Coalition Calls on Secretary Azar to Use Medicaid Waiver Authority to Promote Health Equity

In light of the heightened national attention to the injustice of structural racism, a lengthy list of diverse national and state groups representing patients, providers, racial justice organizations and others sent a letter to Secretary Azar urging him to take two immediate steps with respect to pending Section 1115 Medicaid demonstration requests that would help mitigate racial disparities rather than making them worse. In a time of such high unemployment and extreme public health risks, these waivers are even more out of touch with the realities families face.

The 279 national and state groups ranged from the American Heart Association, AFL-CIO, American College of Physicians, Center on Budget and Policy Priorities, to the NAACP. Many of the signers represented those focused on maternal and child health including Black Mamas Matter Alliance, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the March of Dimes, and the National Birth Equity Collaborative. Groups from 34 states across the country, from New Jersey to Mississippi to Kansas, were represented as well.

The letter, in particular, calls out the racial inequities that would be perpetuated by pending work requirement waivers in non-expansion states such as Mississippi and Alabama, which would disproportionately target Black women for potential coverage losses. Both states submitted requests in 2018 and are still pending.

“We ask you to immediately reject pending proposals to impose punitive work requirements on parents with very low incomes in Alabama, Mississippi, Oklahoma, Tennessee, and South Dakota. In comments on these demonstrations and previous letters to you, many of us have pointed out that these proposals exclusively target very poor parents, who are mostly women with loss of their health insurance and that they also threaten children’s well-being.1 Data from two states with pending requests underscore how these punitive proposals put Black families at risk: In Mississippi, 71 percent of the parents who would be at risk of losing their health insurance are Black, as compared to 37 percent of the state’s population.2 In Alabama, 58 percent of the parents affected are Black, compared to 26.5 percent of the state’s population.3 Imposing work requirements on these parents is bad policy in the best of times, but it is unconscionable in the midst of a pandemic, a deep recession, and widespread recognition of structural racism.”

Instead, the letter urged the Secretary to approve pending requests to extend postpartum coverage beyond the current 60-day cutoff as requested by the state of Illinois and New Jersey.  So far, CMS has not granted any such approvals. Illinois’ application notes that non-Hispanic Black women in the state have a shocking rate of maternal mortality six times higher than non-Hispanic White women.

The letter concludes by saying “Section 1115 demonstrations can be a force for health equity rather than a way to perpetuate structural racism. The Department of Health & Human Services has the power to change their current trajectory. We urge you to do so.”

Unfortunately, as readers of the SayAhhh! blog may remember, Secretary Azar and Administrator Seema Verma were presented with this very choice in the case of South Carolina’s Section 1115 demonstration request and, earlier this year, they approved the work requirements targeted at parents – disproportionately Black mothers. According to the approval letter, the state withdrew its request to extend post-partum coverage and substituted a different proposal – but it is unclear if this was withdrawn in part because CMS was not ready to approve it.

As the election grows closer and the Trump Administration doubles down on rousing its core supporters, concern is growing that CMS will get back to business as usual with its Medicaid waiver policy. There are moments in history when leaders make choices that have lasting impact and this is one of them. Secretary Azar should change his mind and get on the right side of history – at least in this one instance.

Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.