Medicaid confusion

Trump proposals, including work requirements backed by Rauner, cause chaos across health system



By Ted Cox

The Trump administration is sowing confusion across the health-care system and has now turned its attention to Medicaid with predictable results, according to a new study released last month.

President Trump has suggested freeing states to impose work requirements on Medicaid patients — a proposal backed by Gov. Bruce Rauner — but some states are also experimenting with mandatory premiums and health-savings accounts.

A news release from the Harvard T.H. Chan School of Public Health on the study "New Approaches in Medicaid: Work Requirements, Health Savings Accounts, and Health Care Access" says that pell-mell approach "may lead to unintended consequences for patient coverage and access, such as confusing beneficiaries or dissuading some people from enrolling."

Medicaid expands health care like that enjoyed by older Americans to low-income and disabled patients and others in need. Its expansion was key to the Affordable Care Act, implemented under President Obama and also known as Obamacare, which Trump has consistently attacked even as he's failed in attempts to repeal it entirely. The Trump administration has cut funding to promote Obamacare enrollment and otherwise found ways to dissuade citizens from joining by making it unwieldy or appear headed for dissolution.

According to the release, the study examines various approaches to Medicaid in three states: Indiana, Ohio, and Kansas.

Ohio has implemented what's considered a traditional Medicaid expansion without premiums and at minimum cost to patients. Indiana has also worked to expand Medicaid, but while imposing premiums and mandatory health-savings accounts, in which money is set aside by a patient tax-free to pay medical expenses. Kansas has not expanded Medicaid, making the program available only to the very poor and disabled.

The study found some predictable results.

Medicaid coverage rates were, of course, "significantly higher" in Ohio and Indiana than in Kansas. But the health-savings accounts imposed in Indiana proved "confusing for many enrollees." Two out of five Indiana Medicaid patients — 40 percent — had never heard of the requirement, and only 36 percent were making payments into the accounts, thus jeopardizing the coverage for the remaining two-thirds.

Kansas is considering a Medicaid work requirement, but the study found that most state Medicaid patients were either already working or were disabled and unable to work. According to the study, "Only 11 percent of potential enrollees said they would be more likely to seek work if required to do so."

"There’s been a lot of recent research showing that expanding Medicaid leads to improved access to care and better quality of care — which suggests that any expansion will be better for public health than not expanding," said Benjamin Sommers, associate professor of health policy and economics at Harvard's Chan School and lead author of the study. "But our findings suggest that some of the benefits of expanding Medicaid may be at least partially compromised by some of the current innovations in use.

"For both work requirements and health-savings accounts, the policies may operate as intended for modest numbers of Medicaid beneficiaries who understand or react to the incentives," he added. "But there’s a real risk that even greater numbers of low-income adults will be adversely affected because they don’t understand the new policies, can’t afford them, or get tied up in administrative complexity. For these reasons, it’s critical that there be ongoing independent monitoring of these approaches."


A state audit In January questioned Gov. Rauner's administration of the Medicaid program.

Trump has repeatedly taken steps to make Obamacare impractical or unstable, most recently by moving to undercut the "individual mandate" requiring citizens to hold health insurance.

Illinois Gov. Bruce Rauner has also deployed the tactic of sowing confusion to undermine programs in the so-called social safety net, as in the fluctuating requirements in the state Child Care Assistance Program.

Crain's Chicago Business reported late last year that Rauner's attempts to "shake up" Medicaid had caused confusion, and a state audit released in January found that the Department of Healthcare and Family Services "did not maintain the complete and accurate information needed to adequately monitor $7.11 billion in payments" made in the state Medicaid system.

Also in January, Rauner expressed support for Medicaid work requirements after Trump proposed the change.

Rauner spokeswoman Nicole Wilson repeated that Tuesday, saying the governor's position is that "the state's first priority must be improving the jobs climate. We also recognize that Medicaid beneficiaries becoming gainfully employed helps both them and the taxpayers." She added that the state had recently been granted approval for a program "supporting those with behavioral health challenges and helping them find employment."

The study, published online last month in the journal Health Affairs, was culled from interviews with 2,739 low-income residents in Ohio, Indiana, and Kansas.

Ted Cox