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.

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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.

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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.

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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.

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MEDICAID EXPANSION IS VITAL TO VIRGINIA'S RURAL HOSPITALS

The future of rural hospitals in Virginia hangs in the balance in the upcoming debate over Medicaid expansion. As a result of the large population of uninsured and low-income residents in Virginia's countryside, rural hospitals rely heavily on the Medicaid program for financial assistance. If Virginia representatives are unable to expand Medicaid it will most certainly put Virginia's rural, low-income population in jeopardy.

According to the North Carolina Rural Health Research Program (NCRHRP), over 80 of the nations rural hospitals have shut down between January 2010 and July 2017. Beth O'Connor from the Virginia Rural Health Association points out, "Two-thirds of those are in states that have not expanded Medicaid. So while Medicaid expansion may not be the magic wand, it's certainly a big piece of the puzzle for those small rural facilities." Despite the fact that rural communities usually oppose Medicaid expansion, O'Connor believes that supporting it would serve to ensure the survival of these important medical providers.

Given the circumstances, Quentin Kidd, Dean of the College of Social Sciences at Christopher Newport University, believes that the opposition to expansion is about to shift. To him, the fact that Terry Kilgore, House Republican representing the southwest corner of VA, advocates expansion is a sign that the Republican Senate will probably do the same. Kidd states, "it wouldn't surprise me if a good number of them were rural senators because they all know that at the end of the day the dollars and cents are going to be meaningful to their rural hospitals and they need those rural hospitals to stay open."

Rural hospitals anxiously await April 11, when Virginia lawmakers will reconvene in a special session to attend to the state's budget plan and make a decision on Medicaid expansion. Currently, there have been no further changes of position from Senate Republicans on Medicaid expansion.

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THE WINDOW OF OPPORTUNITY IS CLOSING FOR VA MEDICAID EXPANSION

In February, Virginia's work on the Commonwealth's biennial spending plan budget came to a halt because of the inclusion of provisions for Medicaid expansion. In short, the Republican House backs expanding Medicaid while the Republican Senate does not. Due to the divided GOP support, the regular session was adjourned and no budget was successfully passed. Virginia Governor Northam (D) compelled legislators to deliver as soon as possible. He warned that if a proposal was not drafted and on his desk in the near future, he would submit a budget that expanded Medicaid without some of the compromises made with Republicans; such as, imposing co-pays and work requirements.

Northam stated, "We've obviously compromised. If I send an amendment down, and I will if I need to, some of those compromises won't be in there and it will be closer to the original proposal in the budget Governor McAuliffe and I introduced."

McAullife's budget was rejected last December. The failed budget proposal had provisions for Medicaid expansion without conditions like work requirements or co-pays.

In an attempt to assist low-income citizens, Governor Ralph Northam followed through on his warning and revealed his proposed budget last week. He will deliver it to the Virginia General Assembly on April 11. According to the Virginian governor, the plan mirrors McAullife's plan but it will also incorporate an amendment created to invest in a revenue reserve fund.

Northam states, "Virginians have waited long enough for a balanced budget that expands health care access and invests in economic opportunity through education, workforce training, mental health and addiction services, and better pay for public servants. The General Assembly will return on April 11th to pass the budget Virginians deserve, but we shouldn't wait until then to get to work. My team and I are ready to work with the General Assembly money committees to get Virginia families, local governments, institutions of higher education and many others the certainty and resources they deserve by passing a budget that expands health coverage."

Under Gov. Northam's budget, Medicaid expansion would be available to almost 400,000 citizens. As a result of savings from the expansion, investments could then be made into workforce development, opioid addiction prevention, education, mental health services, and increases in pay for state workers. Additionally, the amendment would direct revenues that exceeded those predicted in the budget to a revenue reserve fund. This investment would serve to provide the state additional financial security in economic downturns.

According to Northam, "The budget I am introducing makes a strong investment in our Commonwealth's cash reserves. However, in a period of unprecedented volatility in Washington and economic uncertainty across the globe, we should do everything we can to shield Virginia taxpayers against an unexpected revenue shortfall. By including this amendment we can maintain a fiscally conservative budget and send a message to Virginians and to the rating agencies that this budget will invest wisely while also preparing for unexpected downturns."

After the budget was introduced, House Republicans went on the record claiming that the governor's proposal is "the start of a process that we are confident will lead to the adoption of a new budget long before July 1."

After the announcement, Senate Majority Leader Thomas K. Norment (R) criticized the proposal when Northam characterized it as a guide for discussion. Norment said, "That he (Gov. Northam) continues to make Obamacare's Medicaid expansion integral to that budget, and his refusal to base his plan on a more current revenue forecast means the current standoff can not be resolved quickly."

Medicaid's landscape continues to be a focus between Virginia's lawmakers in 2018. Due to the dispute among Republicans and Northam's recent proposal, it is unclear if Medicaid expansion will occur or if there will be work requirements and other conditions for eligibility. Legislators will reconvene in a special session on April 11 but if they do not successfully pass a budget, Virginia would have its very first government shut down.

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A MEDICAID MODEL THAT INCLUDES WORK REQUIREMENTS, PREMIUMS, TIME LIMITS & DRUG TESTING

In 2017 the GOP and Trump Administration made a number of attempts to reform Medicaid by trying to repeal the Affordable Care Act (ACA) and enforce federal spending caps for the Medicaid program. Although these initiatives were not successful, the future of the Medicaid program is still vulnerable to administrative actions from CMS. It is evident that this administration has a very different vision for the future of Medicaid than its predecessor.

A report performed by the Henry J Kaiser Family Foundation highlights Medicaid's changing landscape. For example, states that grew their Medicaid programs under the ACA such as Kentucky, Indiana, Arkansas, Arizona, and New Hampshire are additionally pursuing work requirements and other conditions for beneficiaries. In addition, some states that did not adopt expansion under the Obama administration, like Virginia, are now taking it into consideration under the condition that work requirements are put into effect.

HOW THIS NEW MEDICAID MODEL IMPACTS THE STATES

The new vision for the Medicaid program is a stark contrast to that of the ACA's. The Kaiser Family Foundation predicts that the work requirements and additional restrictions will affect about 24.5 million people including non-elderly and non-disabled adults. As a result, childless adults are at the greatest risk of losing coverage. In spite of the large population that will be affected by new conditional requirements, it is important to keep in mind that the work requirements and restrictions will not affect the majority of those participating in the program. For instance, children, elderly, disabled, and pregnant enrollees make up more than half of Medicaid enrollees and are either exempt from such laws or covered by federal law.

The work requirements and other conditions are a sign that states entertaining these waivers are making use of them as a method to reduce costs by reversing Medicaid expansion or introducing downsized programs. Medicaid professionals see this as a significant threat and inconsistent with how waivers have been used traditionally. The executive director of Georgetown University's Center for Children and Families, Joan Alker, sees them as a way to simply cut coverage. According to Alker, "Under any previous administration, waivers have not been used to devise ways to cut coverage."

The state of Kentucky, led by Governor, Steve Beshear (D), was amongst the states that had expanded its Medicaid program under the ACA, increasing coverage to an additional 350,000 enrollees. According to Gallup, the state saw a significant drop in its uninsured rates between 2013 and 2016 from 20.4% to 7.8%. Regardless of the increase in eligibility the newly elected Kentucky Governor, Matt Bevin (R), did not agree with the expansion. He believes that the program is for the most vulnerable people and the work requirement works to protect the program and its services. In August 2016, Governor Bevin put forth a new plan that included work requirements to HHS.

According to Kentucky.gov, "the submission of this waiver is the result of many months of extensive research, planning and time spent traveling the state listening to Kentuckians," said Gov. Bevin. "Kentucky HEALTH will allow us to continue to provide expanded Medicaid coverage, but unlike the current Medicaid expansion under Obamacare, it will do so in a fiscally responsible manner that ensures better health outcomes for recipients." Shortly after the New Year, CMS approved Kentucky's Section 1115 demonstration waiver, Kentucky Helping to Engage and Achieve Long-Term Health aka "KY HEALTH." Health Law Policy Matters has documented what this will mean for the state and notes that the full implementation is expected to begin in July of 2018.

After a 5-year period, The Commonwealth Fund predicts that enrollment rates would drop nearly 15 percent. This figure consists of enrollees made eligible from the expansion and traditional enrollment. According to Governor Bevin, those 100,000 people would need to receive insurance coverage from an employer or through a private provider. This may be challenging since KFF has reported that 60% of adults on Medicaid are currently working.

Health professionals, including Cindy Mann of Manatt Health, are worried about the direction Medicaid is headed. They believe that the repercussions of work requirements are not being taken into account. Mann stated, "the people who policymakers and the public would want to protect, with medical conditions, barriers to employment, they're going to be exempt. But the system isn't geared to get these people out of harm's way. It's the people who are least able to gather the paperwork required that will get caught in the cracks and will lose their coverage."

The debate over Medicaid comes down to two competing philosophies. Republicans claim that the program has expanded beyond its initial objective, thereby endangering its capacity to provide coverage and services to the most vulnerable. They argue that work requirements and conditional restrictions are aimed at those individuals for whom the program was never intended; furthermore, the conditions for enrollment are designed to help people become independent from Medicaid. Democrats view the approval of 1115 waivers as a way to simply cut coverage since attempts to reform the program in 2017 were a failure. Democrats argue that Medicaid is intended to provide insurance and not to encourage employment. Cutting costs and reducing coverage only prevents the program from performing its primary mission. As legislators debate, some states have already received approval for their work requirement waivers. It seems, that this is only the start and its very likely that more states will follow suit.

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