CMS Administrator’s Proposed Changes to Medicaid: Reprehensible

Earlier this week, the Administrator of the Centers for Medicare & Medicaid Services, Seema Verma, gave a major policy address to the National Association of Medicaid Directors.

After invoking Hubert Humphrey on the moral tests of government – her office is in the Humphrey building — she characterized expanding Medicaid coverage to uninsured adults without requiring them to work as “soft bigotry.” Jason Helgerson, the director of New York’s Medicaid program, described that remark as “completely reprehensible.”

That’s not all in the address that is deserving of censure. At one point, Ms. Verma claims that the ACA Medicaid expansion has “stretched the safety net for some of our most fragile populations, many of whom are still on waiting lists for critical home-care services while states enroll millions of newly-eligible able bodied adults.”  The implication is that “able bodied” adults are diverting resources from the “most fragile” – seniors, individuals with disabilities, and families with children. This is demonstrably false.

Researchers at the Kaiser Commission on Medicaid and the Uninsured and the University of California at San Francisco analyzed waiting lists for section 1915(c) waivers for home and community-based services in 47 states and the District of Columbia in 2015.

The analysis broke down waiting lists by population, including age, the physically disabled, intellectually/developmentally disabled, and children. Twelve states plus DC had no individuals on waiting lists. If coverage of “able bodied” adults resulted in waiting lists for HCBS services, one would expect most, if not all, of these 12 states (and DC) to be non-expansion states. In fact, three quarters (all but ID, ME, and MO) were Medicaid expansion states.

As our colleague Judy Solomon at the Center on Budget and Policy Priorities noted in her testimony to Congress earlier this year, waiting lists for HCBS services preceded the ACA’s Medicaid expansion by at least a decade.

Failure to take up the Medicaid expansion did not free up resources to end waiting lists: Of the 19 states that did not expand, 16 had waiting lists. And the two states with the longest waiting lists – Florida and Texas – are non-expansion states. The waiting list in Texas – 186,600 individuals with intellectual or developmental disabilities, and 17,900 children – account for close to one third of all individuals on waiting lists in all states in 2015.

There are a number of policy and fiscal reasons why a state might have waiting lists, but taking up Medicaid expansion is clearly not one of them. Ms. Verma, who as CMS Administrator has access to all of this data (and more), has chosen to ignore it. As her remarks make clear, she has a strong ideological objection to Medicaid coverage for low-income “able bodied” adults as provided for under the ACA – even though that coverage is the result of 31 states exercising their flexibility under current Medicaid law.

Administrator Verma is entitled to her personal ideology. But she is responsible for overseeing the nation’s largest health insurance program, which now covers some 78 million Americans. As such, she should have the best interests of all applicants and beneficiaries – even the “able bodied” – in mind. To pit low-income “able bodied” adults against low-income children and people with disabilities and seniors is not consistent with this obligation and the facts. It is reprehensible.