Highlight on Maine: Able-bodied MaineCare recipients could be subject to more stringent requirements

“Able-bodied adults” would be subject to work/education requirements and a lifetime limit of five years under changes Mary Mayhew, director of the Maine Department of Health and Human Services, proposed to Maine’s Medicaid program, MaineCare. In a letter to HHS Secretary Tom Price, Mayhew said she would be seeking the changes in a forthcoming formal 1115 demonstration waiver request.

Mayhew’s letter comes at the heels of a referendum campaign to expand Medicaid in Maine at, according to Mayhew, a cost of $400 million over the next five years. A second motivation is the apparently sympathetic Trump Administration, which has proposed replacing Medicaid with block grants.

Mayhew said that the state has expanded its Medicaid program over decades, resulting in the use of hundreds of millions of state dollars “to turn Medicaid into an entitlement program for working-age, able-bodied adults.” MaineCare serves 270,000 individuals, just over 20 percent of Maine’s population, which, Mayhew said, represents a 22 percent reduction in enrollment since 2011.

Mayhew’s Medicaid proposals include the following:

  • work or education requirements for able-bodied adults in the Medicaid program, similar to the work requirements for Temporary Assistance for Needy Families (TANF) or Able-Bodied Adults Without Dependents (ABAWDs) in the Supplemental Nutrition Assistance Program (SNAP);
  • a five-year lifetime limitation on able-bodied adults’ eligibility for Medicaid;
  • limiting non-emergency transportation (NET) to situations where the underlying service to or from which individuals are being transported is a required Medicaid service and requiring them to access existing transportation resources before accessing NET;
  • requiring monthly premiums for adults who are able to earn income;
  • requiring monthly coinsurance of a set amount (approximately $20) for all members, cost-sharing of $20 for using the emergency department, and fees for missed appointments;
  • applying a reasonable asset test to Medicaid; and
  • waiver of the retroactive coverage of services incurred during the 90 days before Medicaid eligibility.

 

Will the ACA be repealed under President-elect Trump?

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On January 20, 2017, Donald J. Trump (R) will be sworn in as the president of the United States; the Republican Party will retain its majority in both the House of Representatives and Senate, but will fall short of the 60-member Senate majority required to break a filibuster. President-elect Trump campaigned on the promise to repeal and replace the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), President Obama’s signature health care reform law.

Trump’s plan

In a position paper, Trump laid out his plan for health care, which will include:

  • complete repeal of the ACA;
  • permitting the sale of health insurance across state lines;
  • allowing individuals to fully deduct health insurance premium payments from tax returns;
  • enabling all Americans to make tax-free contributions to health savings accounts (HSAs);
  • requiring price transparency from all health care providers;
  • changing the Medicaid structure from a federal-state partnership to a block-grant system;
  • removing barriers to free-market entry for drug providers; and
  • reforming mental health programs and institutions.

The plan also calls for obtaining health care savings by enforcing immigration laws and increasing the employment rate to decrease enrollment in the Children’s Health Insurance Program (CHIP). Most of these proposals are similar to House Speaker Paul Ryan’s (R-Wis) plan for replacing the ACA (see Ryan proposes ‘A Better Way’ to repeal Obamacare, Health Reform WK-EDGE, June 29, 2016).

Without a supermajority in the Senate, the Trump Administration could potentially face a filibuster on its health care plans; that obstacle, however, may be overcome by use of the reconciliation process. Earlier this year, H.R. 3762—a bill repealing the ACA’s coverage subsidies, tax credits, Medicaid expansion provisions, individual and employer mandate penalties, and the medical device and health insurance taxes—made it to Obama’s desk before being vetoed (see Bill to repeal portions of the ACA heads to the President’s desk, Obama veto imminent, Health Reform WK-EDGE, January 13, 2016; Message in a veto: President says ACA stays put, Health Reform WK-EDGE, January 13, 2016).

Effects of Trump plan on uninsurance rate and federal spending

Under the ACA, the uninsurance rate in the U.S. has dropped to 8.6 percent, the lowest level on record (see White House celebrates ACA, Republicans refuse to join party, Health Reform WK-EDGE, October 26, 2016). The Congressional Budget Office (CBO) estimated that 22 million people would lose health insurance if H.R. 3762 became law (see Senate’s ACA repeal would reduce deficits by $474B, Health Reform WK-EDGE, December 16, 2015).

In a different report, the CBO found that repealing the ACA would first increase the federal deficit, but later begin to reduce the deficit while leaving individuals with higher premium costs (see Can health care spending be reduced while improving effectiveness?, Health Reform WK-EDGE, September 28, 2016). Similarly, Ryan’s “A Better Way” plan is estimated to reduce overall insurance coverage from ACA projections while decreasing the deficit (see ‘A Better Way’ would lead to quick gains but lower overall insurance coverage, Health Reform WK-EDGE, August 31, 2016).

The nonpartisan Committee for a Responsible Federal Budget analyzed Trump’s plan and determined that if it were implemented, the uninsurance rate would double; it also found that the Medicaid block-grant proposal lacked sufficient detail to estimate whether it would maintain current spending levels or save hundreds of billions of dollars.

Ongoing developments

In the coming weeks and months, Wolters Kluwer and Health Reform WK-EDGE will continue to provide in-depth analysis and coverage of ACA-related developments. Stay tuned for the practical tips and reliable guidance you’ve come to expect.