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On Thursday, January 28, President Biden signed several executive orders intended to strengthen “Americans’ Access to Quality, Affordable Health Care,” including the Affordable Care Act and Medicaid. For Medicaid, the executive orders direct federal agencies to “re-examine” Medicaid policies that “may reduce coverage or undermine the program,” as well as “policies that make it more difficult to enroll in Medicaid.” Based on this language, we're hoping and expecting that the new Secretary of the Department of Health and Human Services will act on these orders by rescinding the Trump Administration’s guidance on Medicaid Section 1115 work requirement and capped funding waivers. Additionally, we’re hoping the Biden Administration will take proactive steps to help the Medicaid program address the social and economic determinants of health through 1115 waivers, including its root cause, racism.
Past administrations required states to demonstrate that their 1115 waiver proposals would “increase and strengthen” health coverage. The Trump administration, however, replaced this requirement with language encouraging proposals that could hinder access to coverage, such as work requirements. As a reminder, Medicaid work requirements were a policy that required individuals applying for or enrolled in Medicaid to report on a regular basis proving that they were working, looking for work or participating in work-like activities. After Arkansas implemented this policy, over 18,000 Medicaid enrollees lost coverage for failure to comply with it. While work requirements were halted by federal courts, rescinding the guidance and reestablishing the Medicaid objective to “increase and strengthen” health coverage would completely remove the pathway for states to enact this harmful policy.
Withdrawing the capped funding, or “block grant,” guidance would similarly remove the pathway it put in place for states to reduce funding for their Medicaid programs. In addition, it would have an immediate, positive impact on Medicaid enrollees in Tennessee. Last month, the Trump Administration approved Tennessee’s Medicaid block grant waiver, which capped the total budget for the program and provided incentives for the state to spend below the cap, thereby encouraging Tennessee to provide less coverage and care to its Medicaid enrollees. Community Catalyst is hopeful that Biden’s executive orders signal a new era of health policies that prioritize individuals and families who need Medicaid.
In addition to undoing these harms, the Biden Administration could take several proactive steps to help state Medicaid agencies use 1115 waivers in ways that will truly maximize the program’s full potential. For example, we'd like the new Administration to issue guidance on how Medicaid can better address the social and economic determinants of health. The Trump Administration recently issued a “roadmap” which provided a detailed overview of ways the Medicaid law already allows for states to address social determinants by providing benefits such as housing supports, medically-tailored meals and non-medical transportation to certain populations. While this guidance was certainly a comprehensive summary of the options already available to states, the Center for Consumer Engagement in Health Innovation would like to see new, forward-thinking guidance on this subject. For example, North Carolina received approval for its Medicaid program to screen certain enrollees for health-related social needs and refer them to community-based services that can address those needs. Releasing formal guidance so that states can follow the lead of North Carolina and others, for example, would be a great starting point. In addition, publishing guidance on the ways Medicaid can incorporate providers who have been shown to reduce health disparities and undo structural racism in the health care system, such as dental therapists, would also help the program address social determinants by focusing on their root cause, racism.
With these new executive orders in place, President Biden has begun the process of undoing many of the harmful Trump administration Medicaid policies related to 1115 waivers and restoring the initial intent of the program – to develop “imaginative” solutions for state Medicaid programs focused on “innovating the delivery of health care...and improving health outcomes locally.” We look forward to working with the Administration on proactive next steps that can be taken to improve the health and health care of Medicaid enrollees.