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11th hour approval for major changes to Medicaid in Tennessee

With 12 days to go, the Trump administration on Friday approved a long-standing conservative goal: to issue state Medicaid funding in the form of a capped block grant.

The structural experiment in Tennessee, which would become effective once approved by the state legislature, would last 10 years. Block grants for Medicaid have been a priority for Seema Verma, the administrator of the Centers for Medicare and Medicaid Services and a former consultant who has helped states draft waiver requests.

“What we’ve tried to do is take some of what we thought were some of the wins, some of the positive things about block grants that people have been talking about for years,” Ms. Verma said. “And we’ve tried to review and respond to some of the criticisms.”

Tennessee patient advocates, who fear the new structure will cause the poor to lose access to health care, say they are planning a court challenge, and the Biden administration will almost certainly seek to reverse it when it is will take over the Department of Health and Social Services. .

But last week the Trump administration tried to slow down the reversal of its Medicaid experiences. Traditionally, these waivers are agreements between the HHS and the states that can be broken with minimal hassle. But Ms. Verma has sent letters to state Medicaid directors, asking them to sign, “as soon as possible,” new contracts that detail more elaborate processes to end the waivers. Under the terms of the contract, the federal agency agrees not to end a waiver with less than nine months notice.

“It’s so blatant,” said Joan Alker, executive director of the Georgetown Center for Children and Families. “She’s trying to handcuff the Biden administration.”

Ms Verma said contracts were a way to ensure that waivers were only revoked if they were detrimental. “We want to make sure that people don’t take office and, on a political whim, end the waivers,” she said.

The waiver allows Tennessee, one of the twelve states that have not adopted the expansion of Medicaid under Obamacare, to abandon the normal structure of the Medicaid program. Within this structure, the federal government establishes detailed rules to determine who should be covered and what benefits they are offered in return for an unlimited commitment to pay a share of Medicaid patient bills. Tennessee would have new freedom to change the services covered by its program, but its annual funding would be capped according to a formula.

If Tennessee spends less than the block grant amount, it will be allowed to keep 55% of the savings to be spent on a wide range of “health” related services. If he spends more, the difference will have to be made up with public funds. The waiver sets certain limits on what aspects of the program can be changed and would allow the spending limit to increase if more people enrolled in Medicaid, as typically happens in times of economic downturn.

A key area of ​​flexibility in the waiver concerns prescription drugs. Generally, Medicaid should cover a wide variety of drugs, but it is guaranteed to pay the lowest price of any buyer in the United States. Tennessee will be allowed to renegotiate prices with drug manufacturers and may refuse to cover drugs if it deems the prices too high. Massachusetts had submitted a waiver requesting a similar authority without a broader block grant, and it was denied.

In Tennessee, doctors and hospital groups, among others, have criticized the proposal. “The vast majority of comments received by CMS opposed the demonstration proposed by Tennessee,” notes the approval document.

Gov. Bill Lee, a Republican, called the program a “legacy.”

“We have shown that a partnership is a better model than dependency,” he told reporters.

The waivers were a centerpiece of Ms. Verma’s tenure at Medicaid. In addition to the Tennessee block grant waiver, it has approved Medicaid work requirements for certain adults in 12 states. Federal courts have repeatedly overturned these waivers, and few of them are in effect.

Michele Johnson, executive director of the Tennessee Justice Center, a legal aid group that helps poor Tennessians, said she was trying to encourage lawmakers to reject the waiver. A block grant, which she has consistently opposed, fits particularly poorly with a public health crisis, she said, in which health spending could accelerate in unusual ways. “The only way it makes sense is in the context of the Trump administration burning while walking out the door,” she said.

She also noted a history of challenges the state has faced in managing its more traditional Medicaid program. “It’s hard to imagine a state that would be more suited to a block grant than ours,” she said.


Sheryl Gay Stolberg contributed reporting.

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Supreme Court to Hear Case on Trump’s Work Requirements for Medicaid

WASHINGTON – The Supreme Court on Friday agreed to decide whether the Trump administration can impose work requirements on Medicaid recipients, a question that could become moot if the Biden administration removes the requirements.

In February, a panel of three unanimous judges from a federal appeals court in Washington struck down the requirements, which would have denied Medicaid health care coverage to poor people in Arkansas and New Hampshire unless whether they are working, volunteering or training for a job.

The appeals court said the approval of the requirement by Health and Human Services Secretary Alex M. Azar II was illegal – “arbitrary and capricious,” in legal jargon – because it had not considered how this would advance Medicaid’s goal of providing health care to the poor.

Congress had sought to “provide health care coverage to populations who otherwise could not afford it,” Judge David B. Sentelle wrote for the court. “Importantly, the secretary did not take this statutory objective into account in his analysis.

The case of Azar v. Gresham, No. 20-37, will be heard early next year.

Urging the Supreme Court to hear the case, Jeffrey B. Wall, the acting solicitor general, said the government should be allowed to test new approaches to the Medicaid program, especially in light of its expansion under the Affordable Care Act.

The appeals court ruling, he wrote, “threatens to hamper innovations that can make state Medicaid programs more effective and sustainable” and “casts a shadow over approved or pending demonstration projects. of several other States ”.

Mr Wall wrote that requirements similar to those blocked by the appeals court had been approved or were pending in 17 other states.

Lawyers for the challengers told judges the administration’s timing was particularly bad.

“During a pandemic in which 50 million Americans filed for unemployment and nearly 12 million lost employer-sponsored health insurance,” they wrote, “the secretary of health and social services is asking this tribunal to revive demonstration projects that would allow states to kick people out of Medicaid for not looking for and getting jobs that don’t exist. “

The rules require “able-bodied” adults to report to their state each month that they have worked, researched or trained for a job, attended school, or volunteered in order to maintain Medicaid coverage. Administration officials said that work is linked with good health and it helps people avoid poverty and government dependency.

The appeals court questioned this reasoning, saying it was not supported by the objectives of the law.

“The text of the law includes a primary objective, which is to provide health care coverage without any restrictions focused on healthy outcomes, financial independence or the transition to commercial coverage,” Justice Sentelle wrote.

In Arkansas, more than 18,000 people lost their coverage before the work was blocked. Some people with jobs lost their coverage because they didn’t know the rule or didn’t report their hours to the state.

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Chance to Expand Medicaid Brings Democrats in Crucial North Carolina

If registered low-income voters voted at the same rate as high-income voters in 15 states who spoke to Mr. Trump in 2016, including North Carolina, they would equal or exceed his margin of victory in those states, according to the study. And for many, access to health care has been an elusive goal, often with devastating consequences.

In an interview, Dr Barber said the coronavirus pandemic has turned this lack of access into a crisis.

“Covid has forced the conversation on healthcare,” he said. “There’s no way you can’t talk about it.

Dr Barber is quick to remind his audience in North Carolina that Senator Tillis helped lead a successful effort in the legislature to pass legislation banning the expansion of Medicaid in 2013, when he was president of representatives room. The Campaign of the Poor has recruited more than 5,000 volunteers in eight states “who are committed to calling over a million poor, low-wage people who did not vote last time, are ready to observe the polls, or are going. canvas communities with their face shields and masks and gloves, ”he said,“ because it’s a matter of life and death in the truest sense of the word.

Jessica Holmes, a Democrat candidate for labor commissioner, said such efforts motivate people like her 84-year-old grandmother, who she says has never voted in a presidential election until now.

“We’re in the biggest medical crisis of a lot of our lives,” Ms. Holmes said, “and yet all over North Carolina we’re talking about selling hospitals or clinics shutting down.

Joseph Danko, 54, who lost his construction job in March and suffers from asthma, was distressed to learn he was not eligible for Medicaid despite having virtually no income. Anxiety over health care was one of the main reasons Mr Danko, of Raleigh, voted early for Mr Biden and other Democrats, he said, handing over his ballot to vote in person “to be 100% sure” that it would be counted.

“It has been a crazy year,” he said, “but we hope and pray for change.”