Vice President for Health Policy
Maine’s new proposal for a Medicaid waiver seeks radical and unprecedented changes to Medicaid, totally disregarding what Medicaid law allows and targeting the state’s lowest-income adults in ways that would likely leave many without access to needed health care.
The federal government can waive Medicaid provisions as part of a demonstration project that promotes Medicaid’s objective of delivering health care to vulnerable populations who can’t otherwise afford it. Maine’s proposal ignores that threshold, instead seeking to change Medicaid rules with which the state disagrees in order to “prioritize limited resources for children, elderly and the disabled, instead of turning Medicaid into an entitlement program for working-age, able-bodied adults.” Maine didn’t expand Medicaid under the Affordable Care Act (ACA) to cover adults without dependent children, so it’s targeting very low-income parents, people receiving limited coverage for family planning services, former foster children, and adults with HIV/AIDS. Most of these current beneficiaries would be hard-pressed to keep their coverage under the changes Maine is seeking.
Through its waiver, Maine would:
Limit Medicaid coverage to three months in a 36-month period for beneficiaries who aren’t working or engaged in a work-related activity. When Maine applied this same provision to its Supplemental Nutrition Assistance Program (SNAP, formerly food stamps), thousands of adults lost their food assistance after three months. The data don’t support the state’s claim that wages rose dramatically for those subject to the time limit, but there is evidence that their hardship increased. Moreover, applying this provision to women who receive only family planning services is especially misguided, because the purpose of this limited-benefit Medicaid program is to save the state money by preventing unplanned pregnancies. Limiting benefits to three months undercuts that purpose.
Impose monthly premiums on most adult beneficiaries regardless of income. All adults subject to the work requirement would have to pay premiums starting at $14 a month for people with incomes below the poverty line. People who didn’t pay after a 60-day grace period would lose coverage for 90 days and not be allowed to regain it until they paid their back premiums. As we wrote yesterday about Wisconsin’s waiver proposal, a large body of research shows that premiums significantly reduce low-income people’s participation in health coverage programs. Requiring people with no or very low incomes to pay $14 a month on top of the three-month coverage time limit would likely leave very few adults in the program.
Impose an unlawful asset test on all adults. Maine seeks to impose a $5,000 asset test on beneficiaries even though, in the ACA, President Obama and Congress explicitly prohibited the Health and Human Services (HHS) Secretary from granting waivers to allow them. The ACA eliminated asset tests and made other changes to Medicaid rules to align eligibility for Medicaid, the Children’s Health Insurance Program, and subsidized marketplace coverage for children and adults in order to create a system where people can easily transition between insurance affordability programs as their incomes and circumstances change. Allowing an asset test in Medicaid would undermine this system, and states cannot vary from the ACA’s rules.
HHS has rejected state proposals to impose work requirements and to deny coverage to people with incomes below the poverty line when they don’t pay a monthly premium. Maine says that prior denials of the types of waivers it seeks were “short-sighted and drawn from incorrect assumptions.” But, in fact, no state has ever requested waivers as far-reaching and draconian as Maine’s proposal.
As we wrote yesterday, a change in presidential administrations didn’t change the law. States can’t use waiver authority to prioritize coverage for certain groups over others that are equally entitled to coverage, and they can’t waive provisions of Medicaid law simply because they don’t like them, as Maine seeks to do.