Medicaid has been designated as a high-risk government program by the GAO since 2003. The Medicaid program has struggled over the last seventeen years because of insufficient fiscal oversight and other administrative difficulties. These challenges will be exasperated as the program expands and enrollment climbs in the course of the COVID-19 pandemic. If Medicaid is expected to deliver on its goal to serve the health and wellness needs of our nation's most vulnerable low-income individuals and families, it is essential that these administrative problems be addressed.
In a recent report from the GAO, the agency analyzed federal Medicaid policies, state perspectives on challenges they encounter due to present policies, and what federal actions may be taken to resolve these problems. After speaking with Medicaid officials from 50 states and Washington D.C., the GAO was able to determine federal policies, laws, and regulations that caused difficulty to effectively administer the Medicaid program.
Four problematic areas cited by officials include coverage exclusions and care coordination, covered benefits and eligibility, Medicare and Medicaid alignment, and payment methods. In addition, administrative officials brought up reporting requirements and the inadequate guidance. There is also much consternation due to the lengthy delays when states are seeking approval to waive various statutory Medicaid requirements. CMS is already in the process of resolving these problematic areas and has released revised guidance, streamlined the waiver procedure, and is working with stakeholders to develop an updated reporting system.
Additionally, the GAO also found five relevant considerations that broadly apply to the reported areas of concern. They include targeting federal oversight to important areas, making use of program data, balancing oversight and flexibility for waivers and demonstrations, clarifying CMS policy, and responding to change.
IMPORTANT GAO CONSIDERATIONS
Targeting Federal Oversight To Crucial Areas
The GAO determined that program oversight tasks must support beneficiary accessibility to benefits and the proper use of federal expenditures to protect against improper payments. This consideration was based on the GAO's March report that estimated improper payments in the Medicaid program increased $21 billion in FY 2019. HHS stated that the surge was a result of inadequate documentation for eligibility determinations. Additionally, many improper payments resulted from noncompliance in screening and enrollment requirements.
Leveraging Program Data
Poor quality data has been another issue for Medicaid plans in recent times. Incomplete and outdated data make program oversight extremely problematic. The report stated that "accurate and complete data on key measures-- such as measures for beneficiary access and use of services and the costs of providing such services-- are critical for oversight, including ensuring proper payments, and for informing any evaluation of policies." Dependable quality data could help display the cost-effectiveness of expanding Medicaid coverage to other services. States and stakeholders agree that quality data will considerably aid in managing the Medicaid program.
Medicaid has been on the GAO's High-Risk List since 2003 due to poor oversight and other administrative issues. Over the last seventeen years, Medicaid officials have struggled to administer Medicaid due to laws, policies, and regulations. If the program is to become fiscally solvent while properly coordinating care, improving fiscal oversight and accessing quality data is essential.
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