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Trump doesn’t need Congress to overhaul Medicaid

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Republican senators have given up, at least temporarily, on their plans to remake the American health care system.

Republican governors, however, are charging full steam ahead with plans to remake Medicaid into a program that requires beneficiaries to work in order to receive health benefits.

Maine is the newest state to propose adding such a requirement, which would fall mostly on kids aging out of the foster program and on low-income parents.

"What the Affordable Care Act did was foundational, guaranteeing all Americans access to affordable care," says Eliot Fishman, senior director of health policy for the nonprofit Families USA. He worked in the Obama administration from 2013 to 2017, focused on Medicaid waivers. "What this waiver would do is withdraw that promise for a specific population that relies on Medicaid."

Medicaid covers 70 million low-income Americans. While the federal government writes the rules for how the program works, states can (and often do) apply for waivers to test out new ideas.

Maine is the fifth state to propose a work requirement this year. It follows Indiana, Kentucky, Arkansas, and Wisconsin, which all have pending requests with the Trump administration.

These work requirements do not currently exist in Medicaid. Some states asked the Obama administration for permission to test out these features in the mid-2010s, but the federal government denied such requests. Obama officials didn't believe they'd advance Medicaid's goal of expanding health access to low-income Americans.

What makes Maine's request for a work requirement stand out to analysts is that it is the only state in the bunch that has not expanded Medicaid.

Medicaid expansion states cover all residents who earn less than 138 percent of the federal poverty line (about $20,000 for individuals). Those states have many low-wage workers enrolled on the Medicaid program, often in jobs that do not offer health benefits.

But Maine isn't a Medicaid expansion state. In Maine, single adults cannot enroll in Medicaid, no matter how poor they are. The program is restricted to certain categories of people, like low-income parents (who must earn less than 105 percent of the federal poverty line) or older teenagers who recently aged out of the foster care system.

These are the people who would have to abide by the work requirement: finding a job, enrolling in school, or signing up for a volunteer opportunity in order to stay covered. Those who are pregnant or caring for others are eligible to apply for an exemption, although details are still sparse about how those exemptions would be applied.

Maine is also proposing adding premiums to its Medicaid program for those who earn more than 51 percent of the poverty line (about $8,000). Historically, Medicaid has only allowed premiums for enrollees who are above the poverty line. Maine wants to charge Medicaid enrollees in poverty a $10 monthly fee to remain in the program.

Maine would lock Medicaid enrollees out of the program for 90 days if they failed to pay their premium by the end of the month.

"Maine isn't an expansion state, so the policies they're proposing would apply to a very low-income population," says MaryBeth Musumeci, associate director of the Kaiser Family Foundation's Program on Medicaid and the Uninsured, who has analyzed their waiver plan.

The Trump administration has so far spoken favorably about the idea of work requirements, a sharp reversal from the Obama administration's position. It sent state Medicaid directors a letter in March saying it intends to approve waivers that "build on the human dignity that comes with training, employment and independence."

There are five pending waivers sitting with the Trump administration right now — some have been with the federal government for months now. Outside analyses expect we should get a verdict on these proposals in coming months, as more top Trump officials turn their attention away from Congress's stalled health care fight.

The general expectation among Medicaid experts is that the Trump administration will eventually approve these work requirements. They can do so without approval from Congress (although they may have to fight legal challenges in the courts). Even with Obamacare repeal stalled in Congress, these waivers present a clear way for the White House to remake health care in the United States — one they look keen to take up.

Map of the Day

The number of "empty" Obamacare counties is shrinking. A few new entrants into the Ohio and Indiana markets mean we've seen the number of counties with zero health plans signed up to sell shrink. While we also got news this week that Anthem would exit much of Georgia, the state was still able to secure at least one plan for all of its counties. Read more about why some counties have struggled to attract Obamacare insurance plans here.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “Ads target GOP lawmakers for ObamaCare repeal votes”: “A grassroots progressive group is launching a five-figure digital ad buy against 10 lawmakers who voted for versions of an ObamaCare repeal bill. The ads from Save My Care target two of the most vulnerable GOP senators in 2018, Jeff Flake (Ariz.) and Dean Heller (Nev.), in addition to Shelley Moore Capito (W.Va.).” —Rachel Roubein, the Hill
  • “Facing Trump Subsidy Cuts, Health Insurance Officials Seek a Backup Plan”: “Congress is on vacation, but state insurance commissioners have no time off. They have spent the past three days debating what to do if President Trump stops subsidies paid to insurance companies on behalf of millions of low-income people.” —Robert Pear, New York Times
  • “Sanders 'litmus test' alarms Democrats”: “Sanders has decided the moment is right to launch his proposal for the single-payer health insurance system that helped form the backbone of his presidential message. And Democrats who don’t get behind it could find themselves on the wrong side of the most energetic wing of the party — as well as the once and possibly future presidential candidate who serves as its figurehead.” —Gabriel Debenedetti, Politico

Analysis and longer reads

  • “Large employers say health plans will cost more than $14,000 for an employee in 2018”: “Large employers say the cost of health-care plans will grow 5 percent next year, to an average cost of more than $14,000 per employee. The increases, reported in a new survey of 148 large companies, were attributed largely to expensive specialty drugs and individuals with high medical costs.” —Carolyn Y. Johnson, Washington Post
  • “Health insurance exchanges are on shaky ground. Here’s how to stabilize them”: “The health insurance exchanges — which make it possible for people who do not get health insurance through work or government programs to buy it — will continue to function. Right now they are on shaky ground. There are three ways to shore up and improve the exchanges to increase choice and ensure that they operate smoothly.” —David M. Anderson, STAT
  • “Value-based care efforts contribute to increasing burnout at safety-net providers”: “Community health centers, which offer primary care to approximately 24.3 million low-income individuals, are known for their high rates of employee turnover because of the stresses associated with caring for complex patients on a fee-for-service pay model. But efforts to transform care delivery at these centers to value-based approaches also contribute to workplace dissatisfaction and burnout, according to a new study published in Health Affairs.” —Maria Castellucci, Modern Healthcare

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