Will Evaluations of Medicaid 1115 Demonstrations That Restrict Eligibility Tell Policymakers What They Need to Know?

Issue: With thousands in Arkansas losing their Medicaid benefits under the state's work-requirement demonstration, the importance of evaluating such experiments could not be clearer. In Stewart v. Azar, the court concluded that the purpose of Section 1115 demonstrations such as Arkansas's is to promote Medicaid's objective of insuring the poor; evaluations of these demonstrations, as required by law, inform policymakers whether this objective is being achieved. Goal: To examine the quality of evaluation designs for demonstrations that test Medicaid eligibility and coverage restrictions. Methods: Comparison of state evaluation designs against issues identified in Medicaid impact research. Key Findings and Conclusions: Evaluation designs for 1115 demonstrations that restrict Medicaid eligibility and coverage either are lacking or contain flaws that limit their policy utility. No federally approved evaluation designs for Medicaid work and community-engagement demonstrations are yet available, and the Centers for Medicare and Medicaid Services has not issued evaluation guidance to states. Evaluations thus lag well behind demonstration implementation, meaning important impact information is being lost. Eligibility restrictions attached to some approved Medicaid expansion demonstrations remain unevaluated. Moreover, evaluations are not sustained long enough to measure critical effects; systematic evaluation of communitywide impact is lacking; and comparisons to states with no Medicaid restrictions are missing. Without robust evaluation, the core purpose of Section 1115 is lost.

Medicaid's future: What Might ACA Repeal Mean?

Issue: Republicans in Congress are expected to repeal portions of the Affordable Care Act (ACA) using a fast-track process known as budget reconciliation. Goals: This issue brief examines how repeal legislation could affect Medicaid, the nation's health care safety net, which insured 70 million people in 2016. Findings and Conclusions: Partial-repeal legislation that passed Congress but was vetoed by President Obama in 2016 offers some insight but new legislation could go further. It could repeal the ACA's Medicaid eligibility expansions for adults and children but also roll back other provisions, such as simplified enrollment and improvements in long-term services and supports for beneficiaries with disabilities. Additionally, the Trump Administration could expand use of demonstration authority to introduce deeper structural changes into Medicaid, such as eligibility restrictions tied to work, required premium contributions and lock-out for nonpayment, annual enrollment periods, and coverage limits and exclusions. Together, these changes would have far-reaching implications for Medicaid's continued role as the nation's safety-net insurer.

Extending the Children's Health Insurance Program: High Stakes for Families and States.

Issue: Congress must decide whether to extend federal funding authority for the Children's Health Insurance Program (CHIP), which ends September 30, 2017. CHIP operates much like Medicaid, providing federal matching payments for state program expenses, although CHIP's funding rate is higher than the federal rate paid for traditional Medicaid and was further enhanced under the Affordable Care Act. States can use their CHIP funds to expand Medicaid, operate separate CHIP programs, or combine the two approaches. Today CHIP covers 8.4 million children and provides maternity coverage for approximately 370,000 women. Goal: To examine the potential effects of ending federal CHIP funding. Methods: Analysis of legislative and regulatory policy as well as evidence from the literature. Findings and Conclusions: Without congressional action, CHIP funds will be virtually gone by summer 2018. The 4.7 million children who receive CHIP coverage through Medicaid will remain entitled to coverage through 2019, but only at normal Medicaid federal matching rates. Among the 3.7 million children enrolled in separate programs, an estimated 1.1 million could lose coverage entirely, while the rest could face reduced coverage and significantly higher out-of-pocket costs. Congress is facing key decisions, including whether to extend funding, if the ACA rate enhancement should continue, and potential changes to eligibility levels.

Medicaid Payment and Delivery System Reform: Early Insights from 10 Medicaid Expansion States.

Issue: Expanded Medicaid enrollment under the Affordable Care Act has heightened the importance of states' roles as principal purchasers of health care for low-income and medically vulnerable populations. Concurrently, the federal government has augmented states' purchasing tools. Goal: To examine the evolution of payment and delivery system reform in 10 ACA Medicaid expansion states. Methods: Analysis of state managed care policies, including a detailed review of purchasing documents as well as interviews with senior agency officials in 10 states. Findings and Conclusions: States have made health system reform a core element of their Medicaid expansions, with the aim of improving access, quality, efficiency, and population health. States have sought to incorporate evidence-based practice and payment strategies, with an emphasis on populations likely to benefit from improved care management and on better integration of treatment for physical and behavioral health problems. Seven of 10 are directly engaged in provider payment and delivery system reform. Agencies noted the importance of experienced provider networks in addressing complex health and social needs, along with managed care's role in quality improvement and payment reform. States embrace their roles as payers and health care innovators, identifying stability of both coverage and the underlying federal policy environment as key factors.

How Will Repealing the ACA Affect Medicaid? Impact on Health Care Coverage, Delivery, and Payment.

ISSUE: The Affordable Care Act enhanced Medicaid's role as a health care purchaser by expanding eligibility and broadening the range of tools and strategies available to states. All states have embraced delivery and payment reform as basic elements of their programs. GOAL: To examine the effects of reducing the size and scope of Medicaid under legislation to repeal the ACA. FINDINGS AND CONCLUSIONS: Were the ACA's Medicaid expansion to be eliminated and were federal Medicaid funding to experience major reductions through block grants or per capita caps, the effects on system transformation would be significant. Over 70 percent of Medicaid spending is driven by enrollment in a program that covers 74 million people; on a per capita basis Medicaid costs less than Medicare or commercial insurance. States would need to absorb major financial losses by reducing the number of people served, reducing the scope of services covered, introducing higher cost-sharing, or further reducing already low payments. Far from improving quality and efficiency, these changes would cause the number of uninsured to rise while depriving health care providers and health plans of the resources needed to care for patients and invest in the tools that are essential to system transformation

What Would Block Grants or Limits on Per Capita Spending Mean for Medicaid?

Issue: President-elect Trump and some in Congress have called for establishing absolute limits on the federal government's spending on Medicaid, not only for the population covered through the Affordable Care Act's eligibility expansion but for the program overall. Such a change would effectively reverse a 50-year trend of expanding Medicaid in order to protect the most vulnerable Americans. Goal: To explore the two most common proposals for reengineering federal funding of Medicaid: block grants that set limits on total annual spending regardless of enrollment, and caps that limit average spending per enrollee. Methods: Review of existing policy proposals and other documents. Key findings and conclusions: Current proposals for dramatically reducing federal spending on Medicaid would achieve this goal by creating fixed-funding formulas divorced from the actual costs of providing care. As such, they would create funding gaps for states to either absorb or, more likely, offset through new limits placed on their programs. As a result, block-granting Medicaid or instituting "per capita caps" would most likely reduce the number of Americans eligible for Medicaid and narrow coverage for remaining enrollees. The latter approach would, however, allow for population growth, though its desirability to the new president and Congress is unclear. The full extent of funding and benefit reductions is as yet unknown.

How Will Section 1115 Medicaid Expansion Demonstrations Inform Federal Policy?

Section 1115 of the Social Security Act allows the U.S. Department of Health and Human Services and states to test innovations in Medicaid and other public welfare programs without formal legislative action. Six states currently operate their Medicaid expansions as demonstrations and several more are expected to seek permission to do so. While the current Medicaid expansion demonstrations vary, they share a major focus: increasing beneficiaries' financial responsibility for the cost of coverage and care. Demonstrations include requirements that Medicaid beneficiaries pay enrollment fees and cost-sharing that exceed traditional Medicaid limits. Others propose tying beneficiaries' financial responsibility to behavioral changes in health and wellness, while still others impose penalties for nonpayment of enrollment fees. Evaluations must consider the impact of these requirements on access, use of care, and health status, as well as the feasibility of demonstration reforms and their impact on administrative efficiency, providers, and health plans.