By Dan Goldberg
Medicaid has evolved a lot in the five decades since it was signed into law. No longer is it strictly for those living below the poverty line, and that has made it a prime target for Republicans in Washington who say the program is broken.
The American Health Care Act would cut more than $800 billion from Medicaid over 10 years. Rightfully, there has been a lot of focus on what that would mean for low-income adults.
But Medicaid is also a lifeline for roughly 6 million seniors, most of whom cannot afford Medicare’s cost sharing requirements.
Medicaid is the primary payer for long-term care services, which means cuts and changes to the program – whether they come from the federal government or the state government – will ripple throughout the long-term care industry, a fast-growing business that is expected to care for 70 percent of baby boomers in the coming decades.
Roughly 75 percent of Medicaid spending pays for acute care and prescription drugs. The rest pays for nursing home care and other long-term care services.
Because Medicaid is a jointly operated program, federal actions often require state reactions.
Keep in mind
The most important thing to understand is that the rules and eligibility requirements vary from state to state. Make sure to check income requirements and asset tests and be on the lookout for any changes, which are imposed at the state, not federal, level.
- Cuts to Medicaid reimbursements may mean layoffs at long-term care facilities. They may mean the loss of a day program or a van to take seniors off the premises. The impact often stretches far beyond what we traditionally think of as health care coverage.
- Staff, patient ratios may depend on Medicaid revenue. And in rural areas the closure of a facility or the inability to find long-term care services may mean a family member can’t go to work because they have to stay home to take care of an aging parent. As rates of dementia and Alzheimer’s are expected to grow these stories, which can focus on the human toll Medicaid shortfalls take, are likely to become more common.
- Make sure to pay attention to lobbying cash. The long-term care industry isn’t afraid to make itself heard in the halls of state capitols when it feels its interests are threatened. Following the money often helps explain why an idea gets tabled or advanced.
State budgets often provide a trove of stories. Medicaid is among any state’s most expensive, and fastest growing, programs so every governor looks for ways to contain costs. Sometimes these are easy to spot. Changing eligibility requirements or cutting services are common practices, particularly when budgets are tight.
If the Affordable Care Act’s Medicaid expansion is rolled back in a repeal package, governors across the country are going to have some difficult choices to make, and it will be hard to cut services without impacting seniors.
Sometimes state-level changes are subtle and require a little digging to figure out what an administration is up to, but it’s a good bet that if it involves seniors, it involves Medicaid:
- In New York, for example, Gov. Andrew Cuomo, tried to change what nursing homes would be paid when they held beds for seniors who left for a visit to the hospital. The bed-hold policy, which ultimately failed to win support in the Legislature, was really about saving a few dollars for the state’s Medicaid program.
- Pay attention to any change related to long-term care policy. Often this is a way to reduce Medicaid spending and will become that much more important if Medicaid is cut or block-granted under the Trump administration.
- Block granting will likely give the states much more flexibility and allow governors to target long-term care services which have higher than average per-person costs. Seniors older than 85, for example, cost Medicaid about 2.5 times what seniors aged 65 – to 74 cost.
Finally, don’t forget to keep a close eye on who touches all those billions of dollars. As Medicaid rolls grow, Medicaid becomes a larger part of an insurance company’s business and decisions surrounding Medicaid have the potential to upend a state’s insurance market.
In Ohio, for example, Gov. John Kasich wants to turn nursing home care over to managed care companies. The nursing homes, which bill the state Medicaid program directly, have pushed back. The managed care companies argue delaying the switch to managed care costs Ohio $1 million every day.
In Florida, the State Senate president recently said he saw no reason to award managed care companies contracts to do what quality nursing homes were doing anyway.
CMS recently issued a Section 1332 State Innovation Waiver Checklist, which they say will help states to stabilize existing insurance markets. Find out if your state is participating and which programs they’re implementing. Ask if any cost-savings will be passed on to services and programs for older adults.
Resources
- The National Conference of State Legislatures directory provides contact information for officials and staffers. Look for those on the health and budget committees.
- Medicaid.gov has profiles of the program in all 50 states. (scroll to the pull down menu at the bottom of the page)
- Medicaid.gov also has information on 1115 demonstration waivers and a searchable list of state waiver programs.
- Center on Budget and Policy Priorities Medicaid primer
- This Forbes story on how Medicaid cuts will affect seniors. And this one from Huffington Post on the potential impact on family caregivers.
- Here’s how a local Virginia newspaper covered the issue.
Sources
- Judy Feder, professor at Georgetown University and former member of the Federal Commission on Long Term care federj@georgetown.edu
- Andrew Bindman, MD, Professor of Medicine, Health Policy, Epidemiology & Biostatistics and Director of the University of California Medicaid Research Institute http://abindman@medsfgh.ucsf.edu
- Joel Zinberg, Visiting Scholar, American Enterprise Institute, Joel.Zinberg@aei.org
- Deborah Bachrach, partner, Manatt Health Solutions, 212-790-4594, dbachrach@manatt.com
- Enrique Martinez-Vidal, deputy director, State Coverage Initiatives Program, AcademyHealth, 202-204-7509, enrique.martinez-vidal@academyhealth.org
- Matt Salo, executive director, National Association of Medicaid Directors, matt.salo@medicaiddirectors.org
- Here’s the contact list for the Centers for Medicare and Medicaid Office of Communications (OC), Media Relations Group (MRG). Many journalists have reported trouble getting through or lengthy response times.
Dan Goldberg reports on city politics, focusing on hospitals and health care. He writes Politico New York Health Care, an early-morning email that informs the daily conversation in New York among health-industry insiders. Before joining Politico New York, Goldberg was the health care reporter for the New Jersey Star-Ledger.
