Health Reform X.0 Panel Debates Medicaid, Other Topics at Health Policy Conference

Are Medicaid waivers meant to encourage able-bodied adults to work, or a return to poor laws of old? Or are they a means to get states that have not expanded Medicaid to expand?

A diversity of viewpoints on these and other topics were on full display during Health Reform X.O: What Now, What Next?, the first session of AcademyHealth’s National Health Policy Conference, in Washington, DC.

Moderator William Hoagland of the Bipartisan Policy Center led a discussion about events in healthcare over the past year, from changes in the Affordable Care Act (ACA) to Medicaid and the Children’s Health Insurance Program (CHIP), to last week’s news about Amazon, JP Morgan, and Berkshire Hathaway forming a health partnership.

The panelists included Sara Rosenbaum, JD, of the George Washington University School of Public Health; Gail Wilensky, PhD, economist and senior fellow from Project HOPE; Michael Heifetz, former director of Wisconsin’s Medicaid program and currently with Michael Best Strategies; and Jeanne Lambrew, PhD, senior fellow at The Century Foundation.

Before asking panelists to look forward, Hoagland asked them to look backward and share their thoughts about the year that happened since the last health policy conference, citing the Affordable Care Act (ACA), which President Trump had vowed to repeal and replace. While that did not happen, the individual mandate was removed as part of his tax reform legislation in December 2017.

“I think last year certainly for me was the most existential I had been through in 40 years here,” said Rosenbaum. She said, “proposals became unmoored from the facts underneath,” and said no better example of this is the debate over Medicaid.

However, “what emerged over time is that Medicaid is the DNA of the American healthcare system,” Roseenbaum added. Medicaid came out stronger, even if reform is needed.

As a result of the debates over the past year, Wilensky said it has clearly been established that Medicaid coverage is here to stay, but said that it has also “graduated to be a program that people criticized it for when it was never intended to be a program for low income or poor people.” As a result of the ACA, it covers a wider range of people, and both Republicans and Democrats pushed back when faced with the prospect of people losing coverage, which she views as a positive thing.

“The old Medicaid is not coming back,” Wilensky said.

She urged her fellow panelists to “stop moaning and groaning” and pointed out that it shows that any legislation that does not have bipartisan support is not likely to be stable.

Wilensky cited the Amazon-JP Morgan Chase-Berkshire Hathaway announcement last week as one example of frustration on the spending side, and said her immediate response to the news was, “Why do you think you will do better than CalPERS?” referring to the California Public Employees’ Retirement System (CalPERS) which also has a million covered lives.

She said the Amazon partnership may do fine at treating the majority of their employees who spend the least amount of money on healthcare, but it remains to be seen what impact they will have on the small minority of workers who make up the bulk of healthcare spending because of complex, high-cost chronic conditions.

Looking back at the past year, Lambrew, who previously worked in the Obama administration and is also a professor at the Robert F. Wagner School of Public Service at New York University, said, “Policy does matter. Analysis does matter.” She said the ACA replacement plan that was offered “did not include access and did little to improve affordabilty—it just shifted costs.” Unexpected defenders, like Republican governors, as well as newly engaged citizens who did not want to see the ACA repealed, worked to its favor. So did a flawed analysis that said the system of private insurers and Medicaid was broken, she said.

As a former state Medicaid director, Heifetz gave a states’ perspective, explaining that the 40% of Medicaid recipients who are children are not driving budget challenges.

State Medicaid programs operate in instable environments; mergers and acquisitions, for example, impact how state Medicaid will cover its members, or whether the resulting company is nonprofit or for-profit, he added.

The ACA never fully addressed quality issues, where Heifetz said you have to deliver “the right care at the right time to the right patient.”

On Medicaid waivers, Wilensky said they will give states flexibility and urged people dismayed by work requirements to step back, as she thinks it will expand coverage. She is uncertain whether or not it reduces costs.

CMS is currently considering a waiver request from Wisconsin. Haifetz said some parts of the waiver would be new, and other parts, like drug testing and a work requirement, are already present in other state programs. Medicaid was “supposed to be a trampoline, rather than a hammock,” Haifetz said, citing a former boss.

Hoagland asked Rosenbaum to explain polls that show people have favorable views of Medicaid, but also of work requirements and drug testing.

“We’ve brought back poor laws to disrespect a whole set of poor people,” said Rosenbaum, adding that if CMS were going to change the process, they should have done it in a different way.

Wilensky had a different view, saying she viewed the waivers as a lever to get reluctant states to participate in the expansion, and that it is the right of state legislatures, representing those taxpayers, to demand it.

Looking ahead, Hoagland asked the panelists to address Senator Bernie Sanders’ Medicare for All bill, which Senator Tammy Baldwin, D-Wisconsin, has endorsed.

The panelists were blunt about the Vermont Independent’s single-payer healthcare bill, with Wilensky saying “no way” and Rosenbaum noting “this is not a country whose political institutions are built to move abruptly. We could have [a] single payer tomorrow but I don’t think it would make healthcare more accessible. “

One area where all the panelists were in agreement was when Hoagland brought up a report by Senator Ron Johnson, R-Wisconsin, claiming that Medicaid played a role in the opioid crisis. Medicaid played no such role, they all said, and the factors for the opioid crisis are much more complex. If anything, an expansion of Medicaid can help combat the crisis.

"I think people in Congress could use a course in the difference between correlation and causation," said Wilensky.