Dana Bacon serves as regional director of government affairs for The Leukemia & Lymphoma Society.
As required by both executive order and state law, the Oklahoma Health Care Authority (OHCA) released an 1115 Medicaid waiver proposal for SoonerCare on July 3. Oklahoma hopes to join a handful of states in requiring some adults on Medicaid to report their work-related activities to the state, without any misunderstandings or technical glitches, or risk losing their health coverage.
The Leukemia & Lymphoma Society (LLS), like many patient advocacy groups and other organizations with an interest in health care, has deep concerns about Medicaid reporting requirements such as these. LLS has adopted a set of Principles for Meaningful Coverage to help us judge the value of health care reform ideas. We embrace ideas that would improve access, quality, affordability, and stability in health care, and discourage ideas that would make it harder for patients to get the life-changing care they need.
There’s no question that reporting requirements will cause people on Medicaid to become uninsured; the only real question is, “how many people?” Just a week before OHCA issued its proposal, the federal district court in Washington, DC struck down a similar proposal from the state of Kentucky. The judge said the state and the federal agency that approved the waiver, the Centers for Medicare & Medicaid Services (CMS), failed to consider the impact of 95,000 state residents losing their health coverage, a figure that came from the state’s own estimates. A brief filed in support of the Kentucky plaintiffs suggested substantially higher coverage losses – between 175,000 and 297,500 people – but even the lower estimate from the state was troubling enough to attract the judge’s concern.
Federal rules (Section 431.408(a)(1)(C)) require each state to show an estimate of how its waiver would impact yearly Medicaid enrollment and costs in order to help the public evaluate the impact of each proposal. While Kentucky made this data available in its reporting requirement proposal, several states, including Oklahoma, Mississippi, South Carolina, and South Dakota, appear to be testing the limits of this law. The OHCA proposal says nothing about how many people will lose health coverage under this plan.
Avoiding this question won’t reduce the impact of reporting requirements on SoonerCare enrollees. CMS Administrator Seema Verma cautioned states that have not expanded Medicaid coverage (such as Oklahoma) to be careful about the “subsidy cliffs” their waivers could create. Andy Slavitt, who held the post before her, recently wrote that reporting requirements would harm three groups of people:
…the many who work, but can’t maintain consistent hours to meet the state’s standards; those with disabilities that aren’t recognized by the state; and many individuals who would be caught in a web of administrative paperwork under new systems being designed to monitor people’s work and other habits.
For all these reasons, it’s hard to imagine how OHCA’s waiver proposal won’t result in people losing coverage. Even people who comply fully with the rules would be at risk. The single parent of one child who works 20 hours a week at minimum wage would be priced out of SoonerCare. That same parent almost surely doesn’t have access to employer-based coverage or earn enough to afford coverage through the federal marketplace. As for signing up for Insure Oklahoma, that program only accepts people who work for companies with fewer than 250 employees (500 employees in the case of nonprofits). Work for a company that’s too big, like a big-box store or fast food chain, and this option would come off the table, too.
People love government innovation when it works as promised, and for good reason: smart changes give you better value and better outcomes. Reporting requirements for SoonerCare will unfortunately deliver the opposite results. Despite OHCA’s best efforts to carry out the task assigned to them by the Oklahoma Legislature and Governor, people will lose health coverage if this waiver is approved. Dollars will be spent on bureaucratic systems and uncompensated care that could have been better spent on SoonerCare enrollees. Some of our most vulnerable neighbors will be hurt. That’s innovation we can’t afford.
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