New Medicaid boss, mentor Pence and Trump seek changes in program like some Bevin has asked her agency to approve for Ky.

Seema Verma (Getty Images)

By Al Cross

Kentucky Health News
The newly confirmed director of the nation’s Medicaid program quickly served notice that she wants states to make changes like those she has helped make in Indiana and helped design in Kentucky, including work requirements. Then President Trump and key members of the U.S. House backed her up, in an effort to pass their initial bill to repeal and replace the Patient Protection and Affordable Care Act.

The Senate voted 55-43 Monday night to confirm Seema Verma, an Indiana health care consultant and protégé of Vice President Pence, to run the Center for Medicare and Medicaid Services. The next day, she and Health and Human Services Secretary Tom Price sent a letter to governors, “urging states to alter the insurance program for poor and disabled people by charging them insurance premiums, requiring them to pay part of emergency-room bills and prodding them to get jobs,” Amy Goldstein reports for The Washington Post. The letter “also derides the Medicaid expansion that 31 states and the District of Columbia adopted under the Affordable Care Act.”

Under Pence as governor and Verma as his consultant, Indiana expanded Medicaid, but under a federal waiver of certain Medicaid rules. Then Verma helped design a waiver request for Kentucky that would establish small, income-based premiums, impose work-related requirements and make other changes. That request is now pending before her agency, and Gov. Matt Bevin has suggested that it will not only be approved, but expanded to include other changes that the Obama administration frowned upon.

Critics of the Indiana plan say it “has been confusing for beneficiaries and some have incurred penalties through no fault of their own,” reports Ricardo Alonso-Zaldivar of The Associated Press. “At her Senate confirmation hearing, Verma defended her approach by saying that low-income people are fully capable of making health care decisions based on rational incentives.”

The letter from Verma and Price called for “a new era” in Medicaid “where states have more freedom to design programs.” They said, “The best way to improve the long-term health of low-income Americans is to empower them with skills and employment.”

However, “Such requirements would be nearly impossible to enforce, conservative and independent experts on the Medicaid program said Friday,” Max Ehrenfreund reports for The Washington Post. “About 78 percent of adults enrolled in Medicaid who are not elderly live in households with at least one person working, according to an analysis by the nonpartisan Kaiser Family Foundation. Those who are not working might have good reasons for doing so, said Diane Rowland, an executive vice president at the foundation.” The foundation says “about 18 percent of adult Medicaid beneficiaries who are not working are in school. Another 28 percent report that they are taking care of members of their family, and 35 percent say that they are sick or disabled.” But work requirements are “a long-held goal of conservative reformers,” Ehrenfreund reports.

To attract more votes from strongly conservative House members in a floor vote set for Thursday, March 24, Trump embraced amendments that the House Budget Committee said should be added to the bill. Those include allowing states to impose work requirements on healthy Medicaid enrollees who don’t have dependents, Alan Fram and Erica Werner of The Associated Press report. Also, “The agreement would let states accept lump-sum federal payments for Medicaid, instead of money that would grow with the number of beneficiaries.” However, “It seemed clear that GOP leaders remained short of the 216 votes they’ll need, and additional changes were in the works.”

Pence told a meeting of the financially conservative Club for Growth in Palm Beach, Fla., Saturday night, “We’re going to have an amendment to allow states to include a work requirement for able-bodied adults on Medicaid so we can ensure the program is there for people who actually need it.” Earlier in the day, with Verma at his side, he told a crowd in Jacksonville, “We’re going to have an orderly transition to a better healthcare system in America that makes affordable, high-quality health insurance accessible for every American.”

Beginning in 2020, the House Republican health-care bill backed by President Trump “would limit overall federal financing for Medicaid in the future. Taken together, those changes could leave 24 million more people uninsured by 2026, the Congressional Budget Office said Monday in an assessment,” Goldstein notes. The impact would be greater in rural areas, The Wall Street Journal reports.

To see a Democratic-compiled rundown of how CBO thinks the bill would affect each of the 435 congressional districts, click here. Among Republican districts, Kentucky’s 5th District has the third highest Medicaid expansion enrollment in the nation, about 105,000 out of the 440,000 expansion enrollees in Kentucky. The district also had the third largest decline in percentage of its population without health insurance, from 17.4 percent to 5.7 percent.

The 1st District, almost as rural, ranked 20th in decline of the uninsured, falling from 15.1 percent to 6.8 percent, with 76,000 in Medicaid expansion. The 2nd District was 25th, with an uninsured rate that dropped from 13.2 percent to 5.3 percent. It has 68,200 expansion enrollees. The 6th District has 75,100, the 3rd District 62,200 and the 4th District 53,000.

This story was first published on March 15 and was updated March 18, 19 and 20.

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