Despite a recent federal court ruling creating some uncertainty about the future of Medicaid expansion, industry experts express optimism about several recent developments that they believe will give way to better patient care going forward.

For one, November’s midterm election results may spell more Medicaid expansion, particularly in historically Republican-controlled states. Voters in three states approved measures to extend Medicaid coverage, and three Democratic governors unseated Republicans who did not support expansion.

By Lauren Flynn Kelly

Despite a recent federal court ruling creating some uncertainty about the future of Medicaid expansion, industry experts express optimism about several recent developments that they believe will give way to better patient care going forward.

For one, November’s midterm election results may spell more Medicaid expansion, particularly in historically Republican-controlled states. Voters in three states approved measures to extend Medicaid coverage, and three Democratic governors unseated Republicans who did not support expansion.

From a policy perspective, given that Congress is “fairly neutered in the split in the House and the Senate, then the bigger macro level, seismic changes like per capita caps are probably off the table vs. more under-the-radar, yet significant impacts you see from a regulatory and even judicial perspective,” predicts Alex Shekhdar at Medicaid Health Plans of America.

“In terms of patient engagement, payment reforms and so forth, the biggest tool that the administrator and the secretary have to effectuate the Medicaid programs is the 1115 waiver,” he says, referring to the demonstration waiver that states can use to make broad changes to their Medicaid programs or modifications that focus on a specific population or service over a five-year period. “And [CMS] has indicated that there is no stop and believes they have the legal authority to continue to push forward on the waivers.”

“I think the tide has turned and the red states realize that Medicaid is an important part of the continuum of health care in the U.S.,” weighs in Jerry Vitti, CEO of Healthcare Financial, Inc. “But I also see the potential for more work requirements, lockout periods and premiums, copayments, deductibles…and I think there will be a continued push to get those approved” via 1115 waivers. As a result, Medicaid managed care organizations may see a “burst of enrollment” from expansion, followed by churn due to various requirements that make it difficult for people to maintain coverage, he predicts.

Meanwhile, states and plans are hoping for more leeway to address social determinants of health, adds Vitti.

HHS Sec. Alex Azar in public comments last fall hinted at a possible demonstration addressing social determinants through the Center for Medicare and Medicaid Innovation. Given some of the work already being done by Medicaid MCOs to address housing and other non-medical factors through local partnerships, CipherHealth’s Friso van Reesema says he is optimistic that CMS will “follow suit” and start reimbursing for those types of services.

With the aim of expanding health care coverage and affordability for residents who would not otherwise qualify for Medicaid or federal subsidies to purchase Affordable Care Act marketplace coverage, several states are exploring the concept of allowing people to buy into their Medicaid programs. New Mexico may be the furthest along in that process, having commissioned a two-part study to seriously consider the financial implications of four different Medicaid buy-in scenarios.

By Lauren Flynn Kelly

With the aim of expanding health care coverage and affordability for residents who would not otherwise qualify for Medicaid or federal subsidies to purchase Affordable Care Act marketplace coverage, several states are exploring the concept of allowing people to buy into their Medicaid programs. New Mexico may be the furthest along in that process, having commissioned a two-part study to seriously consider the financial implications of four different Medicaid buy-in scenarios.

According to the report produced by Manatt Health, “Evaluating Medicaid Buy-In Options for New Mexico,” Medicaid is the largest payer in the state, covering more than 40% of the state population. By contrast, the BeWellNM marketplace covers about 50,000 individuals, or 2% of the population. While marketplace coverage may be affordable for some, there are various reasons why eligible individuals are opting out, such as rising premiums and cost-sharing affordability, especially if they do not qualify for federal subsidies, observed the report.

The report also suggests that individuals would pay premiums and cost-sharing, but by leveraging Medicaid’s purchasing power, provider networks and reimbursement rates, the cost of buy-in coverage would be less than the cost of private coverage. That report made a qualitative assessment of four options:

(1) Targeted Medicaid Buy-In Program, where the state offers Medicaid-like coverage off the BeWellNM marketplace to those not eligible for Medicaid, Medicare or subsidized marketplace coverage.

(2) Qualified Health Plan Public Option, where the state offers a lower cost public option product on the marketplace to individuals and small employers, although it could be expanded outside of BeWellNM for people who are not eligible to purchase individual coverage.

(3) Basic Health Program, a state-offered option for individuals with incomes up to 200% of the FPL who are not Medicaid-eligible and are otherwise eligible to purchase coverage through the marketplace.

(4) Medicaid Buy-In for All, where the state offers Medicaid coverage to everyone (except those covered by Medicare) as a lower-cost option off the marketplace.

According to Patricia Boozang at Manatt, the consulting firm and its actuarial partner Wakely Consulting Group are now in the second phase of the study, working “to develop an actuarial analysis that projects the number of people likely to be covered through one or two variations on the Option 1 Targeted Buy-in model” outlined in the paper.