Governor-elect Brad Little (R) will implement the initiative. The state is now obligated to submit an amendment plan to CMS that will carry out the expansion within 90 days of the approval. Additionally, the Idaho Department of Health and Welfare is authorized to take any actions needed to put the regulations into effect.

NEBRASKA

In spite of Governor Pete Rickett's (R) resistance to Medicaid expansion, Nebraska Initiative 427 successfully passed. The state will be required to submit a state plan amendment or documents for waiver approval on or before April 1, 2019 to CMS. Furthermore, the Department of Human Services is responsible for taking "all actions necessary to maximize federal financial participation in funding medical assistance pursuant to this section."

UTAH

Utah Proposition 3 was voted in favor of and it calls for Utah to expand Medicaid by way of the ACA starting April 1, 2019. The effort also restricts future changes to the program or CHIP that could possibly reduce coverage, benefits, or payment rates below policies from January 1, 2017. In order to fund the program expansion, the proposition will also increase the state's sales tax by 0.15%.

PRO EXPANSION GOVERNORS

While Kansas and Maine did not expand their programs with ballot initiatives, they are going after it with support from newly elected pro-expansion governors.

KANSAS

In 2017, the Kansas legislature passed a bill that would have extended Medicaid. However, the governor at that time, Sam Brownback (R), vetoed it. Presently, with Governor-elect Laura Kelly (D) assuming office, Medicaid expansion could very well materialize. Kelly has been a supporter of expansion and even ran on it.

MAINE

In 2017, Maine also passed a ballot initiative to expand Medicaid but the then governor, Paul LePage (R) refused to carry out the regulations. In fact, LePage even claimed that he would go to jail before putting the ballot initiative into action. Regardless of his resistance, voters elected Janet Mills (D) on Tuesday. The governor-elect ran on Medicaid expansion and is committed to implementing the 2017 initiative immediately after she takes office.

Medicaid expansion has bipartisan appeal. Based upon the Midterm results, voters appreciate better access to care and improved outcomes for low-income Americans.

Health economists have been monitoring the program's development and are optimistic about the impact expansion will have. Benjamin Sommers analyzes Medicaid expansion at Harvard and states, "In terms of what happens to patients, we have 40-plus studies looking at this over the past decade. It makes a major difference in patients' ability to access health care, to pay their bills, and in many studies, we see improved health outcomes too."

According to research, populations in states that expand the program have improved access to a larger range of health services. Individuals also declare that by having coverage, they incur less debt and are more capable of paying their health care bills. Other research found that states who expand Medicaid see a larger decline in infant mortality compared to states that do not participate in the program.

The discoveries from these studies highlight the benefits of Medicaid expansion. After the recent elections, a number of states move closer to expanding coverage and making a difference in nearly half a million lives.

Click here and read more. 

PREVENTION OF IMPROPER PAYMENTS

Of the $4 trillion spent by the government in 2017, nearly $141 billion were improper payments. These are payments made in error either to the wrong beneficiary, in the incorrect amount, or for a service that is not legitimate. Fraud, antiquated data systems, and methodologies all lead to this wasteful spending.

Earlier in the year, the Trump administration released their efforts to address the problem with the CAP Goal Action Plan, Getting Payments Right. The plan takes a cross-agency approach to reduce the cost related to improper payments while at the same time improving the efficiencies of government programs.

PREVENTION

For starters, the CAP emphasizes incorporating preventative measures in order to reduce improper payments before there is ever a need for post-payment recovery. Recovery initiatives are largely ineffective and agencies generally recover much less than what was originally paid.

STRENGTHENING PARTNERSHIP 

The plan also noted the importance of bolstering partnerships between states and federal agencies to decrease improper payments made by federally funded state-administered programs. Currently, states have access to federal databases for data matching and analytics in order to prevent and identify improper payments. However, much of the data is not current, complete, or accurate. The CAP directs agencies to identify state agency partners that will help in screening and determining eligibility before payments are made.

Medicaid is one of the major government programs that deals with improper payments. While fraud does take place within the program, it isn't the primary contributor to improper payments. The problem Medicaid faces is that eligibility data is housed in massive data repositories, and that data is largely stale, old, and unusable. In order to provide the program with improved data, CMS is trying to develop the Transformed Medicaid Statistical Information System (T-MSIS), however it is years away from completion.

COST AVOIDANCE AND IMPROPER PAYMENTS

In addition to the Trump administration and CMS efforts to deal with improper payments, there is also progress being made in the private sector. Syrtis Solutions (Syrtis) recognized the need for a solution to reduce wasteful spending within Medicaid. The company takes advantage of e-prescribing data to provide the payer of last resort market with technology-based solutions to prospectively cost avoid pharmacy claims and increase medical cost recovery. Medicaid plans that employ the tool can optimize the efficiency of their adjudication processes while conserving valuable resources.

Based on the administration's plan, efforts from CMS and the private sector, it is obvious that the most effective way to battle improper payments is with prevention. Properly identifying claims before they are paid and cost avoidance measures will be vital steps to maximizing program efficiency. In addition, improving the quality of data used to identify claims will be paramount.

Improper payments have cost the government and it's taxpayers billions of dollars. While a few of these payments are fraudulent, the vast majority are a result of poor quality data and out-of-date methodologies. Moving forward, it will be important for agencies and states to utilize new technologies in order to improve efficiency.

Keep reading here.

HEALTHCARE MEGA-MERGERS

Over the last year, there has been a wave of PBM and health care provider mega-mergers. The acquisitions have been under rigorous evaluation and the approvals indicate that government regulators are more comfortable with vertical integration rather than horizontal. Here is an overview of these mergers.

CVS HEALTH ACQUIRES AETNA FOR $69 BILLION

CVS Health revealed that it would merge with Aetna on December 17, 2017. The decision would add a PBM to one of the nation's leading health insurance companies.

CVS Health's President and Chief Executive Officer, Larry J. Merlo, said, "This combination brings together the expertise of two great companies to remake the consumer health care experience. With the analytics of Aetna and CVS Health's human touch, we will create a health care platform built around individuals. We look forward to working with the talented people at Aetna to position the combined company as America's front door to quality health care, integrating more closely the work of doctors, pharmacists, other health care professionals and health benefits companies to create a platform that is easier to use and less expensive for consumers."

The decision to merge went under review by the DOJ and has been met with criticism from industry groups. In June, the American Medical Association objected the deal and started pushing for regulatory authorities to block it.

In a hearing held by the California Department of Insurance, the AMA's President, Dr. Barbara McAneny, stated, "After very careful consideration over the past months, the AMA has come to the conclusion that this merger would likely substantially lessen competition in many health care markets, to the detriment of patients. The AMA is now convinced that the proposed CVS-Aetna merger should be blocked."

In August, California's Insurance Commissioner, Dave Jones, asked the DOJ to block the merger over Part D concerns. He contended that lowering competition for drug plans would lead to higher premiums. Currently, CVS Health possesses 24% market share and Aetna has 9% of Part D plans.

On October 10th, the merger was authorized by the DOJ under the condition that Aetna would sell its private Medicare drug plans. Despite criticism from industry specialists, Larry J. Merlo, stated that this, "is an important step toward bringing together the strengths and capabilities of our two companies to improve the consumer health care experience."

CENTENE PURCHASES FIDELIS CARE 

On September 12, 2017, the Centene Corporation announced that it agreed to merge with the healthcare provider, Fidelis Care. According to the terms of the deal, Fidelis Care will become Centene's health plan in New York and Centene will take ownership of Fidelis Care's assets.

In July 2018, the procurement was finalized. The deal was worth $3.75 billion and it increased Centene's position in government-sponsored healthcare significantly. As a result of the merger, Centene's national membership rose to 14 million members and the corporation assumed a leadership position in the four largest managed care membership states: New York, California, Florida and Texas.

"We are pleased to have completed our transaction with Fidelis Care on schedule and to enter the New York market by joining with a company with which we are closely aligned on many levels," said Michael F. Neidorff, Chairman and CEO of Centene. "By bringing together two leaders in high quality, affordable health care with a shared mission of promoting accessible care and services for all, this transaction creates opportunities for us to further transform the health of the communities we serve, one person at a time."

WELLCARE HEALTH PLANS ACQUIRES MERIDIAN

In May, WellCare Health Plans announced that it was looking to merge with Meridian Health Plan of Michigan, Meridian Health Plan of Illinois, and MeridianRx. Over the course of 4-months, the company obtained all the necessary regulatory approvals and on September 1st the acquisition was completed. The merger was worth an estimated $2.5 billion.

Because of the merger, WellCare will have the top Medicaid membership market share in Michigan and Illinois. Furthermore, the company will increase its leading market position from four to six states.

In addition to expanding in the Medicare Advantage market, the health care provider's Medicaid membership is projected to grow nearly 40%. WellCare's CEO, Ken Burdick, believes that the addition of a proprietary PBM platform will help support growth within government-sponsored programs.

CIGNA MERGES WITH EXPRESS SCRIPTS HOLDING COMPANY

In early March, Cigna announced that it would purchase Express Scripts Holding Company for $67 billion. Cigna is the fifth largest health insurer in the country and Express Scripts is the biggest stand-alone PBM.

Shortly thereafter, the DOJ Antitrust Division conducted a thorough six-month investigation. They investigated if the merger would significantly decrease competition among PBM services or increase the cost of these services for rival insurance providers. During that time the DOJ received more than two million documents, examined transaction data, and spoke with over 100 knowledgeable industry participants.

On September 17th, the DOJ cleared the pending merger. According to the DOJ's Assistant Attorney General of the Antitrust Division, Makan Delrahim, "After a thorough review of the proposed transaction, the Antitrust Division has determined that the combination of Cigna, a health insurance company, and ESI, a pharmacy benefit management company, is unlikely to result in harm to competition or consumers."

To learn more, click here.

GAO CRITICIZES MEDI-CAL'S OUT-OF-DATE REPORTING MODEL AND IMPROVED MEDICAID OVERSIGHT

In August, the GAO issued a report to Congress that focused on what CMS would need in order to better target risks and improve Medicaid oversight. The review discovered that one of the critical problems the agency is facing is the failure to incorporate new reporting technology. Currently, California's Medicaid program is still using paper files to report expenses and that translates into thousands of documents.

Carolyn Yocom is the Health Care Director at the GAO that focuses on Medicaid. She stated, "For this type of reporting on expenditures, California really should be able to provide that electronically."

Medi-Cal provides services to 1 in 3 Californians with a combined federal and state budget of $104 billion annually. Presently, the state utilizes 92 separate computer systems to run the program. However, according to DHCS, "Given system limitations and the magnitude of the supporting documentation, providing it electronically is currently not feasible."

Over the course of the program's lifespan, Medi-Cal has been unsuccessful in implementing new technology. For example, in 2010 Xerox acquired a contract worth $1.7 billion to create a new system for the program. However, the deal was terminated after six years of delay and according to the state, Xerox paid more than $123 million as a settlement deal. Conduent was then spun off into a separate company from Xerox to continue running the system and process claims.

The issue is even more problematic when you take into consideration that California's outdated paper reporting system is not only a problem within the state but its also entrenched across the country's healthcare system.

States are mandated to send Medicaid data to the federal government on a quarterly basis. This data consists of expenses and supporting documentation including invoices, cost reports, and eligibility records. Even though California provides its spending reports electronically, its supporting documentation is not.

Recently, California has made some attempts to upgrade its systems that would result in improved Medicaid oversight. DXC Technology was granted a contract in August to take over some of the functions of Conduent. In addition, program officials are also planning for a new system that would cost an estimated $500 million. If approved, the federal government would be accountable for 90% of the design and implementation costs and the state would cover $50 million out of pocket.

As the state begins updating its operations, a remedy to the program's reporting issues remains a focus among government officials. According to Elaine Howle, a state auditor, Medicaid's information technologies system, "needs to be replaced, because it is more than 40 years old, its operations are inefficient, maintaining the system is difficult and there is a high risk of system failure."

Howle wrote a letter to Governor Brown and other officials in June. She stated that California is paying roughly $30 million a year to maintain the 40-year old system.

The GAO also criticized CMS for its lack of Medicaid oversight. The report disagreed with the fact that the agency appoints nearly the same amount of staff to review case files regardless of the size of a state's program. As an example, under the ACA, California had ten times the amount of new enrollees as Arkansas. For that reason, California is at higher risk of enrollment errors and improper payments due to its program's size. Regardless of the substantial difference in enrollment figures, both states were assigned 30 staff members to review claims. In addition, the authors of the report specified that California represents 15% of federal Medicaid spending, while Arkansas only represents 1%.

Carolyn Yocom commented that CMS "needs to step back and assess where are the biggest threats and vulnerabilities." She also stated, "If you aren't looking, you don't know what you aren't catching."

According to the GAO, from FY2014 to FY2018 federal Medicaid spending rose to around 31% and at the same time, CMS financial oversight decreased by about 19%.

In a July letter to the GAO, DHHS agreed with the report's Medicaid oversight recommendations and wrote that it "will complete a comprehensive national review to assess the risk of Medicaid expenditures reported by states and allocate resources based on risk."

Click here to read more. 

GOVERNMENT OFFICIALS AND AGENCIES LOOK INTO MEDICAID'S INTEGRITY

In 2017, improper payments within the Medicaid program reached a total of $37 billion according to CMS. That amounts to 10 percent of the federal dollars spent on the program. Furthermore, 99.2 percent of the payments made are overpayments.To make matters worse, under the current legislation, national health spending is predicted to reach $5.7 trillion by 2026. When considering the rising costs of healthcare and the programs growth from expansion under the Affordable Care Act, government officials are concerned over the programs sustainability.

In an effort to address Medicaid fraud and overpayments, the Senate Homeland Security and Governmental Affairs Committee held a hearing in June. Those present to investigate the problems and solutions were Chairman Senator Ron Johnson (R) WI, Senator Clair McCaskill (D) MO, Comptroller General of the United States Government Accountability Office, Eugene L. Dodaro, and the U.S. Department of Health and Human Services Assistant Inspector General for Audit Services, Brian P. Ritchie. Over the course of the hearing, the ranking members and witnesses discussed the rising costs associated with the Medicaid program and what efforts should be made so that federal funds are spent efficiently and effectively.

GAO Recommendations

Comptroller General Dodaro represented the GAO at the hearing and suggested actions to mitigate improper payments and program integrity risks. He indicated that Medicaid's unique state-by-state structures combined with the size of the program are two elements that make overseeing the program difficult.

The GAO identified improper payments, supplemental payments, and demonstrations as three areas of risk within Medicaid that are estimated to exceed $900 billion by 2025. In order to strengthen oversight and address risk, the GAO recommended the following:

Improve Data
"The Centers for Medicare & Medicaid Services (CMS), which oversees Medicaid, needs to make sustained efforts to ensure Medicaid data are timely, complete, and comparable from all states, and useful for program oversight. Data are also needed for oversight of supplemental payments and ensuring that demonstrations are meeting their stated goals."

Target Fraud
"CMS needs to conduct a fraud risk assessment for Medicaid, and design and implement a risk-based antifraud strategy for the program."

Collaborate
"There is a need for a collaborative approach to Medicaid oversight. State auditors have conducted evaluations that identified significant improper payments and outlined deficiencies in Medicaid processes that require resolution."

Click here to see the GAO's full report.

DHHS Recommendations

Inspector General for Audit Services, Brian P. Ritchie represented DHHS and also weighed-in on the obstacles facing Medicaid. The Inspector General identified high improper payments rates, inadequate program integrity safeguards, and beneficiary health and safety concerns as risks that jeopardize the integrity of the program. Additionally, he testified that in order to preserve the program there needs to be more robust efforts made in regards to prevention, detection, and enforcement.

According to Ritchie, "CMS must do more to ensure that Medicaid payments are made to the right provider, for the right amount, for the right service, on behalf of the right beneficiary."

DHHS emphasized the importance of complete and reliable national Medicaid data for successful oversight and program management. They determined that the deficiency in quality data obstructs enforcement efforts. DHHS advised that CMS do the following:

"Ensure the completeness and reliability of data in the Transformed Medicaid Statistical Information System"

"Ensure that States report encounter data for all managed care entities"

"Reduce improper and wasteful payments and ensuring compliance with fiscal controls"

"Improve the oversight of Eligibility Determinations"

"Ensure that national Medicaid data are complete, accurate, and timely" 

"Facilitate State Medicaid agencies' efforts to screen new and existing providers by ensuring the accessibility and quality of Medicare's enrollment data"

Read through the department's complete list of recommendations here.

CMS's Efforts To Address Medicaid's Improper Payments, Waste, Fraud, and Abuse

Nearly a month after the meeting, the Senate Homeland Security and Governmental Affairs Committee conducted an additional hearing with the Administrator of The Centers for Medicare and Medicaid Services and the US Comptroller General. The hearing concentrated on examining CMS's efforts to protect against fraud and overpayments within Medicaid. The GAO expressed that while CMS has taken measures to address these threats, additional action is needed in order to strengthen the program's integrity.

CMS's Administrator, Seema Verma, testified at the hearing and presented CMS's efforts. She discussed the following:

• New audits of state beneficiary eligibility determinations
• Targeted audits of state managed care claims for federal match funds and rate setting
• Addressing the inherited backlog of disallowances
• Designated State Health Programs (DSHP) funding phase-out
• Intergovernmental transfers
• Budget neutrality policies for 1115 Medicaid demonstration projects

Furthermore, Administrator Verma promoted the optimization of data. She also pointed out it's significance in protecting the integrity of the program

According to CMS, "Improving Medicaid and CHIP data and systems is a high priority. Through strong data and systems, CMS and States can drive toward better health outcomes and improve program integrity, performance, and financial management in Medicaid and CHIP."

CMS is working to strengthen the Medicaid program's integrity by employing advanced analytics and technologies for the collection of health services data. In June, each of the 50 states, including Washington D.C. and Puerto Rico, began sending data from their programs to the Transformed - Medicaid Statistical Information System (T-MSIS). The system is designed to keep track of key information such as: enhanced information about beneficiary eligibility, beneficiary and provider enrollment, service utilization, claims and managed care data, and expenditure data for Medicaid and CHIP. Moving forward, the agency will be in charge of determining the quality and completeness of the data submitted.

Click here to read Administrator Verma's full statement.

The Medicaid program is one of the nation's largest sources of funding for medical and health-related services. As a result of concerns over the program's fiscal oversight and it's substantial amount of improper payments, Medicaid has been on the GAO's "High Risk List" since 2003. As the program continues to expand, government officials and federal agencies are working to address issues rooted in waste, fraud, and abuse.

Learn more here.

AN UPDATE ON MEDICAID EXPANSION - IDAHO, NEBRASKA, UTAH, MAINE & VIRGINIA

Support for Medicaid expansion is on the rise as states move toward general elections this fall. Supporters of expansion have been busy in recent months as they aim to expand their programs through ballot initiatives. In May we reviewed a number of states considering expansion. Here is an up-date on their progress:

NEBRASKA

Nebraska has not been able to expand Medicaid for the previous seven years and the latest legislative effort, Legislative Resolution 281CA, is in gridlock between lawmakers. However, in March, Senator Morfeld backed a petition that would give citizens the opportunity to vote on the issue. Under the Insure the Good Life petition, 84,268 valid signatures were needed by July 6th in order to have the issue on November's ballot. The ballot initiative would extend coverage to 90,000 Nebraskans.

The petition effort exceeded the required amount of signatures with 133,000 submitted for review. While this boosted the outlook of expansion supporters, it has been countered by an attempt to block the petition. Two Republican lawmakers, Senators Lydia Brasch and Mark Christensen, have filed a lawsuit against the effort. The senators are worried about the negative effects it could have on taxes and also it's impact on existing coverage.

The proposal would expand coverage to single adults and couples without minor children that are not eligible for Medicaid presently. In addition, parents and disabled individuals whose income is up to 138% of the poverty level would be covered. Over an 8-year period, it's estimated that the expansion would cost Nebraska $100 million per year.

Meg Mandy, campaign manager for Insure the Good Life, denounced the lawsuit calling it, "a desperate attempt to block the people's ability to voice their opinion on this issue and ensure affordable health care for 90,000 Nebraskans." According to Mandy, these are "two politicians who have failed to find solutions for working Nebraskans to access health care."

IDAHO

Idaho's ballot initiative, Reclaim Idaho, strongly believes that expansion will save taxpayers money and aims to expand coverage to 62,000 citizens. Advocates of the initiative contend that the 62,000 individuals are in a coverage gap between Medicaid and insurance on the state exchange. They are either making too much money to receive Medicaid or not enough in order to secure insurance on the state exchange.

On July 17th, the initiative paid off and Idaho's Secretary of State, Lawerence Denney, verified that the ballot initiative had obtained enough signatures in order to have Medicaid expansion on November's general election ballot.

The initiative looks to extend coverage for those who are not otherwise eligible for any other coverage under the state plan. If passed, Medicaid eligibility will expand to include people under 65 whose modified adjusted gross income is 133% of the federal poverty level or below.

At the start of August, a number of Republicans began to show support for the initiative. Among the advocates was the chairman of the State's Legislature House Health and Welfare Committee, Fred Wood (R). He announced his endorsement for the initiative and told Times-News, "The Legislature's been struggling with this problem for years." The chairman believes that it is the best solution for the uninsured population within the coverage gap.

UTAH

Medicaid expansion is being pursued by two separate fronts in Utah. While advocacy groups are going after expansion through a ballot initiative, Governor Herbert has signed a bill asking for partial expansion from the federal government.

Bill HB472 would expand the state's Medicaid program under the stipulation that it would only expand to 100% of the Federal Poverty Level (FPL), instead of the federal mandate of 138%. By 2020, 72,000 residents would be eligible for coverage and the out of pocket expenses would be far less under the bill.

According to The New York Times, CMS is no longer considering Utah's partial expansion. However, that may change after the midterm elections.

On the ballot initiative front, Utah Decides obtained the required signatures in order to have expansion on the November 6th ballot. If approved by voters, the expansion would increase coverage to 138% of the FPL. That equates to almost $17,000 a person, or $34,000 for a family of four. It's estimated by organizers that an additional 150,000 adults would gain eligibility as a result of the expansion.

VIRGINIA

After almost 6 years of resistance from Republican legislators, Virginia voted in favor of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to more than 400,000 Virginia residents was included in the General Assembly's approved budget. However, it came at a cost. Republicans only accepted the expansion under the condition that it would incorporate a 20-hour-a-week work requirement.

As Virginia prepares for Medicaid expansion there may be additional barriers ahead, postponing and possibly preventing the increased coverage. Critics consider the work requirement to be a violation of the law because it could possibly block a person from access to healthcare. They argue that many of the people that would be eligible for coverage under expansion would have to choose between working more hours and healthcare.

Regardless of the controversy over work requirements, government officials are confident that Medicaid will expand this coming year whether or not the requirements are enacted.

MAINE

Last November, Maine's Medicaid program received support for expansion after 59% of voters supported it through a ballot initiative. Despite its approval, the state's Governor, Paul LePage opposed the initiative and placed expansion in a legislative deadlock.

Governor LePage is concerned over the financial strain that expansion would put on the state. The governor stated, "this fiscally irresponsible Medicaid expansion will be ruinous to Maine's budget."

Shortly thereafter, Maine Equal Justice Partners submitted a lawsuit against DHHS for the failure to act and refuse residents coverage. MEJP asserts that the governor is denying newly eligible applicants coverage that is mandated by law. After evaluation, a Superior Court judge ruled in favor of MEJP; however, the state's administration is appealing the judgment. Presently, a decision on the matter is pending in Maine's Supreme Judicial Court.

At the moment, expansion is still in deadlock but that has not prevented citizens from applying for coverage. Additionally, the LePage administration and Maine's Department of Health and Human Services is promptly rejecting these applications. Despite the rejection of applications by the LePage administration, MEJP is instructing people to continue applying for Medicaid.

Nearly 80,000 low-income citizens would be eligible for Medicaid coverage as a result of the expansion. This number includes parents that were not formerly eligible and childless adults.

When asked about the status of expansion, DHHS has declined to comment due to the pending lawsuit. The state could end up spending nearly $200,000 for a lawyer to defend the LePage administration.

Regardless of the Trump administration's attempts to reform Medicaid on the federal level, a number of states are going after Medicaid expansion by carrying out ballot initiatives. These efforts are enabling voters to step out in front of their legislatures and voice their support for expansion at the polls this fall.

Click here to learn more.

MEDICAID EXPANSION HAS IMPROVED THE ACCESS TO QUALITY CARE

While Medicaid expansion supporters are encouraged by the most recent developments in Maine and Virginia, there are concerns about the access to quality care as the Medicaid population expands. To answer these questions, a number of studies have been conducted to help assist the states considering expansion and those that are making adjustments to their current programs.

Medicaid Expansion And Rural Areas

Since the majority of the rural populations are below the poverty line and uninsured, rural areas across the nation rely on community health centers for primary care. The increased federal funding from the Affordable Care Act and Medicaid expansion were thought to be solutions for improving the access and quality of care for these communities.

In a report from Health Affairs titled, Medicaid Expansion And Community Health Centers: Care Quality And Service Use Increased For Rural Patients, analysts looked into the changes in quality and access between 2011 and 2015. After comparing community health centers from states that expanded with centers in states that did not, the report indicated that patients covered by Medicaid rose to 13% and uninsured patients decreased by 11%.

Researchers also reviewed urban centers from areas that expanded Medicaid with urban centers in areas that did not, but the study did not discover any notable changes to the quality of care.

As opposed to the urban community health centers, rural centers from states that expanded Medicaid saw substantial improvement. Researches strongly believe that these improvements may be a result of more affordable prescriptions under Medicaid or perhaps as a result of the fact that insurance access to care makes visits to health professionals less costly.

Are More Conservative Versions of Medicaid Working?

Health Indiana Plan 2.0 was the outcome of the state expanding Medicaid by way of the 1115 waiver process. In order to qualify, program enrollees are required to contribute to a health savings account. Any time an enrollee fails to make a payment, their benefits are reduced. Furthermore, enrollees that make more than the poverty line are locked out of coverage for 6 months if they miss a payment.

Indiana University explored the effects of the state's decision and compared it to other states that expanded. Using data from the American Community Survey, analysts aimed to see if adults between the ages of 18 and 64 had insurance coverage or Medicaid coverage from 2009 to 2016. According to their analysis, states that expanded their Medicaid programs saw greater gains in comparison to states that did not. Generally, states that had higher insurance coverage rates before expanding saw more gains. Out of 27 states, Indiana ranked in the middle at 13.

Regardless of Indiana's additional conditions for coverage, the state experienced notable Medicaid coverage gains. Whether or not the gains could have been larger without the requirements could not be determined. Also, Indiana's cost-sharing requirements may be the reason for the state's underperformance.

A 30,000 Foot View Of Medicaid After Expansion

From the start of Medicaid expansion, there have been 77 research studies released with 440 unique analyses. More than half of the studies indicate that the effects of Medicaid expansion are in line with the goals of the Affordable Care Act. 35% of the studies showed no significant discoveries and 4% discovered a negative effect after expanding Medicaid.

Up to this point, the studies that have been carried out show that the effects of Medicaid expansion have been positive. The lead author of Indiana University's study, The Effects Of Medicaid Expansion Under The ACA: A Systematic Review, Olena Mazurenko says "With dozens of scientific analyses spanning multiple years, the best evidence we currently have suggests that Medicaid expansion greatly improved access to care, generally improved quality of care, and to a lesser degree, positively affected people's health."

Click here and read more. 

TRUMP ADMINISTRATION INDICATING POTENTIAL LIMITS TO MEDICAID 1115 WAIVER APPROVALS

From the very start of Donald Trump's presidency, he has vowed to grant states the flexibility they need to design their own Medicaid policies. HHS, collaborating with governors and state legislatures, could make dramatic state-by-state modifications to Medicaid using section 1115 waivers allowed under federal law.

Section 1115 waivers give states the possibility to forgo key provisions of federal Medicaid law. The changes made possible by Section 1115 waivers are not as dramatic as those featured in the failed bills. For example, states cannot use 1115 waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to eliminate federal reimbursements for Medicaid expansion; however, they are still significant.

Under the President Trump's administration, CMS has authorized 1115 waivers that the former administration consistently rejected. Many states, for instance, have been allowed to make employment a condition for Medicaid enrollment. (The state of Kentucky; however, is presently in court proceedings over the new policy.).

Trump's administration is likewise allowing Kentucky to require beneficiaries to report income changes while Arkansas is disenrolling beneficiaries for the remainder of the calendar year if they do not comply with the work requirement.

The list below is what CMS has previously declined, as well as what is still under deliberations:

MEDICAID 1115 WAIVERS THAT HAVE BEEN REJECTED BY CMS

Lifetime limits

In May, CMS rejected an 1115 waiver application from Kansas to set up a three-year time limit for people enrolled in the Medicaid program.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said in a statement that she was "... pleasantly surprised by that."

Utah, Wisconsin and Arizona have also sent similar 1115 waiver applications to CMS for lifetime limits, which Alker anticipates will also get rejected.

In a statement by Seema Verma concerning Kentucky's attempt to sanction lifetime limits on Medicaid enrollees, she stated "We seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

Partial expansion

CMS rejected Arkansas' bid to decrease the number of people who qualify for the state's Medicaid program. Arkansas was looking to reduce the eligibility requirement from 138 percent of the federal poverty to 100 percent; however, it was not a firm denial, rather, CMS stated it could not back the waiver application "at this time."

Whenever states vote to expand Medicaid the federal government pays 90 to 100 percent of the program's expenses. If Arkansas were permitted to simply cover people up to 100 percent of poverty, the formerly enrolled members who lose their Medicaid coverage would be eligible for federal health insurance subsidies. This would shift the liability to pay healthcare expenses from the state to the federal government. This scenario is most likely not attractive to the Trump administration.

OTHER 1115 WAIVERS CURRENTLY PENDING

Work requirements for non-expansion states

Besides the denial of permitting lifetime limits on Medicaid enrollees, an additional component of Kansas' 1115 waiver application is still pending; namely, a work requirement. But unlike Arkansas, Indiana and Kentucky, Kansas didn't expand Medicaid by way of the Affordable Care Act (ACA); so demanding individuals to maintain an employment (minimally 80-hours per week) would most likely exclude them for the state's Medicaid program since they would be making too much money.

Oklahoma, Alabama, South Dakota and Mississippi are other states that didn't expand under the ACA exploring work requirements. The Center on Budget and Policy Priorities issued a report that highlights the catch-22 of these proposals.

In the state of Mississippi, for example, a single parent can not earn over $370 per month to receive Medicaid. Nonetheless, if they acquired 20-hour per week employment at minimum wage, they would earn $580 a month, which is too much income to qualify for Medicaid.

"They will be complying with the work requirement but still lose coverage. You're in this situation that can't be fixed," says Jessica Schubel, a senior policy analyst for the Center on Budget and Policy Priorities.

CMS' Verma has stated that she is concerned about this "subsidy cliff" and wants to find a "pragmatic and empathetic" approach to work requirements and other new Medicaid initiatives.

Drug testing for Medicaid enrollment

Finally, last year Wisconsin was the first state to ask for authorization to drug test Medicaid applicants allowing the denial of enrollment if they test positive. Specialists say that there is no way to tell where the federal government will decide the issue. Having said that, CMS has indicated that they would advocate the use of Medicaid funds to cover neonatal abstinence syndrome (a withdrawal ailment that takes place when an infant is born with an opioid addiction from their mother's use during pregnancy). Medicaid experts say it is hypocritical for the federal government to cover babies with drug-related problems but not their parents.

Click here and learn more. 

MEDICAID SCORECARD INTRODUCED BY CMS TO ASSESS PROGRAM'S ADMINISTRATION

The Center for Medicare and Medicaid Services recently released a Medicaid Scorecard to improve transparency and accountability. The scorecard contains care quality data from 2015 statistics provided by participating states, in addition to federally reported information. By combining this data, CMS and the states look to evaluate the performance of Medicaid plans, the program's administration, and outcomes. Any effort to improve efficiencies within the Medicaid program is met with unanimous support across the country; however, industry experts are concerned with the quality of the data used and the underlying purpose of the Medicaid Scorecard.

CMS's preliminary Medicaid scorecard intends to improve state and federal alignment, beneficiary health outcomes, and program administration. It functions to analyze how effectively states are delivering health services to their beneficiaries; at the same time, it takes a look at the timespan it takes for the federal government to authorize waiver requests from the states. The Medicaid Scorecard focuses on three particular areas of measurement:

• State Health System Performance measures "how states serve Medicaid and CHIP beneficiaries across key domains."

• State Administrative Accountability provides "insight into how states and the federal government work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

• Federal Administrative Accountability provides "insight into how the federal government and states work together to administer Medicaid and the Children's Health Insurance Program (CHIP).".

The Chief of CMS, Seema Verma, views the scorecard as a means of improved accessibility to Medicaid data and the program's care outcomes. Verma declared, "This is about bringing a level of transparency and accountability to the Medicaid program that we have never had before." Over time, CMS says it will make updates to the Medicaid Scorecard enabling it to address additional issues.

The National Association of Medicaid Directors (NAMD) has raised concerns. According to NAMD, "There are significant methodological issues with the underlying data, including completeness, timeliness, and quality." They call into question the quality of the data and what conclusions can be made from it. In their point of view, the data itself is out of date, rendering it an unreliable source to identify a state's performance. Additionally, they point out that any determinations made from the scorecard will be problematic since it compares states with significantly different Medicaid structures.

The Association for Community Affiliated Plans (ACAP) is encouraged by the introduction of a Medicaid Scorecard but also recognizes inconsistencies. The groups CEO, Margaret Murray, sees CMS's initiative as a good start. Murray shared, "we agree with Administrator Verma's note that this is a beginning in terms of how we talk about quality, rather than an endpoint. For one thing, the draft scorecard brings into sharp relief the need for more uniform, consistent data reporting across the Medicaid program."

CMS has recently issued their Medicaid Scorecard with hopes to improve state and federal alignment, beneficiary health outcomes, and program administration; however, Industry experts are calling into question its methodology.

Discover more Medicaid news here.

VIRGINIA LEGISLATURE APPROVES MEDICAID EXPANSION, NOW EYES TURN TO UTAH, IDAHO, NEBRASKA AND MONTANA

After months of deliberation among Republican representatives in both the House and Senate, lawmakers in Virginia voted in support of Medicaid expansion under the ACA on May 30th, 2018. The provision to expand the state's Medicaid program to over 400,000 Virginia citizens was included in the General Assembly's approved budget. Democratic Governor, Ralph Northam signed the bill at the state's capital on June 7th. Virginia will fund the expansion with the aid of a 90% funding from the federal government. According to The Commonwealth Institute, "The new Medicaid coverage would require state contributions totaling $1.02 billion over eight years, resulting in a net savings to the state of $1.06 billion."

The ruling to expand was motivated by two contributing factors. First and foremost, last November, the Republicans were at risk of losing their majority rule due to their resistance to Medicaid expansion. Second, Virginia's growing uninsured population is a strain on the state's ability to provide healthcare to its residents. Since the Affordable Care Act was introduced, the uninsured population has expanded as a result of increasing costs for coverage. Proponents feel that Medicaid expansion will strengthen Virginia's health care system and benefit both program members and people with private insurance. However, critics are worried about the related costs and sustainability of expanding the program.

The vote for Medicaid expansion in Virginia is encouraging news for supporters of other states around the country looking to expand their programs. At the moment, there are four states debating the issue.

Utah - In spite of support from lawmakers for a partial expansion, activists in Utah pulled together the required number of signatures to have a full expansion of Medicaid on the state's November ballot. At this time, polls suggest that over half of the state's voters back expansion.

Idaho - According to healthcare advocates, activists in Idaho have accumulated the required signatures for a ballot initiative. The initiative would allow residents to vote in November on a expansion of the states Medicaid program. At the time of this post, the signatures have been submitted to county clerk's for confirmation by June 30th.

Nebraska - Supporters of expansion in Nebraska have been collecting signatures since April for the Insure the Good Life petition. They will need 85,000 signatures from registered voters by July 5th in order to vote on the matter in November's general election. According to groups collecting signatures, momentum is on the side of Medicaid expansion for Nebraska.

Montana - Montana's Medicaid program is wanting to extend their expansion since it is set to expire in 2019. In order to fund the expansion, a ballot initiative requiring 25,000 signatures has been authorized by the Secretary of State. Unlike other efforts, Montana proposes an increase on taxing tobacco by $2.00 a pack alongside a 33% increase of the wholesale price for tobacco products. At this time, proponents are promoting the initiative and securing signatures.

As Virginia neared its first government shutdown, recently legislatures finalized a state budget that incorporated Medicaid expansion. 400,000 residents will now be eligible to enroll in the program. The choice to expand the program, despite resistance from Republican leadership, could be a good indication as to what will occur in other states seeking to expand this year.

Click here to learn more. 

STATES PLAN TO USE MEDICAID 1115 WAIVERS TO WAIVE KEY PROVISIONS OF THE PROGRAM

The repeal of the Affordable Care Act with its existing provisions for Medicaid did not materialize at the national level in 2017; nevertheless, states are looking into reform independently by way of Medicaid 1115 waivers. These waivers concentrate on priorities within the states and allow local governments the flexibility to test coverage models that do not reflect program rules of the federal government.

Medicaid 1115 waivers provide states the opportunity to waive key provisions of federal law. The changes made possible by Section 1115 waivers are not as dramatic as those included in the failed bills-- for instance, states cannot use these waivers to fully restructure Medicaid under block grants or per capita caps, neither can the federal government use them to take away federal reimbursements for Medicaid expansion-- yet they are still significant.

In an attempt to "support states helping Medicaid beneficiaries improve well-being and achieve self-sufficiency", CMS released new guidance for waivers that imposed work requirements on January 11, 2018. Along with work requirements, states are also looking into provisions such as eligibility time limits, drug testing, and premiums. Because of this, these waivers are controversial and have brought up policy issues throughout the country.

At the moment, a number of states have submitted waivers for approval from the federal government. Here is some of the highlighting waiver activity within the states.

NEW HAMPSHIRE'S MEDICAID 1115 WAIVER FOR WORK REQUIREMENTS

New Hampshire was the fourth state to be permitted by the Trump administration for Medicaid work requirements. Under the state's Medicaid 1115 waiver, able-bodied adults will either need to work, develop job skills, or be involved in community service in order to receive premium assistance and program benefits from the state's Medicaid expansion.

Chief of CMS, Seema Verma congratulated the state and pointed out, "the Trump Administration has helped create one of the strongest job markets in our nation's history and we want to make sure able-bodied, working-age adults receive the necessary skills to join our growing workforce."

Governor Chris Sununu (R-- NH) said, "Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs."

Critics of the waiver are concerned that its ramifications will not support the original goals of the Medicaid program. A number of Democratic lawmakers are in opposition to the work requirements, strongly believing that they undermine access to the healthcare program. Supporters of the waiver see it as means of safeguarding the program's sustainability. They assert that Medicaid should be reserved for the country's most vulnerable and low-income individuals and families.

KANSAS IS DENIED 1115 WAIVER FOR LIFETIME LIMITS

Support for Medicaid expansion in Kansas came to a halt in February despite efforts from the Senate Public Health and Welfare Committee and House Democrats. Kansas Governor, Sam Brownback (R) vetoed the bill. Had it been approved, an estimated 150,000 residents would have been eligible.

While expansion failed, Kansas is one of five states, including Utah, Maine, Arizona, and Wisconsin, to ask for lifetime limits from CMS. This would have made it possible for the state to restrict coverage to three years/36 months for some of its recipients. CMS has declined the request making Kansas the first of the five states requesting lifetime limits to be denied.

Verma defended the decision saying, "we seek to create a pathway out of poverty, but we also understand that people's circumstances change, and we must ensure that our programs are sustainable and available to them when they need and qualify for them."

MEDICAID REFORM IN KENTUCKY 

Kentucky was the very first state to get approval from CMS for an 1115 waiver (January 12, 2017). The waiver will implement work requirements, monthly premiums for low-income parents and expansion adults, dis-enrollment and coverage lockouts, the elimination of retroactive eligibility, the addition of deductible and incentive accounts, and waiving non-emergency medical transportation.

Kentucky's governor, Matt Bevin (R), plans to start the overhaul of the state's Medicaid program on July 1, 2018. It will begin in Campbell County and reach across the state over a period of six months. These changes will predominantly affect able-bodied beneficiaries with incomes up to 138% of the federal poverty level that obtained coverage during the program's expansion in 2014. Due to the overhaul, it's approximated that Kentucky and the federal government will save $2.2 billion over five years. Additionally, the Center On Budget and Policy Priorities expects that over the duration there will be a 15 percent drop in adult Medicaid enrollment.

On January 24, sixteen Kentucky Medicaid beneficiaries took legal action and sued the federal government over the waivers provisions. The group sees the Trump administration's approval as a violation of several federal laws and a threat to the lives of tens of thousands of low-income families.

HEALTHY INDIANA 2.0 CLAMPS DOWN ON ENROLLMENT AND ELIGIBILITY

CMS signed off on the amended extension of Healthy Indiana 2.0 on February 1. Initially, the state's waiver expanded the program under the Affordable Care Act (ACA) from February 2015 through January 2018 by changing the states pre-ACA limited coverage expansion waiver, Healthy Indiana Program 1.0. While other state's waivers focus on adults enrolled during expansion, Indiana's also includes changes to the terms of coverage for non-expansion adults. This encompasses low-income parents as well as those eligible for transitional medical assistance.

Healthy Indiana Program 2.0 features provisions such as: raising premiums by 50% for tobacco using members beginning the second year of enrollment, eligibility work requirements for most adults in 2019, dis-enrollment and coverage lockouts, introducing a tiered premium structure, and restricting transitional medical assistance eligibility to between 139% and 185% of the federal poverty level.

While there are a number of exemptions in place to help beneficiaries secure and keep coverage, the launch of these provisions will definitely alter program eligibility. Now that the state has received approval for their provisions, Indiana confronts the task of implementing them.

ARIZONA'S FOUR 1115 WAIVERS UNDER REVIEW 

Arizona is looking to update and reform their Medicaid program, Arizona Health Care Cost Containment System (AHCCCS). Currently, the state has pending Medicaid 1115 waivers with CMS. The amendments include a retroactive eligibility request, an Institution for Mental Disease (IMD) waiver, work requirements, and an uncompensated care payment model.

Originally, Arizona also requested for approval of a 5-year lifetime time limit on Medicaid enrollment. However, this was recently taken out from the state's requests after CMS turned down Kansas's similar request for a 3-year time limit. No other state at this time has lifetime limits. In regards to the decision to delay the lifetime limit request, Deputy Director of AHCCCS, Jami Snyder said, "We have removed the lifetime limit from the waiver request, really for the purpose of expediting approval of the work requirements request." Right now, Arizona is still in discussions with CMS.

Regardless of the federal government's inability to reform Medicaid, states are now taking action to do it themselves through submitting 1115 waiver requests to CMS. Around the nation, local governments are now taking into consideration provisions such as work requirements, drug testing, lifetime limits, and premiums. A few states have received approval while others are encountering strong resistance. While reform through Medicaid 1115 waivers is supported by many state legislators, the way in which they are carried out will be vital to ensuring the future of the Medicaid program.

Read more by clicking here, 

A MEDICAID EXPANSION ROUND-UP

Throughout the 2016 Presidential campaign and not long after entering office, President Trump was set on repealing the ACA's provisions for Medicaid expansion. As a matter of fact, President Trump and the supervisor of The Centers for Medicare and Medicaid Services (CMS), Seema Verma, are presently considering waivers to the Medicaid program that the prior administration rejected. In spite of the Trump administrations unsuccessful efforts to reform Medicaid on the federal level, a number of states are making attempts to expand their programs. Below is a summary of states in varying stages of expansion discussions.

STATES CONSIDERING MEDICAID EXPANSION

Nebraska: Within the past six years, any attempts to expand Nebraska's Medicaid program have failed as a result of Republican leadership. Republican Governors, Pete Ricketts and his predecessor Dave Heineman both argued that the state could not afford to expand Medicaid. Additionally, they think that expanding Medicaid would favor able-bodied citizens instead of low-income residents, for whom the program was designed.

Nonetheless, that may all shift this November at the voting booths. Currently, there are a number of healthcare associations and advocacy groups in the process of collecting signatures from locals to secure a proposal under the Insure the Good Life Petition. Having noticed the success of Maine's ballot initiative, supporters in Nebraska are building up confidence that they will produce a similar result. In order for the proposal to be included on the ballot, a total of 85,000 signatures from registered voters are needed by July 6, 2018. According to Insure the Good Life coordinators, people have been receptive to the idea of expanding Medicaid.

Idaho: Even with resistance from the Republican-leaning legislature, Idaho activists are seeking to expand their Medicaid program to 78,000 residents under the ACA using a ballot initiative. Expanding the program would serve to cover Idahoans who fall into a coverage gap because they make too much money to be eligible for Medicaid but not enough to be given subsidized health insurance in the exchange.

In order to get on the November 6th ballot, advocacy groups had to secure at least 56,192 signatures from 18 districts around the state by May 1, 2018. The advocacy groups filed the signatures before the deadline and claim they have the required threshold needed to land a place on November's ballot. At this point, the signatures will need to be verified by county clerks before June 30th, in order for the expansion proposal to be voted on.

While hopes are high among advocates, implementation of expansion will fall on the governor and state lawmakers; additionally, they have the power to reverse voter-passed initiatives. Republican candidate, Rep. Raul Labrador will resist the expansion initiative if he is elected. According to Labrador," I think that they need to be informed about what Medicaid expansion would do for the state. If you look at every single state that has expanded Medicaid, they're spending more money than they expected to spend ... and that's taking away money from all the other needs."

Utah: Despite having the available federal funding and the states Republican Governor, Gary Herbert's (R - UT) support of Medicaid expansion, there has been enough resistance from the state legislature in Utah to prevent any expansion momentum. Advocates of expanding Medicaid in Utah pushed back by passing a ballot initiative similar to Maine's.

Aside from that, Governor Herbert also signed the HB472 bill. The bill seeks authorization from the federal government to expand his states Medicaid program to 100% of the federal poverty level (FPL) while also implementing work requirements in order to deal with the coverage gap. Expanding that states program to 100% of the FPL would extend coverage to 72,000 residents by 2020 instead of 150,000 under 138% FPL. If the bill successfully passes, Utah's out of pocket costs would be far less than if their program expanded to 138% FPL.

Arkansas submitted a similar plan that would have capped eligibility at poverty level instead of 138% of the FPL. CMS did not approve the request and it is not likely that CMS will endorse the governor's bill since the federal government has only approved these types of requests under the stipulation that states expand to 138% of the FPL.

While the governor's administration would like to receive approval for the bill, Utah voters will also have a chance to weigh in at the ballot boxes in November to fully expand Medicaid to the 138% FPL.

Virginia: In February, The Virginia House of Delegates voted and approved a budget accepting ACA Medicaid expansion in conjunction with work requirements for enrollees. However, Virginia's Senate budget did not incorporate arrangements for expansion. Due to the split support for Medicaid expansion, the Virginia legislature was unable to settle a budget. Consequently, the implementation of Medicaid expansion and Virginia's FY 2019 budget are currently deadlocked. It has been close to two months since Virginia's General Assembly adjourned without consensus.

On May 14th, the Senate met for a special session to discuss a spending plan and the Senate Finance Committee will proceed with work on the budget today. The entire Senate will reconvene on May 22. In order for Virginia to expand its Medicaid program, there will need to be a majority vote in both the House and Senate. If Virginia administrators cannot come to an agreement by June 30th, the state could experience its first government shutdown.

MAINE HAS ADOPTED MEDICAID EXPANSION BUT IS IN LEGISLATIVE DEADLOCK

Maine's Medicaid program, MainCare, was authorized for expansion last November through a ballot initiative. Voters advocated the expansion by 59%. Nevertheless, for 80,000 low-income residents who would have been eligible for coverage, the state missed the state plan amendment submission deadline to CMS (April 3, 2018). Maine's legislature is presently facing a deadlock due to Governor LePage's (R) resistance to expansion.

After the vote, the governor declared, "this fiscally irresponsible Medicaid expansion will be ruinous to Maine's budget."

Under the law, it is estimated that Maine would spend $55,000,000 annually on the program and the federal government would cover at least 90% of the cost of MainCare's new enrollees. LePage says that the cost of the expansion is twice the amount estimated by the state legislature and refuses to implement the plan unless his requirements are met.

LePage's stipulations consist of:

• That taxes will not increase
• Stabilization money funds won't be used
• The funding mechanism will be ongoing
• Waiting lists for the disabled and elderly are fulfilled before Medicaid eligibility expansion.

Due to Governor LePage's resistance, Maine Equal Justice Partners (MEJP) has submitted a lawsuit against DHHS for failure to act. MEJP argues that the administration is denying residents coverage that is required by law. They are afraid that an estimated 70,000 low-income residents seeking coverage will not be able to enroll by the next deadline, July 2, 2018. Maine's State Attorney General, Janet Mills, declined to represent the governor in the case. However, she did permit LePage's request to seek outside counsel for representation in the case.

The landscape of Medicaid is changing as reformists submit waivers and introduce work requirements. Additionally, Republican leadership across the country is resisting Medicaid expansion, strongly believing that it goes against the programs original objective. Despite the GOP's opposition, there is a significant amount of activity amongst expansion supporters to expand their state's Medicaid programs. Through ballot initiatives, voters are stepping out in front of their legislatures to voice their support for expansion at the polls this coming fall.

Read more here. 

THE SOARING COST OF DRUGS FOR THE MEDICAID PROGRAM

Last month, President Trump delayed introducing his plan to deal with the soaring costs of prescription drugs. Inspite of the delay, New York's Medicaid Drug Utilization Review Board (DURB) took it upon themselves to negotiate with drug companies. DURB voted in favor of decreasing the price its Medicaid program is willing to pay Vertex Pharmaceuticals for the company's cystic fibrosis drug.

The federal government's aversion to lower drug prices for the Medicaid program is the main driver of rising costs. Private health insurance companies can make their own formularies and negotiate pricing. Medicaid has much more negotiating power because of its massive membership, but by rule, is limited from doing the same.

The Centers for Medicare & Medicaid Services (CMS) is projecting that prescription drug spending will be the fastest growing category of health spending over the next decade. CMS is well aware of the situation and according to the head of CMS, Seema Verma, "the bottom line is that insurance premiums have skyrocketed and there's a number of people that just can't afford to pay."

Pharmacy Benefits Consultants investigated wholesale drug prices from the beginning of 2017 to 2018 and found that "twenty prescription drugs saw their prices rise by more than 200%." Additionally, The Senate Homeland Security and Governmental Affairs Committee Minority (HSGAC) carried out a review and found that "prices for each of the 20 most-prescribed brand-name drugs for seniors have increased dramatically every year for the past five years." That rate is "approximately ten times higher than the average annual rate of inflation." Moreover, from 2012 to 2017, "twelve out of the 20 most commonly prescribed brand-name drugs for seniors had their prices increased by over 50 percent."

The Trump administration, CMS, and other government authorities are aggressively evaluating the situation and trying to find a remedy. One approach is proposed in Trump's 2019 budget plan. The recommendation is to put into place a pilot program that would permit state Medicaid programs to test drug formularies that would promote more competitive drug pricing.

MASSACHUSETTS MEDICAID: THE MEDICAL HUB AND HEALTHCARE LEADER

Medicaid's lack of ability to negotiate with drug companies is one factor leading to soaring drug prices. In Massachusetts alone, drug prices have doubled in the last 5 years. MassHealth's drug spending is extending the state's spending plan as drug costs have increased to over $2 billion a year. In response to the climbing costs, Massachusetts's Governor, Charlie Baker, has sent a waiver to the Trump administration to develop a selective drug formulary that would allow the state to negotiate pricing and remove ineffective medications. State officials are certain that by minimizing the quantity of drugs in the formulary and by limiting the amount of drug manufacturing companies who provide them, it will establish the negotiating power needed to decrease costs.

While health-care policy specialists and CMS back the plan, the state's proposition to eliminate drugs from the formulary could be problematic. Consumer groups assert that the people benefiting from the program may need a number of drugs for their conditions. Depending on what drugs administrators deem ineffective, patients could potentially lose access to needed care. Critics of the proposal suggest that it does nothing to deal with drug costs and it will in fact hurt people that rely on the program. In fact, there is a high possibility that drug companies will raise drug prices as their competition decreases.

Assuming the governor's plan is approved, MassHealth will need to develop an appeal process for doctors to prescribe drugs not present on the formulary so patients can access the medications they need. If states thinking about this model can show that patient's access to needed drugs is intact and their programs can save money, it may be a remedy to rising drug prices across the nation. At the moment, the president's 2019 budget would allow five states to try what Massachusetts is proposing.

NEW YORK'S SOLUTION TO AFFORDABLE MEDICAID DRUG PRICES

New York representatives also see the significance of having the option to negotiate drug prices. In an effort to deal with increasing drug costs, New York's state Medicaid program's DURB voted to enact a law that uses supplemental rebates to manage drug costs. The law focuses on drugs that are "priced disproportionately to their therapeutic benefits." When the state experiences a drug spending surge of 2.4% to 15.1%, DURB can ask for discounts to a more reasonable price.

The first test will be carried out with Vertex Pharmaceutical's cystic fibrosis drug, Orkambi. In the past, the drug cost $250,000 a year for patients, the proposed cost has been reduced to $83,000. That equates to a 67% discount.

On a global scale, pharmaceutical manufacturers seldom, if ever, consider demands for discounts. These companies believe that competition is the solution to regulating drug pricing. They argue that drugs like Orkambi have no competitors and that $250,000 yearly is reasonable. They also assert that high prices support their capacity to research and create new drugs. This claim does not ring true considering that nine out of the ten largest pharmaceutical manufacturers spend more on marketing than on developing new drugs.

Drug prices continuously rise and it is putting patients access to care in jeopardy. Consequently, government officials are making efforts to lower the costs and achieve fair prices. Ultimately, the existing reality of hyper-inflated drug prices cannot be maintained, not only for public programs like Medicaid and Medicare but for everyone.

Click here to read more.

BILLIONS LOST AS A RESULT OF IMPROPER MEDICAID PAYMENTS

Medicaid is losing billions of dollars from improper payments. According to HHS Agency Financial Reports, improper Medicaid payments reached $30 billion in 2015 and grew to nearly $37 billion in 2017. The vast majority of these improper payments were determined to be improper claims payments due to data errors.

The federal government often points out such substantial figures as evidence of prevalent fraud, waste, and abuse that purportedly is present in federal government health care programs. Yet in point of fact, a 2013 HHS-OIG report presents some much needed perspective, pointing out that 57 percent of the "improper" Medicaid payments originate from more commonplace, routine issues, involving the "eligibility errors" that occur when a patient moves from one state to another and doesn't provide Medicaid with a change of address. Fraud in the Medicaid program may well still be a dramatic problem, but when "improper payments" are the outcome of such "eligibility errors" instead of fraud, the true scope of the challenge can better be recognized.

With the increased awareness that government officials have paid to the need for accurate Medicaid claims information within federal government healthcare systems, one may have expected that now, nearly five years since an inspector general testified that much of the data used to identify improper payments and fraud is not "current, available, complete, [or] accurate", the issues would certainly be tended to and the federal government's records rendered more reliable.

In a statement to the House Oversight and Government Reform Committee, Carolyn Yocom, GAO Health Care Director mentioned, "despite efforts to reduce improper payments in the Medicaid program by the Centers for Medicare & Medicaid Services, which oversees the program, overall improper payments continue to increase."

The climb in improper payments can be contributed to the large size of the program and unsatisfactory oversight. Director Yocom testified that Medicaid has been on the list of high-risk programs dating back to 2003 and that its oversight is insufficient. She stated, "the size and complexity of Medicaid make the program particularly vulnerable to improper payments-- including payments made for people not eligible for Medicaid or made for services not actually provided."

The GAO characterizes an improper payment as "any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. Reducing improper payments-- such as payments to ineligible recipients or duplicate payments-- is critical to safeguarding federal funds, but the federal government has consistently been unable to determine the full extent of improper payments and whether its actions to reduce them are appropriate."

Improper payments also consist of:

• Any payment made in error when the payment was the liability of a third party
• Any payment to an ineligible recipient
• Any payment for an ineligible service
• Any duplicative payment
• Payment for services not received (except where authorized by law).
• Any payment that does not account for credit for applicable discounts.

In a two-year time span, improper Medicaid payments have risen by $8 billion dollars. This is an obvious sign the program does not have effective oversight. To preserve the vital federal-state health insurance program and safeguard taxpayer dollars, the complications that develop from poor eligibility data within the Medicaid program must be resolved.

Read more here.

AN UPDATE ON THE VIRGINIA MEDICAID EXPANSION DISCUSSION

Legislators in Virginia were unable to approve the Commonwealth's biennial spending plan earlier this year; which included arrangements for Medicaid Expansion. Because of a divide in Republican support within the House and Senate, the lawmakers agreed to reconvene for a special session, which took place Wednesday. Leading up to the session, in an effort to encourage Republican Senate support for Medicaid expansion, House Speaker M. Kirkland Cox (R) proposed strictly enforcing work requirements. He recognizes the concerns of conservatives but also understands the need for healthcare for the 400,000 uninsured Virginians. Regarding the work requirements, Kirkland said, "We're going to look at that and try to, you know, strengthen that somewhat. I think among conservatives that's something that's very important."

Despite the split support in the last regular session, some lawmakers that had opposed expansion are now reevaluating supporting it. One of those who had previously been against expansion is Senate Majority Leader Thomas K. Norment Jr. (R). His desire to support expansion is contingent on a more conservative approach and it would need to be developed collaboratively. In an interview with WCVE radio, Norment stated, "if, in fact, there is going to be a fiscally responsible and conservative Medicaid expansion plan, it has got to be developed on a more collaborative basis. One person can't develop that plan, come in and drop it down in front of 21 Republican senators and say, 'Here it is.' That is not going to work."

In order to approve a budget and expand Medicaid, lawmakers will need to have their plan prepared by July 1 or the state will experience its very first government shutdown.

Senate Minority Leader Richard L. Saslaw (D) says, "This is something that should have been done three or four years ago, but better late than never. Between 350,000 and 400,000 Virginians will get the health care that's needed."

This week's two-hour special session concentrated primarily on procedural moves. The next step will be to address Governor Ralph Northam's (D) newly proposed budget bill that he revealed in between the sessions. It will make its way through the House and Senate finance committees and then onto the chambers for voting. Finally, a conference will be held to sort any standing details between the House and Senate. It will require two Republicans to successfully pass Medicaid expansion within the Senate; however, just one vote from Republicans is necessary to pass it in the form of a budget amendment.

According to Governor Northam's estimations, savings as a result of Medicaid expansion will be around $421 million. The House would like to see funds invested into education, raises for educators, and other areas so they predict the savings from expansion to be closer to $307 million as a result of varying start dates.

Traditionally, Virginia's Republican representatives have not supported Medicaid expansion, but in recent months it's starting to look like that will change. Even Though the Republican Senate did not hold elections last year, the chamber just about lost its majority to Democrats in November. As a result of the coming elections and the need for support from voters to maintain control of the House, Republicans are now making efforts to convert Republican opposition to back Medicaid expansion.

To keep reading, click here.