In particular, it targeted waivers that allowed states to divert Medicaid monies into subsidies for hospitals rather than insurance for individuals. Prior to Obama, several states had obtained waivers that allowed them to establish special funding pools for hospitals that served large numbers of uninsured people. These states included Florida, Kansas, Tennessee, and Texas, all of which had declined to expand Medicaid.
The Obama administration saw no need to continue these hospital pools when the state could address the problem of uncompensated care by expanding Medicaid. Thus, when Florida sought to renew its hospital pool, CMS announced its intent to phase out the program.
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In late June, Florida officials withdrew the lawsuit. The Trump administration repudiated key components of the Obama waiver legacy. In altering federal waiver policy, President Trump relied in part on another important tool of the administrative presidency—political appointments. The former head of a health policy consulting firm, she had assisted Indiana, Kentucky, and Ohio in developing market-oriented waivers emphasizing individual choice and personal responsibility. Once approved by the Senate, Verma quickly joined Secretary of Health and Human Services Tom Price in signaling receptivity to waiver provisions that the Obama administration had rejected.
It also endorsed premiums and other enrollee cost sharing as well as fees that would penalize enrollees who used hospital emergency rooms for non-urgent care. Reversing Obama administration efforts to reduce the administrative burdens of obtaining Medicaid coverage, the letter invited governors to restore some of the barriers that had historically depressed take-up rates.
In November, Verma further articulated many of these themes. The CMS website was changed to no longer list coverage expansion as a goal of the Medicaid demonstration waivers Cohen By early , ten states, all with Republican governors Arizona, Arkansas, Indiana, Iowa, Kansas, Kentucky, Maine, New Hampshire, Utah, and Wisconsin , 18 had submitted waiver documents to take advantage of this new federal posture.
A few other states were considering comparable waiver requests. These proposals contained myriad provisions but five themes stand out.
First, all of these states, except Iowa, sought to impose work requirements on able-bodied enrollees. States typically specified that the community engagement and employment requirement be at least twenty hours per week. Second, several proposals called for lock-out periods if enrollees failed to comply with certain program requirements.
For instance, the Kentucky amendment proposed a six-month disenrollment for beneficiaries who failed to report changes in income or employment status promptly. Former enrollees could shorten the lock-out period by completing a financial or health literacy course. Third, certain states sought to establish a time limit on eligibility. For instance, Wisconsin set the limit at four years for poor, non-pregnant childless adults from age nineteen through forty-nine.
Once an enrollee reached that limit, he or she would be locked out of coverage for six months before being able to reenroll with a new four-year limit. Fourth, Wisconsin proposed mandatory drug screening for poor, childless adults from age nineteen through sixty-four. If the initial screening indicated the need for a drug test and the applicant refused, Medicaid coverage would be denied.
So too, the state would reject any applicant who tested positive for drugs but refused to enter a substance abuse treatment program. Fifth, Arkansas proposed a waiver amendment that would reduce the cohort covered by the Medicaid expansion. The Arkansas proposal sought to eliminate Medicaid coverage for those earning between and percent of the poverty line.
Instead, this group would purchase insurance on the exchanges. If those with incomes from to percent of the poverty level enrolled in Medicaid, the state would have to supplement federal funding with a match drawn from its own coffers. If these individuals were ineligible for Medicaid, they could obtain insurance through the exchanges and be wholly subsidized by the federal government. Concerned about possible legal challenges to these waivers, especially to their work requirements, CMS moved slowly to approve them.
Organizations representing Kentucky Medicaid enrollees promptly sued to block implementation, asserting in part that the federal executive branch had exceeded its statutory authority in acting unilaterally to transform Medicaid Stein The success of the Trump administration and various states in using waivers to impose work and related requirements therefore came to rest with the federal courts.
The extent to which the courts will constrain or expand the power of executive federalism to shape policy hangs in the balance. What are the implications of the legislative and executive branch actions examined here for the durability of the ACA? Durability connotes a political strength that allows a program to resist retrenchment, erosion, or termination.
It also captures whether a program manifests growth or enhanced effectiveness. Patashnik and Zelizer underscore that the threat to durability increases when, like the ACA, a program features divisive congressional enactment with overwhelming support from one party and massive rejection by the other. Under this circumstance, durability depends largely on what the opposition party does when it gains control of Congress and the presidency. The case of the ACA vividly illustrates that even under conditions of intense partisan polarization and unified Republican government, accomplishing legislative goals may be problematic.
While President Trump and the vast majority of congressional Republicans favored repeal and replace, the veto points built into the American separation-of-powers system, the thin Republican majority in the Senate, and the unanimous opposition of Democratic lawmakers thwarted the attempt.
Medicaid has defied the prediction that means-tested programs especially those assigning major discretion to the states tend to erode Peterson ; Thompson , 23— Research on Medicaid has identified several factors that have fortified the program, including support from healthcare providers, backing from the intergovernmental lobby, 20 and favorable public opinion e. All three manifested themselves in the politics of repeal and replace and helped protect Medicaid from major retrenchment, albeit barely and perhaps only temporarily.
Throughout , providers especially safety-net hospitals, nursing homes, and managed care organizations along with various advocacy groups strongly opposed repeal-and-replace legislation. So too, a highly motivated minority of Republican governors joined all their Democratic counterparts in opposing the Medicaid retrenchment proposals. A favorable social construction of Medicaid and supportive public opinion also helped buttress the program. Polls taken in found that nearly 60 percent viewed Medicaid as an important program for them and their families; over 70 percent opposed converting Medicaid to a block grant; nearly 85 percent said it was important to continue federal funding for states expanding Medicaid under the ACA.
It seems unlikely that the limited legislative success of the Republican repeal-and-replace initiative will move the party toward tacit acceptance of the ACA in general or Medicaid in particular. Ideologically, party leaders remain committed to gutting the ACA and curbing healthcare entitlement programs should a policy window open. Nor should one assume that the sources of program durability discussed above will protect Medicaid from major retrenchment going forward.
For instance, most Republican governors publicly behaved as members of a vertical partisan coalition, responsive more to national party leaders and ideology than the immediate interests of their states in sustaining Medicaid. The number of Republican governors willing to resist national partisan pressures may in the future decline still further. Supportive public opinion may also become a weaker defense mechanism. On balance, Republican proposals for Medicaid and ACA retrenchment were more extreme than the views of the general public and their core partisan supporters. Rather, and especially among Republicans, ideologically driven policy elites reinforced by the conservative media, the libertarian Koch network, and major donors often pursue options far to the right of the public and many members of their own party Skocpol and Hertl-Fernandez Executive branch actions under Trump also have implications for ACA durability though uncertainty shrouds the magnitude of their impact.
These data were not readily available as we completed this article. We do, however, have evidence on exchange enrollments, which dropped by much less than many observers expected. After gains in these enrollments during the last three years of the Obama administration, those signing up on the exchanges declined by about four percent in and , respectively. Nearly 12 million Americans purchased individual insurance on the exchanges in despite the sabotage efforts of the Trump administration.
The data also point to differences between the eleven states along with DC that fully operate their own exchanges and the thirty-nine that rely on the federal enrollment portal. State-run exchanges witnessed enrollment increase of nearly 2 percent in and 1 percent in National Academy The better performance of state-run exchanges probably reflects greater ideological support for the ACA in these states. In , Hillary Clinton won all of these states except Idaho and 64 percent of them had Democratic governors. The elimination of CSR payments kindled significant premium hikes for But consumers with incomes below percent of poverty are protected from these increases due to ACA provisions that limit their costs to a certain fraction of their incomes.
Meanwhile, insurance commissioners in at least forty states devised premium adjustments that mitigated the financial toll on insurance companies of losing the CSR subsidies. These negotiations frequently allowed the insurance companies to hold the line on premiums for certain exchange offerings Sanger-Katz Other factors also moderated enrollment declines. Private nonprofit groups and volunteers e. Moreover, the steady media coverage of the ACA probably heightened public awareness of its benefits.follow site
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CMS did not, for instance, seek to disrupt the standard operating procedures and enrollment technology which, after a rocky start in late , had become increasingly efficacious in facilitating enrollments. Whether the erosion of enrollments will accelerate in subsequent years remains an open question. The elimination of the tax penalty associated with the individual mandate in will heighten the challenge of sustaining them. Trump administration initiatives also threatened Medicaid enrollments.
CMS was responsive to waiver requests that allowed resistant states to fund hospitals rather than individuals, thereby dissipating pressure on them to expand Medicaid. More fundamentally, the agency announced its openness to waiver themes that prior presidential administrations had rejected. If these waivers win approval, Medicaid take-up rates will likely fall. Greater cost sharing will fuel this decline as will the greater administrative burdens on individuals seeking to obtain and retain enrollment.
For instance, on the face of it work requirements apply to a small percentage of Medicaid enrollees. An estimated 80 percent of able-bodied, non-elderly adult enrollees are in working families with close to 60 percent employed themselves Musumeci But the reporting requirements associated with these and other waiver measures will adversely impact many workers who fail to forward the necessary information to officials in a timely fashion.
Lengthy lock-out periods for these reporting infractions will exacerbate take-up problems. In considering the negative implications of these waivers for Medicaid enrollment, however, three caveats deserve note. First, it remains to be seen whether the federal courts will approve these waivers. Second, waivers take two to tango. Despite federal encouragement of these waivers, nearly 80 percent of the states, including those with the largest Medicaid enrollments, had not applied for them as of early While other Republican-dominated states may well seek them in the future, the effect of these waivers in reducing overall Medicaid enrollments may be limited.
Third, some states may seek to impose work requirements as a condition for expanding Medicaid under the ACA leading to net gains in enrollment within their boundaries. The emergence of the Trump administration and a Republican Congress in provides an important new context for the study of health policy and federalism. This article explores how federalism dynamics played out in the congressional politics of repeal and replace with particular attention to the role played by the intergovernmental lobby.
Virtually all of the repeal-and-replace proposals would have appreciably enhanced state authority to shape healthcare policy while significantly disempowering them by reducing federal financial support. Repeal-and-replace developments also speak to the importance of executive federalism as a driving force in American governance even under conditions of unified partisan government.
All of the bills that Congress considered would have delegated huge latitude to federal and state administrators. The failure of comprehensive reform meant that the Trump administration relied all the more heavily on executive branch action to shape the exchanges and Medicaid. While waivers have often expanded Medicaid enrollment, the Trump administration vividly illustrates how this tool can be deployed in an effort to achieve the opposite effect.
The experience with some Section waivers also indicates that at times a commitment to federalism—to the principle of deference to state preferences—may triumph over the policy objective of sabotage.
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Meanwhile, Democratic attorneys general sued the Trump administration for its failure to defend federal executive branch prerogatives to provide CSR payments without congressional appropriation. On the other hand, many of these commissioners also supported federal initiatives to increase the availability of lower-quality health insurance. On balance, these developments suggest that as congressional control of the executive branch has ebbed, states have often stepped in to reinvigorate checks and balances within American governance.
These developments not only possess important implications for who gets what, when, and how from the health care system, but also for theories of executive federalism. Oxford University Press is a department of the University of Oxford.
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Volume Article Contents. The Tribulations of Lawmaking and the Intergovernmental Lobby. Executive Branch Action and the Insurance Exchanges. Executive Federalism and Medicaid: Waivers to the Fore. Implications for ACA Durability. Rutgers University in Newark and New Brunswick. Email: fthompson ifh. Oxford Academic. Google Scholar.
Michael K Gusmano. Rutgers University and the Hastings Center. Shugo Shinohara. International University of Japan. Cite Citation. Permissions Icon Permissions. Abstract This article assesses the politics and partial success of Congress in repealing the Affordable Care Act ACA , known as Obamacare, with particular attention to lobbying by governors. Table 1. Source : See description in text. We thank John Dinan and our anonymous reviewers for helpful comments on a previous draft, and Cynthia Golembeski for her invaluable research assistance. Medical care has been easy to access on Medicaid.
She paid for none of it. She spends most of her income on paying off her car, a used Prius with , miles on it, and her last outstanding student loan. For Ms. Before that, she had a job with benefits but quit because of her difficult pregnancy. And when Harry was up all night sobbing with a fever recently, she hesitated briefly before seeking medical help, again at urgent care.
News stories in New Hampshire have stoked the resentment Ms. Hurd and others facing spiking premiums have felt. The story was about a report that found Medicaid recipients used health care more aggressively than marketplace customers, presumably because their coverage was free.
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Instead of giving its new Medicaid recipients traditional coverage through the program, New Hampshire uses Medicaid funds to buy them private plans through the Obamacare marketplace. The firm found this raised average claim costs — a proxy for premiums — for everyone by 14 percent. One of the conditions that Gov.
Chris Sununu has attached to continuing expanded Medicaid here is that most adult recipients without a disability or small children will have to work, volunteer or get job training, at least 20 hours a week. New Hampshire is among eight Republican-controlled states asking the Trump administration for approval to impose work requirements; two others, Kentucky and Indiana, already got permission last month. But research has found that most Medicaid recipients without disabilities, like Ms. DiCola, already work at least part-time. DiCola started driving for Uber and Lyft three years ago, after stints at a Panera and a train station cafe.
Her days include pitching in on cooking and other household duties, auditions, rehearsals and studying musical scores on her couch, a cat or two by her side. She hopes to get a college degree, find a more stable career and get access to employer health coverage.
Health Insurance: Premiums and Increases. Oregon rates reflect preliminary changes from the state. Delaware, Iowa, Nebraska, Ohio, Oklahoma, and Wyoming figures are the average on-exchange rate increases for exchange-participating insurers. Oscar is planning to enter the Arizona, Florida, and Michigan marketplaces.
Presbyterian is planning to reenter the New Mexico marketplace. Wellmark is planning to reenter the Iowa marketplace. Medica is planning to enter the Missouri and Oklahoma marketplaces. Centene is planning to enter the North Carolina, Pennsylvania, and Tenessee marketplaces. Geisinger Quality Options is reentering the Pennsylvania marketplace. Bright Health is planning to enter the Arizona and Tennessee marketplaces. Virginia Premier is planning to enter the Virginia marketplace.