Medicaid Healthy Adult Opportunity – or Block Grants by Another Name

  

On Thursday, January 30, Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, introduced the Healthy Adult Opportunity (HAO) proposal, which would allow states the flexibility to essentially create block grant programs for certain adult Medicaid beneficiaries, primarily the Medicaid expansion population, through the Medicaid 1115 demonstration waiver process.

Initial HAO demonstration models would initially last for five years and would be financed annually either through a per capita model or a total expenses model. Per capita and total expenses models’ funding levels would be calculated together by CMS and a respective state by using a trendline based on historical expenditures and within the bounds of the projected rate of medical spending inflation. The administration has touted the HAO proposal as a way to provide states with greater flexibility to operate their Medicaid programs while reining in state and federal Medicaid spending. However, health policy experts have expressed concerns over how this proposal might impact beneficiary eligibility and coverage levels.

HAO demonstration models could include adults eligible for Medicaid through Medicaid expansion (individuals with income up to 138% of the Federal Poverty Level) and other adults under age 65 who are eligible for Medicaid on the basis of something other than a disability – including low-income parents and pregnant women covered under state options and other populations covered under other 1115 demonstration models. States that implement a HAO model would be required to apply certain beneficiary protections for individuals with HIV and those with behavioral health conditions (including opioid use disorders), particularly when it comes to the availability of drugs used to treat or prevent these conditions.

States implementing a HAO model could also include conditions on eligibility. Such conditions include work requirements (or community engagement requirements) and premium and co-payment requirements (not to exceed 5 percent of annual household income). States could also eliminate retroactive coverage or hospital presumptive eligibility provisions for beneficiaries covered under the HAO model. While states could technically set an income limit and asset tests under a HAO model for beneficiaries currently covered under Medicaid expansion, these would forfeit the ability to receive the enhanced federal matching for this population (permanently set at 90%).

The CMS proposal also requires states to report a suite of 25 quality metrics (taken from the CMS Adult Core Set) to CMS, including flu vaccinations, screening for depression and follow-up care, controlling for high blood pressure, and comprehensive diabetes care. States would also be required to report quarterly to CMS on a set of metrics related to enrollment, retention, and access to care, including the number of providers actively enrolled and seeing patients, retention of beneficiaries at renewal, and complaints regarding difficulty in accessing timely services. Requiring states to report these metrics would allow CMS to address concerns over access to care in a timely manner.

It is currently unclear what impacts the HAO proposal will have on Medicaid coverage. Past experiences in other block grant programs and implemented work requirements, however, do not indicate positive results. Since the Temporary Assistance for Needy Families (TANF) program was converted to a block grant in the 1990s, Congress has held funding flat, despite inflation and growing need, which has resulted in reduced benefits and fewer beneficiaries without necessarily transitioning beneficiaries out of poverty. Furthermore, Arkansas’ implementation of controversial Medicaid work requirements resulted in 18,000 beneficiaries losing Medicaid coverage in the last six months of 2018. On the other hand, the HAO proposal could entice some states that have not already done so to provide coverage to the Medicaid expansion population, while it is unlikely that many (if any) of the states that have already implemented Medicaid expansion would opt-in to a HAO model.

Financial sustainability is critical in a program as large as Medicaid; however, it is equally critical that that sustainability does not come at the expense of beneficiary access to care. ANA’s principles for health system transformation state that the U.S. health system must ensure universal access to a standard package of essential health care services for all citizens and residents, and registered nurses stand at the front line of that care.

While ANA supports the protections included in this proposal for individuals with HIV and behavioral health conditions, it is essential that CMS and the states ensure that no citizen or resident loses access to comprehensive healthcare services. In states where Medicaid leaders pursue HAO waivers, nurse advocates have an opportunity to engage in stakeholder and official comment processes. Policymakers should consider nurses’ perspectives on specific proposals and program designs for a given state. Key areas to address include access choice of provider, healthcare workforce issues, and accountability for healthcare quality.

What are the Biggest Issues to Watch for in State Legislatures in 2020?

  

Many state legislative sessions have or will be launching soon. Although there is no shortage of issues, with 80 percent or 6,000 state legislative seats up for election across 46 states in November, there’s a desire to wrap up sessions and get out to campaign.  As such, agendas may be limited.

Commencement of the 2020 census in April with subsequent congressional/state legislative redistricting to follow in 2021 is prompting one defining theme in state capitals this year – election security and reform.  

In general, state economies are doing well with record low unemployment. However, annual budgets are always important; all but one State’s Constitution (Vermont) necessitates that the budget be balanced. Education and healthcare are almost always a state’s largest budget expenditures, so attention to issues within these two buckets are generally prevalent.  

Keeping the economy strong includes reducing barriers to employment and this has been particularly evident for those occupations requiring licensure. Occupational licensure reform efforts are still ubiquitous, including re-evaluation of select occupations and the continued need for licensure, expedited licensure particularly for military spouses, and a significant growth in health profession interstate compacts.

More than 40 states introduced scope of practice legislation during the 2019 legislative sessions. Fifty-four bills from 30 states were enacted into law related to behavioral health providers, physician assistants, nurse practitioners and oral health providers. More needs to be done to increase access to care by reducing barriers for qualified practitioners. ANA and state nurses’ associations continue to seek full practice authority for all four roles of Advanced Practice Registered Nurses (Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse Midwifes).

Closure of rural hospitals has led to an increased demand for telehealth services. Legislation and regulation are defining what constitutes as telehealth, which varies, as well as who can use technology, under what circumstances, and how payment issues are resolved. More than 30% of rural Americans do not have access to broadband at home, further complicating use of technology for access to services.

As we await the US Supreme Court’s ruling on the Affordable Care Act (ACA), states are still expanding Medicaid, some with the addition of work requirements, and there is an increased interest in block grants.  While Republicans dominate in both state legislative bodies as well as the Executive Branch, it is likely additional states will attempt to advance legislation to ban abortions. Other health related policy carry overs from 2019 include legalizing medicinal and / or recreational cannabis, with much of this having been done through ballot initiative due to reticent policy makers. Almost 900 bills were introduced in 2019 to address pharmaceuticals and their costs and continued efforts to curb the opioid epidemic, generally viewed as a non-partisan issue. Other public health issues expected to draw attention again include immunizations, gun violence prevention, and efforts to curb e-cigarettes / vaping. 

While it’s unclear how much will be accomplished, your engagement remains critical.  If you are a member of one of ANA’s state affiliates, you have access to intel. Many state nurses’ associations have a vehicle to communicate updates and grassroots alerts. Additionally, sign up for your elected official’s newsletter to follow discussions and debates. Email your state senators and representatives with questions and requests. Better yet, set up an appointment to meet when they are at home in the district. And be sure to get out and vote in November.

To follow ANA’s Federal agenda and locate resources, go to www.RNAction.org

Your Newest Member of the Policy and Government Affairs Team

  

Hello, and Happy New Year!

I’m Jacqueline Hixson, the newest addition to the American Nurses Association’s (ANA’s) Policy and Government Affairs team.

It’s no mistake that I came to work at ANA. Nursing has always been near and dear to me, as my mother is a psychiatric nurse. I remember the hard work she put into her job and the long hours she worked while she was getting her master’s degree to become a child and adolescent therapist, all while raising two children as a single mom. Nurses live every day for their patients, and I couldn’t be happier to have landed here at ANA where I can support nurses every day.

Coming to ANA has been a great opportunity for me to live my personal values in my professional life. When I was 18, I was a professional ballerina living without health insurance. I was one injury away from bankruptcy – which to me is unacceptable. Working for ANA means I can make a big difference in the lives of citizens by advancing health care policy that has patients in mind – just like my mom did and nurses everywhere do.

My background is in political campaigns: as a fundraiser, communications director, manager, and consultant on campaigns nationwide. Originally from Georgia, I’ve had great opportunities here in the Washington, D.C. area to make a difference in my community and for our nation.

Now that you know how I got here, let me tell you a little bit about what I do!

As you may know, ANA has long had a Political Action Committee (PAC) dedicated to electing nursing leaders to Congress. Sometimes, we’re fortunate enough to elect a nurse (like Congresswoman Lauren Underwood (D-IL-14)), which is always exciting!

An association’s PAC raises funds from voluntary member contributions to elect officials who align with the association’s purpose, values, and priorities. As ANA-PAC’s Coordinator, I have the distinct opportunity to help elect leaders who advance legislation and policy that move nurses and the health care field forward every day. What a dream job!

If you have any questions regarding the ANA-PAC I’m always happy to chat. Give me a ring at 301-628-5014 or email me at jacqueline.hixson@ana.org; I’d love to hear from you! Of course, you can always learn more at www.anapac.org.