Washington state’s waiver request stirs fears that the public is losing accountability, review
Health care officials in Washington state say their Medicaid Section 1115 waiver request will give them the necessary flexibility to preserve services for many beneficiaries who have been added over the years.
The critics have another view. They contend that proponents are illegally seeking a blank check to make whatever cuts they want to make without public review and accountability. State officials make the case for their waiver request by asserting first that Washington has been a national leader in providing health care to children, vulnerable adults, and the working poor.
"In a time of lower health care costs and more state funding," according to Olympia-based Department of Social and Health Services (DSHS) literature, "the state was able to expand coverage.
"But now health costs are continuing to increase significantly, and the demand for coverage and services continues to grow. At the same time, state funding sources are not able to keep pace.
"The Medicaid program gives states like Washington few options with its all-or-nothing approach. This makes it difficult to manage Medicaid benefits and choices. The Medicaid reform waiver will give the governor and legislature more sensible management options, and at the same time, continue to offer protection to the most vulnerable groups protected by Medicaid," DSHS states.
Roger Gantz, who heads Medicaid policy and analysis in DSHS, tells State Health Watch that Washington is breaking new ground in some of its waiver request provisions. He says the provisions are consistent with national policy direction in programs such as the Children’s Health Insurance Program (CHIP) and congressional interest in flexibility. They also build on the Medicaid reform requests of the National Governors Association.
Flexibility sought in several ways
What Washington is looking for is the flexibility to bring in cost-sharing with beneficiaries, changes in benefit design, and enrollment caps for optional groups, while maintaining commitments to mandated groups, Mr. Gantz says. Cost-sharing could involve a point-of-service copayment as well as a shared premium. Benefit design changes are sought in terms of comparability of services and requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
Currently, if the state offers a service to one eligible group, it must offer that service to all eligible groups. The state wants to waive that provision so it could decide which groups would receive a given service. They also want to waive EPSDT for optional Medicaid children program coverage.
Mr. Gantz defends the proposal as giving policy-makers an opportunity to design benefits differently for different groups so that, for instance, benefits might be restricted for those with higher incomes. He says the EPSDT proposal is controversial, because if services are identified through a diagnosis or screening, the state must provide them even if they are not a covered service in the state plan. The agency will voluntarily maintain a benefit design floor in its Basic Health program and for outpatient therapy services, Mr. Gantz says.
If approved, the enrollment caps would be the first in Medicaid, he says. They want the ability to impose such caps if program expenditures exceed legislative appropriations. They also want to be able to use unspent CHIP funds to provide coverage through the Basic Health program for parents and possibly childless adults.
Sustain coverage commitments’
"We look at this waiver request as a way that we can continue to sustain our coverage commitments," Mr. Gantz says. "The intent is not to cut people off the program, but to be more flexible in how we apply the program. It could mean that some families that right now have free health coverage could be asked to help pay. I believe that a reasonable copayment could have an impact on utilization. There wouldn’t be any copayment for preventive care."
The agency has not yet put a dollar figure on any of the options to get a sense of how much would have to be done, he adds. "What we’ve said in the request is that we want to expand the policy options for our governor and legislature. Implementation of any particular changes would be up to them. The waiver does not say specifically what we will do; it says that there are things that we want the freedom to do."
But it’s that very lack of specificity that concerns advocates for Medicaid beneficiaries.
Joan Alker, associate director of governmental affairs for Families USA, says her group opposes any waiver request that asks that a state be given approval in advance to make any cuts that it wants to when the need arises. "It would be very bad policy for the Centers for Medicare & Medicaid Services to grant the Washington waiver," she tells State Health Watch. "There would be no accountability for federal tax dollars being spent or for Congress’ intent for the Medicaid program. The state is just trying to avoid public scrutiny of what they’re doing. States already have a lot of flexibility without a waiver like this."
Can CMS legally approve request?
The National Health Law Program’s Washington, DC, managing attorney, Steve Hitov, tells State Health Watch that Department of Health and Human Services Secretary Tommy Thompson doesn’t have legal authority to approve such a waiver.
"The secretary is charged with determining whether a waiver is likely to further the objectives of the act. He can’t do that if he doesn’t know what the state is going to do. Suppose the state imposed an enrollment cap so that only one disabled person in the whole state is eligible. That wouldn’t further the purposes of the act. It may seem silly, but there’s nothing in the waiver request that would stop them from doing that," he says.
Mr. Hitov also says that Thompson has no authority to waive prohibitions against cost-sharing. "He might think cost-sharing is the best idea in the world, but he has no authority to approve it. Many states are requesting things from the National Governors Association wish list for Medicaid reform. Since much of that wish list is based on cost-sharing, the secretary’s authority is more circumscribed than the states seem to think. It’s probably the wrong road for states to head down."
He points out that expansion of Medicaid coverage to optional populations in Washington and other states generally came about because a political constituency demanded them. If those constituencies still exist, cutting their benefits could be difficult and thus there needs to be a well-aired political debate on any such proposal. "But the Washington waiver request is a perfect example of a document that no rational human being could read and know what is planned. That’s not a debate."
Janet Varon, the executive director of Northwest Health Law Advocates, tells State Health Watch that her organization’s concern is the state is asking the federal government to "waive quite a few federal provisions without specifying how they will be implemented. [It} wants an opportunity to decide later. There are no specifics on the populations affected, on when changes will be applied, whether changes will affect just one population or be spread across many. There’s no indication of demonstration or control groups, although this is supposed to be a demonstration program and nothing on how it will be evaluated. We don’t think state officials have demonstrated that they will affect as few people as possible. There’s nothing that guarantees that. It could result in a crumbling of the health care infrastructure."
Always questions of trust
Ms. Varon says the reason the Medicaid act has protections built into it is to prevent the kinds of problems that the waiver request could cause. While DSHS has done good things in the past with its expansion efforts, she says, there always are questions of trust with any governmental agency. "There’s no guarantee going forward that the people and processes involved will be what we’ve had. It’s undefined in the request how they will decide what to implement."
A better approach, Varon says, would be to focus on ways to control significant cost drivers such as prescription drugs, and to do a waiver just on use of unspent CHIP funds, without all the other changes being requested. Even with that proposal, she says, it’s not clear if the result would be an expansion of coverage in the Basic Health program.
Wanted: Flexibility
Doug Porter, who recently moved north from California’s MediCal program to become Washington’s Medicaid director, tells State Health Watch that what Washington wants to do is use the flexibility some other states have gotten to preserve the commitments the state already has made.
"For example, if we don’t get the right to impose enrollment caps, the alternative might be that we have to terminate everyone in a particular category. It’s true that most other waiver requests specify what will be done and when. We’re listing options we want to be able to pursue if needed," he explains.
Mr. Porter says he understands the anxiety felt by critics of the proposal because of the lack of specificity. "But I’d ask people to look at our request in light of some from other states. There are many states that are just now asking to cover things that we’ve covered for some time.
"We’re not seeking to reduce coverage. But without the waiver, we’ll be forced to scale way back the benefit package for everyone and take many people off the rolls." (A Louisiana Medicaid program involving waivers for children is in search of itself. See "Advocates now are feeling more positive toward Louisiana's Children's Choice program for disabled," in this issue.)
[Contact Mr. Gantz at (360) 725-1880, Mr. Porter at (360) 902-7806, Mr. Alker at (202) 628-3030, Mr. Hitov at (202) 289-7661, and Ms. Varon at (206) 325-6464.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content