Flexibility and Innovation


Please note: This is an unedited transcript. Note: This is an unedited transcript. For direct quotes, please see video at http://allh.us/9AEg

SARAH DASH:  Good afternoon, everybody and welcome. Thank you for joining us here today for today’s briefing on flexibility and innovation in Medicaid.  My name is Sarah Dash, and I am President and CEO of the Alliance for Health Policy. For those of you who are not familiar with the Alliance, we are a non-partisan organization dedicated to advancing knowledge and understanding of health policy issues. We want to say hello as well to those watching us live on CSPAN today, and if you’re following us on Twitter, we’ll be live tweeting during the event, and you can join the conversation using the hashtag Allhealthlive, as well as ask a question over Twitter at the appropriate time.

So this year’s state Medicaid policies have made national headlines, and while states have always had significant flexibility to tailor their Medicaid programs within parameters established by the federal government, there is ongoing discussion about additional changes that have been allowed this year and recently, and we’re going to have a good discussion about those today. Many states are considering changes to their Medicaid programs, which include perhaps most notably work in community engagement requirements, as well as expanding coverage to additional beneficiaries, and establishing innovative care models to address the opioid epidemic and other challenges. We are really pleased today to have a panel of distinguished Medicaid experts here to talk about how states are responding to the administration’s new priorities for the Medicaid program, as well as the role of the courts in shaping Medicaid policy.  And we’re particularly pleased to be joined by the leaders of Medicaid programs in two states: West Virginia and Arkansas, who are leveraging flexibility through 1115 waivers to alter the design of their Medicaid program.


So before we get started, I’d like to thank the Commonwealth Fund for making today’s briefing possible, and introduce Rachel Nuzum, Vice President of Federal and State Health Policy at the Fund, who will join me as co-moderator during today’s briefing. And Rachel, I’m going to introduce the panel, and then we’re going to turn it over to get you started with some brief opening remarks. Terrific.


So joining us today we are really pleased to have today Calder Lynch, who is Senior Counselor to the Administrator of the Centers for Medicare and Medicaid Services. Prior to this role, Mr. Lynch served in several senior level health policy positions in state governments. Most recently, he served as Nebraska’s Medicaid Director, under Governor Pete Ricketts.


Next we will hear from Thomas Barker.  Thomas is partner and co-chair of the healthcare practice at the law firm, Foley Hoag. Mr. Barker established, and is a contributor to the firm’s blog, Medicaid and the Law. Prior to joining the firm, he served in a series of senior level positions at the Centers for Medicare and Medicaid Services, and the Department of Health and Human Services, during the George W. Bush Administration.


Following Thomas’s presentation, we will hear from Cindy Beane, who is Commissioner of the West Virginia Bureau for Medical Services. She led policy implementation for changes under the Affordable Care Act, which enabled approximately 165,000 West Virginians to gain healthcare coverage. Commissioner Beane manages and oversees project development, implementation of health policies and assures compliance with federal and state regulations, while creating innovative healthcare services to address the needs of West Virginians.


We will also hear from Cindy Gillespie, the Director of the Arkansas Department of Health and Human Services.  Her previous career includes serving as a principle at the multinational law firm Dentons, where she lead the health policy and health insurance exchange teams, and as advisory to Massachusetts Governor Mitt Romney on health policy, and federal programs.


Finally, we will hear from Leo Cuello, who is the Director of Health Policy at the National Health Law program. Prior to joining NHealth, Leo worked at the Pennsylvania Health Law Project for six years, focusing on a wide range of healthcare issues dealing with eligibility and access to services in Medicare and Medicaid.


So we have a full panel and we’re really excited to hear what everybody has to say. Before I turn it over to Rachel, how many people have a burning question  you want answered? Can we just have a show of hands? How many people came here because you have a burning question you want answered about Medicaid and what’s going on in the States? Come on, there’s got to be more burning questions than that. You are going to get to write your questions down, and ask them later, so get ready. Before that, I’m going to turn it over to Rachel.


RACHEL NUZUM:  Great, thanks so much, Sarah, and thanks to all of you for being here. I am Rachel Nuzum, I’m the Vice President for Federal and State Health Policy at the Commonwealth Fund.


I just want to take a couple minutes just to kind of lay the groundwork. I think for those who work in health policy, we don’t really need to explain why we’re talking about Medicaid, but for others that may be wondering, well, how much do really need to focus on this program? I just want to give a little bit of context into how central of a role it is actually playing in our healthcare system federally, but also in the state level. There has been a lot of discussion now about Medicaid as the largest insurer in the nation, and in fact, it is the largest single insurer. We also know that it covers the majority of births in the United States, it also covers the large proportion of care at the end of life, and more recently it has emerged just the importance of Medicaid as a provider of behavioral health services. About over half of the behavioral health services in the country are provided, and financed by the Medicaid program, and the estimate is about 20% of Medicaid and these do have behavioral health needs. This is a really critical program that is serving a number of Americans. The old adage about Medicaid is that if you’ve seen one Medicaid program, you’ve seen one Medicaid program, and I think that’s probably never been more true than it is today. Not since the program’s inception in 1965 have we seen this much variation across the country. States have always been unique. States have always developed their Medicaid programs to reflect their own communities, their own marketplaces, their own populations, their own financial and legislative framework. But right now we see a very varied landscape when we look across the country. 25 states have expanded Medicaid, about eight are advancing expansions with the use of 1115 waivers, like Sarah mentioned. Work requirements are kind of the issue of the day that a lot of people are focused on, and interested in, and we are starting to see those. Ten states have work requirement provisions submitted, included in an 1115 waiver. Some of those have been approved, one has been blocked, we are going to hear more about those, and just hear about this. But the use of waivers is not new in Medicaid. I just wanted to kind of remind us that that’s been kind of a guiding principle all along that states have always had this flexibility to ask for additional opportunities to really craft their program, and design it in a way that makes sense to them. And so I’m looking forward to having a discussion about how those trends have happened over time and what we’re seeing now in terms of those impacts.


We are seeing additional waves of states considering next steps on Medicaid, such as the ballot initiatives and perhaps more so this year than we’ve potentially seen in years in the past. And why does this really matter? It matters because Medicaid has been solely responsible, or singularly responsible for some of the biggest changes in the rate of uninsured over the last couple of years. All states between the years of 2013 and 2015 saw a reduction in rate of uninsured. We saw much larger rates of uninsurance obviously in the states that expanded. And the big reason to focus on Medicaid is because actually having coverage does matter. This slide shows just a part of a study that we did with Ben Summers and his colleagues that looked at Medicaid beneficiaries and their ability to access a personal doctor, how often they went to the Emergency Room, and whether or not they were able to get a check-up. To really help answer this question, are we just extending a Medicaid card? Or are we actually kind of connecting folks to care, which is obviously the goal, and something that we’ll be talking about as this panel goes on.


And then finally, Medicaid is a driver of innovation, it’s not just about the way we cover and about, you know, discussions around our benefits and design and eligibility. Medicaid as a program has a tremendous amount of leverage and market power, and it also plays a very distinguished role in terms of finances for the safety net system, and for many state and local economies. So with that, I’m going to turn it over and so we can get started with our panel, thank you.


SARAH DASH:   Fantastic. Thanks, Rachel.  We will turn it over now to Calder Lynch. Thanks, Calder.


CALDER LYNCH:  Good afternoon. Thank you for the opportunity to be here today, I’m Calder Lynch, I serve as the senior counselor to CMS administrator, Seema Verma. I’m pleased to be here to talk about some of the administration’s work and priorities around Medicaid, and then engage with this very distinguished panel this morning.


So let me begin by saying that the work that we’re doing in Medicaid is really guided around three pillars that the administrator outlined nearly a year ago last fall at the National Association of Medicaid Director’s Conference, and those are:  Flexibility, Accountability, and Integrity.  And I will talk about some of our work around each of those, of course focusing on the flexibility aspects since that’s the topic of today’s briefing.


I will begin with Flexibility. That’s been articulated in a number of efforts. Of course we are working on a number of regulatory provisions to provide states with increased flexibility and to remove some of the administrative burdens they face. But much of that has been articulated through our work around 1115 research and demonstration waivers, which we heard a little bit about here this morning. The first area I will talk about, before we move into community engagement, is focused on the work done by states really respond to the growing opioid epidemic across the country. A year ago, we released guidance to states, opening new opportunities for them to more quickly gain access to substance use disorder waiver authority, to be able to expand access to residential treatment, as well as build out community-based treatment options for people facing substance use disorder. I’m happy to say that we’ve since that time approved ten states under that more flexible guidance that we released, bringing the total number of states with an SUD waiver authority to 15, and we have several more pending before us. And so that’s something that’s really important that we really work to try to issue and be responsive to the national epidemic, and give states that flexibility. And we’re seeing some very positive results already from the early implementers of that authority in terms of reductions in Emergency Room visits, and improvements in care for individuals.


The other piece I will talk about that I think we’ll hear a lot about today, is the community engagement demonstrations. This January we released guidance to states really in response to strong interest that we’d heard, that states were very interested in finding ways to connect non-disabled adult beneficiaries to working community engagement opportunities through Medicaid. Since the Affordable Care Act was implemented, the Medicaid program has expanded to over 15 million working age adults that have newly enrolled into the program. So this was a growing interest and concern that we’d seen from states. So in response to that, we worked really hard over the course of 2017 to understand those requests, and to craft guidance and policy to better facilitate them, and that culminated in the release of a state Medicaid director letter in January that outlined our commitment to that approach, as well as the considerations that states would need to undertake to design such a waiver, including protections for beneficiaries, encouragement to align their programs with what exists already in the SNAP and TANF programs; really encouraging partnership between state agencies and state partners to be able to help better serve individuals how to be successful in meeting those requirements, and outlining the kinds of things we’d expect to see in a demonstration for us to be able to approve it. We’ve obviously had very strong interest, as you’ve seen, across the country, in terms of states submitting demonstrations in response to that guidance. We have three that are currently approved. One that has implemented that we’ll here more about today, and we’re learning a lot as we move through this process, about how this is working on the ground. So to that effort, we’ve engaged states in a learning collaborative to be able to learn from each other’s implementation, to be able to provide better guidance to states that are working on these policies. We have had 18 states engaged with us in this learning collaborative, we’ve had several webinars, our first in-person session, and really getting down to some of the nuts and bolts around how to operationalize community engagement demonstration programs effectively, how to partner with your other sister state agencies, your workforce programs, to be able to connect beneficiaries to the types of resources that will help them be successful. How to build the right systems to be able to better support those initiatives, to be able to connect the different existing state data sources. To be able to verify employment and participation in ways that reduce administrative burden for beneficiaries. So a lot of real heavy work is going into this to try to have good results for folks, and we’re going to continue that effort with the current states we had before, and some more that are coming through.


The next pillar I want to quickly touch on is Accountability, because this goes hand-in-hand with our commitment to flexibility. As we offer states greater flexibility, we respond to their requests to test new and innovative demonstration designs, we want to make sure we have accentuality for achieving the outcomes we’re setting out to achieve. So with that effort we — this is something that we spent a lot of time focused on, especially considering just the growth in spending in Medicaid. It’s gone from 10% of state budgets, to 26% over the last 30 years. We’ve seen over $100 billion in increased federal spending in just the last five years, so a lot of interest in having accountability on what are we getting for this investment, especially on behalf of the 75 million beneficiaries that we’re serving. So that’s why we’re working specifically in the 1115 space to standardize metrics across waivers, to have stronger evaluation designs that states need to use when they’re implementing these programs, to use consistent monitoring and evaluation terms across all of our 1115 demonstrations, so that we can have better transparency, better consistency in knowing the types of outcomes that we’re producing. That’s also why early this summer we released the first ever Medicaid and CHIP scorecard, to begin public reporting around both outcome and administrative performance metrics, for the first time actually looking at both state and federal administrative performance, where we are already seeing reductions in things like state plan processing times, managed care rate approval processing times, and we are able to begin reflecting that into a public dashboard that we can report on. We are going to continue to evolve and update that dashboard, add additional measures and metrics to it, new functionality as we update it at least annually. And you’ll see that reflected in future versions.


And the final pillar I want to touch on in my remaining time is Integrity. With all of these program’s enhancements, investments that we’re making, we want to make sure the dollars are being spent on behalf of eligible beneficiaries for qualified services, so earlier this summer we released an outline, a comprehensive Medicaid program integrity strategy that would really focus on making sure that the program is spending dollars where it needs to be spending them. So that strategy includes looking closely at state eligibility determinations, and responses from OIG audits we’ve seen, make sure that process is being done accurately and appropriately, looking at state managed care, financial rate setting and claiming, which we see as managed care use continues to grow across the country. Making sure that those rates are being set appropriately and being reported appropriately. And also looking at how we can better utilize claims and provider data in our program integrity efforts. Many of you probably heard of TMSIS, this is our new Transform Medicaid Statistical Information System, where we now have every state and D.C. and Puerto Rico reporting in a much more robust data set to CMS. We are able to begin utilizing that, and looking at program outcomes, program integrity measures, to understand how the program is performing.  And in 2019, we’ll begin releasing our first analytic files to the research community to be understanding better how the Medicaid program is performing.


So I think you can see there is a lot of work happening across the agency, a real commitment across those three pillars of flexibility, accountability, and integrity, and very much view those as going hand and hand, and complimentary of each other, as we continue to work to implement the vision that the administrator has set out.  Thank you.


THOMAS BARKER:  Thank you, and good afternoon everyone.  My name is Tom Barker, I am a partner at the law firm of Foley, Hoag, and I co-chair our firm’s healthcare practice. I have a couple of slides that I’m going to walk through. I’m going to give sort of a background on Section 1115 of the Social Security Act, waivers in general, and then I’m going to say a little bit more about some of the points that Calder focused on; some of the guidance that the administration has issued, and some of the history of waivers in this administration.


So just by way of level setting, or by way of background, Section 1115 of the Social Security Act allows the Secretary of HHS to waive “any of the requirements of Section 1902 of Medicaid, if in the Secretary’s judgement, doing so would promote the objectives of Medicaid.” So what is Section 1902? So if you are ever on Jeopardy, and the clue is “This is the longest sentence in the English language.”  If you were to say, “What is Section 1902 A of the Social Security Act, Alex”,  likely, you would win. Because Section 1902 A begins with the words “A state plan for medical assistance must…” and then it lists, if I’m not mistaken, 83 requirements that a state plan for medical assistance must comply with. All Section 1115A is doing, is allows the secretary to waive any of those 83 provisions. And some of the provisions for example; benefits have to be available statewide; benefits have to be made available with reasonable promptness; beneficiaries have a free choice of provider; payment rates have to be set through a public hearing process. All of those provisions can be waived if, in the secretary’s judgement, doing so would promote the objectives of Medicaid. Section 1115 also allows the secretary to fund programs in Medicaid that would not otherwise be authorized under allowable expenditures under Section 1903A of the Social Security Act.


One of the key phrases in that sentence is:  “If in the judgement of the secretary…” So the courts had been incredibly deferential to the secretary over the years in implementing or assessing Section 1115 waivers. Generally speaking, courts do not see it as their role, to second guess a decision that’s been made by the secretary in granting a waiver. Never the less, there is some case law that suggests that the secretary’s discretion is not absolute. There are a couple of cases from the 9th Circuit going back to the mid ‘90s that suggest that a state has to at least provide some cursory level of review to a state’s request, and of course more recently Leo will talk more specifically about the most recent example of a court setting aside a 1115 waiver, based on the principle that the failure of a state to consider whether a waiver promotes the objectives of Medicaid can be fatal. And we’ll say a lot more about that as we go on this afternoon. I would also say waivers cross political boundaries, so I thought Rachel made a really good point in her presentation when she said we’re talking a lot about waivers now, but Rachel’s point was, but waivers have been around for a long time. And so at least as far back as the Carter Administration, where President Carter and Secretary Califano approved waivers of cost-sharing; the cost-sharing prohibitions in Medicaid. President Reagan, if I’m remembering the history correctly, personally directed HHS to approve what became called, or known as Katie Beckett waivers, which really now are Section 1915B, home and community-based services waivers. The genesis of those was the so-called Katie Beckett waiver that if, again, if I’m remembering correctly, arose because President Reagan received a letter from a family saying that their daughter had to live in a nursing home in order to qualify for Medicaid. President Clinton approved a waiver that I remember reading about back in the early ‘90s, for the State of Oregon that really completely transformed Oregon’s Medicaid program. President George W. Bush approved waivers for the State of Florida that expanded the use of managed care in Medicaid, and also allowed states to impose a global cost cap in Rhode Island and Vermont. And then in the Obama Administration, some degree of the Medicaid expansion in the ACA was implemented via waivers, and the Obama Administration was also quite aggressive in approving delivery system reform waivers as well, and of course the Trump Administration now is also very aggressive. And so I’d like to turn to that now.


So Calder mentioned a lot of the guidance that’s come out. Some of what I’m going to say, duplicates his comments, although one thing I didn’t hear Calder mention to me, at least as an outsider, it all started with a letter that Administrator Verma and then Secretary Price sent to the governors in April of 2017, announcing what they called “a new era” in Medicaid. And they said in that guidance that they would give priority to waivers that focus on improving program management, community engagement, so the concept of community engagement goes back to the Spring of 2017, just a couple months after President Trump took office, in that letter. There was an information bulletin to states that came out in November of last year, that came just a couple of months after Administrator Verma’s speech to the Medicaid directors that Calder mentioned in his presentation. Calder mentioned the community engagement requirements that came out in January of this year, and Administrator Verma made some announcement just a couple of weeks ago — made some announcements, or sort of reiterated the administration’s position at a Medicaid Managed Care Summit a couple of weeks ago.


A couple points:  It seems to me that CMS has been quite aggressive in approving community engagement waivers, despite the obvious litigation risks. The administration seems to be continuing forward with the concept of community engagement waivers. CMS is also using waivers to combat the opioid epidemic, and I think that is worth focusing on a little bit, so there’s this quirk in the Medicaid program called the IMD exclusion, which essentially prohibits Medicaid from paying for services in an institution for mental disease, for individuals between the ages of 21 and 65. And that exclusion, that IMD exclusion, really historically CMS has been very, very reluctant to waive. Legally, it’s not quite as easy to waive it, as there are other provisions in Medicaid, but this administration has been quite aggressive in approving waivers of the IMD exclusion, at least to the extent that it’s to deal with the opioid crisis. CMS clearly has some limits. The Massachusetts waiver, we saw that Governor Baker wanted to waive provisions of the Medicaid prescription drug rebate program and the CMS rejected that waiver, so there are some limitations.


So I’m going to wrap up there, happy to take questions after we’re all done speaking and I’m going to pass this down, if I may.


SARAH DASH:  Thank you, Tom, and before we hear from Cynthia Beane, can I just ask if you could elaborate a little — what kind of falls under community engagement specifically?  If you could elaborate on that. Either Calder or Thomas, actually.


CALDER LYNCH:   Sure, I’ll elaborate. So really our guidance outlines a number of activities that states can count toward meeting a community engagement requirement, including work, volunteering, education, training, and states have some flexibility. What we’ve encouraged states to do is look at the activities that count under other existing work and community-engagement programs like those used in SNAP and TANF, and potentially align with those. Or add additional activities as they think appropriate for the population of the targeting through the Medicaid waiver, but really have a lot of flexibility in designing that at the state level.


SARAH DASH: Thank you.  Okay, Cynthia Beane from West Virginia.


CYNTHIA BEANE:  Hi, Cindy Beane, I’m the Commissioner at West Virginia Medicaid. I’ve been there in my position for about four years and before that, I was the Deputy Commissioner at Medicaid. So a lot of history with West Virginia Medicaid, and we have gone through a lot of changes. What I want to do is highlight the West Virginal footprint, and all the changes that CMS has made available for us to tailor our program to meet the needs of West Virginians.


So West Virginia Medicaid, just to give you an idea of the footprint of what Medicaid is in West Virginia, one out of every four adults in West Virginia is covered by West Virginia Medicaid, three out of five low income individuals, one out of every two children born in West Virginia are covered by Medicaid, three out of four of all our nursing home residents, and one out of every two people with disabilities. So in West Virginia, Medicaid has quite a large footprint in our healthcare system. So when the decision was whether or not we were going to expand Medicaid under the ACA, one of the things that was taken into consideration is, we need a healthy workforce in West Virginia. Our economy is changing, and at that time of expansion, we were starting to see the rise of the opioid epidemic in West Virginia. 20,000 of our Medicaid expansion members actually have a primary diagnosis of SUD, 50,000 of our expansion members actually have a secondary diagnoses of SUD. So when we expanded Medicaid in West Virginia, we used one of the flexibilities that was offered, and we used it at modified 1115 waiver in order to get people on the roles. Our actuaries predicted that by year two or three, we would have 90,000 individuals enrolled. We were very successful. We had over 100,000 individuals enrolled within a period of six months. What we found was, there was a lot of demand with individuals that previously didn’t have healthcare. We found individuals had a healthcare need that were no longer able to work. We had a hairdresser give testimony on that. She had to have a knee replacement, couldn’t afford it, got an expansion, got her knee replaced, and was back to work. So that’s how expansion worked in West Virginia.


Speaking of the opioid epidemic, and I think it’s mentioned here a couple times, about the 1115 opportunity for SUD. This stat is devastating for the state of West Virginia. We lead the nation in overdose deaths. You can see the national average is around 19, and we are at 52 per 100,000. So we were very excited with the opportunity that CMS gave to produce SUD waivers to get services out there, to get full, continuous services for individuals with SUD. We were the first state to be approved under the Trump Administration for our waiver. Our waiver basically provides a continuous services for individuals that are suffering SUD in West Virginia. It goes from an passement to actually in-patient treatment, waives those IMDs, so we can have some short in-patient stays, and also does some peer recovery supports, and also expands our use of medication assisted treatment, which is an evidenced treatment for SUD, and so in West Virginia, as soon as we applied for that waiver, we got lots of calls from individuals who previously were going to perhaps a methadone clinic, paying cash. I remember one call I took from a grandmother who said, you know, crying on the phone, “Thank you, I hear you’re covering this now, I didn’t know how much longer I was going to be able to hang on. My car is breaking down, but I’m paying the methadone clinic for my grandson, and this is the best he’s been in five years. I’ve getting him back, and I can’t — I don’t know how we would have hung on.” So those are things that are going on in West Virginia, and that’s how Medicaid is making a true difference in the lives of West Virginians.


With the 1115 waiver, with the new administration and it’s always been — an emphasis is an increasing accountability. So with the evaluation, we have partnered with our university — West Virginia University — to really do a robust evaluation of our waiver, and we’re doing a comparison study with regards to our waiver, it’s impact, and actually doing a different study with another state. And we’re also trying to get another state to come on board, but that’s where we’re at right now.


Neonatal Abstinence Syndrome; this is something that happens to babies when they’re exposed to drugs in the womb during pregnancy, and it’s basically the withdrawal of those babies. So a baby with Neonatal Abstinence Syndrome is not best served in a NICU with bright lights and lots of noise. So we actually had a unique opportunity, we had some nurses at one of our NICUs that were being inodiated with these children, and started a place called Lily’s Place, and it is actually a place where these babies are weaned off and withdrawn in a setting that is more conducive to the baby;  not in a bright light NICU. We worked with CMS to figure out, how can we get this approved? CMS actually worked with us for months, and we got a state plan approval for that, and we are the first state to be able to do that and we are very excited about that program.


Another flexibility that West Virginia has taken advantage of is our health home flexibility. This flexibility gives an opportunity for you to have the health home that integrates both your physical and behavioral health, and it gives a team approach to that individual, follows up, makes sure they are following up for their appointments. We have two health homes running in West Virginia. Our first health home was a Bob Hohler Hepatitis C Health Home. Also, due to different factors we lead the nation in hepatitis as well. And we went from a 25% screen rate to a 100% screen rate for hepatitis for our individuals participating in our health  homes.


Just some quick statistics for our first health home. This was our Bob Hohler Health Home and we actually started out in a pilot area, so we had a six county pilot, and then compared it to a six county cohort pilot in another area of West Virginia to see some dramatic results of what it took to get that team approach in health homes. Here is another statistic with our health home, this shows you compared to the cohort, the decrease in hospitalizations as well.


Lastly, one of the flexibilities that West Virginia uses, we are about a 78% managed care state. Our managed care companies have brought to the table different mechanisms for flexibilities such as value-based payments. We are looking at some different employment supports, and incentives through our managed care agencies, and also they have value-added services that they can offer our members as well. So in West Virginia we take a multi-prong approach to do whatever it takes to meet the needs of the members.


SARAH DASH:   Thank you so much, Cindy. Now we will her from Cindy Gillespie from Arkansas.


CINDY GILLESPIE:   Thank you. I was going to give just brief overview. I’m going to put in context — I’m mostly going to talk today about what we’re doing to implement the working community engagement requirement, but as Cindy Beane just showed, and was said earlier, every state is different. Our state, we have about one of every three resident is in Medicaid. We have a lot going on in addition to the implementation of working community engagement requirements. And while I’m not going to spend time on all of this, I wanted you to see how in every state simultaneously, major shifts are always underway, and they are always playing back against each other. You’re never doing one program change in isolation. So right now, for example, we are focused on really shifting Arkansas’s Medicaid program in many ways to have a more client-centered approach to service delivery across all populations. And when I say “all populations”, we are focused not just on them from the standpoint of traditional versus expansion populations or behavioral health and intellectually developmentally disabled, but also our foster kids, the youth we have in juvenile justice, these specific populations, we are doing certain directed Medicaid programs towards them. To put it at a very high level, so you can see the way we’re going at this, first we want to make sure we begin to integrate a lot of the non-medical programs that are available in the state, into the case plans and the work going around our citizens in Medicaid. We see that they do not work together well, and to help people move out of poverty, and to get to better health, we have to integrate those programs, so we are focused on that. We are also focused on improving communication. There has not been an effective outbound communication program with Medicaid beneficiaries over the years, and we’ve realized the need to make that a core part of being able to be effective.


A more client-centered approach. In the past, Arkansas has been very provider centered; work through the provider to get to the beneficiary. Instead, it’s beginning to look at the individual beneficiary and what programs and services do they need. And then finally, probably most importantly, expanding the services available. Cindy’s presentation — we did not have a robust spectrum, for example, of substance abuse services available. As of July of this year, we now do. And those kinds of services, it’s incredibly important that Medicaid make them available for us to be successful.


Brief look back at what’s happened with Medicaid expansion in Arkansas, because this affects what our waiver looks like. Arkansas expanded in 2014 in a unique demonstration where they enroll — they called it the private option. Beneficiaries were enrolled into plans available through the exchanges, through the marketplace. So they are enrolled in the QHPs, the goal was to increase access, and increase coverage in the state and that was achieved in the four years of that demonstration. The uninsured rate was cut in half.  In 2017 we began to amend this waiver. One element of the amendment was to increase the focus on assisting those individuals in the waiver, access services that could help them move towards economic security. So as part of that, we were going to refer individuals on the expansion program to services available for education, training, job search, et cetera. There were other elements in that amendment, and we worked with that through the year. We did not see the referrals working, and interestingly, doing these referrals we began to have a lot of discussion with our fellow agencies that provide education services, training services, job services, et cetera. And realize that they, in a state with low unemployment, and unfortunately we do not have the labor participation we need, that they were having trouble finding people to use the services. And the next year, we amended the waiver under the Trump Administration, and put in the work in community engagement requirement for able bodied enrollees under 50 years of age, without dependents. And I will talk about how we are implementing that. It applies only to those who are in a QHP. Anyone who is medically frail and is not enrolled in these private insurance plans, it does not apply to them. We do still have a request pending around income eligibility limits.


So very quickly through this:  If an enrollee is over 50, they are not subject to the work requirement. If they are subject to the work requirement, they are exempt from reporting if they meet certain other conditions. If they meet an exemption — the exemptions I will go through in a minute, but the exemptions are as Tom Barker mentioned earlier: If you have a dependent child in the home, if you are caring for an incapacitated person, if you are working 80 hours a month, if you are in behavioral health treatment, if you are in substance abuse treatment, there is a long list. If you have a chronic disease. There is a long list of exemptions that are available for someone, and then they are not at risk for losing their Medicaid coverage, if they have these exemptions. If they are required to report work activities, they then have a risk of losing their Medicaid coverage for the rest of the plan year, if they have three months of non-compliance during a plan year. For those of you who have been following the way the Affordable Care Act was implemented here around QHPs, a lot of this will sound very familiar. It is the same type of, after three months of non-compliance, you lose coverage until the next plan year, when you can re-enroll. It’s always tied back to the insurance world. The state validates the exemptions. This is part of what Calder was talking about. We validate the exemptions wherever we have the data. So if we have data available from someone’s Medicaid application that shows that they have a dependent child in the home, we give them the exemption. If we have data available that shows that their income level is such that they would be working more than 80 hours a month, if they were earning minimum wage, they are given the automatic exemption. Other exemptions they have to notify us, I will give you a simple example, one here, pregnancy how it works. Someone who is pregnant is exempt. So they notify us they are pregnant, they are then exempt through the rest of the pregnancy, at which point they notify us that they had the child, and then they are exempt until the child leaves their house. So those exemptions follow in that way. Other exemptions have to be reported and they have to notify us, for example, if they are in behavioral health treatment, they notify us that they are in that. They are exempt for two months. After two months, they notify us that they are either continuing or that they are now out of that and have moved on either to another exemption or moved hopefully into work.


A couple of unique elements:  The demonstration has been built on the use of QHPs, as I said. Those who are in a QHP usually have a broker, an agent, a commercial — they have these commercial insurers, they have someone who is there to work with them to help them with employment, education and training. A key part of the way we have built this, has been to use the fact that these individuals have an insurance carrier who cares about ensuring that they keep their coverage. The other thing to be aware of is we use a lot of proactive outreach tools. Not only us, but the carriers use them, our Department of Workforce Services, we have had an extensive use of social media. For the first in Arkansas, I talked about wanting to begin doing more where we communicate more with clients. For the first time we are doing outbound communication with clients. That has been part of the way the whole program has come together. All total, we have sent over 160,000 letters, 150,000 phone calls, there have been people knocking on folks’ doors, we’ve had emails going out in the hundreds of thousands. The carriers have been data mining claims and calling people. The Department of Workforce Services has been reaching out; it’s been an extensive effort.


What I want to mention here, is technically how that outreach effort works. When someone enrolls in Medicaid, and they are going into the expansion category, the first thing that happens for them is they are given to our outbound education center. And they reach out in the first ten days that the individual is enrolled. Before they even are assigned to a carrier. And they educate them on the fact that they have a working community engagement requirement and try to see how they can help them meet it, whether with exemptions or whether with referring them over to services that can help them. They are then given to an insurance carrier who works with them. And so there is always at least 45 days to 60 days before the person goes actually onto the QHP and their requirement starts. And it is in that period that we work with them to get them ready to be in this new world of having a working community engagement requirement. All of it is about trying to get them to the services that can help them with education, training, work, et cetera. So they do report their activities online through a portal. It’s a self-service portal that we’re using around Medicaid in general. They usually will either have an online account already, or we will help them get an account set up. There has been confusion, I think, in some of the coverage that has gone on about the online portal. If an individual cannot use the online portal, they can just like they do when they apply for Medicaid, they can also come into one of our county offices where we help them, and we have also set up they can call, and there are people who will  help them report over the phone. The insurance carriers provide those. So there has been a way for people to be able to get to that kind of coverage.


Final note here, this has not been an effort just by the Medicaid program. We are working very closely with career education, and with our workforce services agencies. They have also had some assistance from the Trump Administration as you will see here, that has allowed them to use TANF administratively to be able to support these activities. So all of this is about how do we tie these services together around someone?


Finally, I think you have in your packets our latest report, we started this in June. We are four months into the program. Right in this last month, out of the 250,000 people in Arkansas Works, we had 73,000 subject to the work requirement, 53,000 met the requirement for the month, and 4,100 had their third month of non-compliance enrolled. We are implementing this over a four month period this year where we are taking existing beneficiaries and they are rolling onto the program; that’s why the numbers are as they are. We are moving larger groups through.


Finally, this is what closures look like for us, just because there is always a lot of question about it. In September we closed about 15,000 cases at the end of the month. As you can see, 4,100 of those were for non-compliance with the work requirement. As you also see, a lot of these are for people’s income going up. It’s for people who have a higher income, they have moved out of state, they might be incarcerated; there is a lot of reasons people’s income and work changes around Medicaid month to month. Could have had someone move into the home, or move out of the home. So we are tracking this and implementing the program.


At the end of the day, I think the main thing I want to say is, we’re the first to do this, and we are trying very hard to implement the program aimed at our goal, which is to help these individuals that are on the program, access the rest of the services available that can help them move up the economic ladder. Thank you.


SARAH DASH:  Thank you so much, Cindy.  We will now here from Leo Cuello from the National Health Law Program, and then we will move into our Q&A. Thanks, Leo.


LEO CUELLO:  Thanks everybody for being here, thank you to the Alliance and to Commonwealth Fund for having us and all the great work you do.


I’m going to talk about Medicaid flexibility and recent litigation. And I’m going to give you my major points up front. Flexibility can be good and Medicaid is already flexible. Slashing coverage, however, is a bad use of that flexibility from the point of view of policy. And sometimes bad policy is also illegal. So that’s the summary. If you want to do a nine minute power nap, go ahead.


I just want to start making the point that’s already been made, which is that we are all in agreement that Medicaid is already flexible, and that is by definition in statute, so there is no arguing about it, you can see a bunch of the flexibilities on this slide. So flexibility is not a dirty word, right?  But we always have to ask ourselves:  Flexibility to do what? And that leads us to the Kentucky example, where you see a bunch of the flexibilities they requested, which when you add them together, lead to 100,000 people, losing coverage. These are not innovations. They are things that reduce spending and reduce coverage. Now we are on the Hill, and I want to say to those of you who are on the Hill, the design of your statute does not say to states, “Here is some federal money, now go make eligible whoever you feel like making eligible.” Your statute says to states, “Here’s a deal which you can take, or not, here is some federal money, if you make eligible ‘all individuals’ who are eligible.” That is the deal that Medicaid offers states; that is not what is happening here.


So let’s talk about federal standards a little bit. We’ve been talking about Section 1115, which has many requirements, it’s not a carte blanche to just do whatever you want, and I want to talk about two of the most important requirements. One of them is that an 1115 project must be experimental. We are talking about something that must be an innovative type of pilot program. I want to start with a basic proposition that not all innovations are a good idea, right? We can all imagine things that are innovative and might raise suspicions. So if you have a group of people who are living in poverty, and rely on transportation support to get to the doctor, and what you do is you just take away their transportation support. We can intuitively understand what that’s going to lead to. But I’m not asking you to relying on intuition because we also have waivers of things like premiums where we have 40 years of studies telling us what happens when you charge premiums to people who are lower income. It won’t be surprising to you that they drop off coverage and/or are afraid of even applying for coverage. That’s the result. Our second major requirement is that 1115 demonstrations must promote the objectives of Medicaid. Luckily for us, the statute actually defines what that means, which is to furnish medical assistance and other health services. You look at that list of waivers in Kentucky and it looks more like this, right? It looks like barriers to people actually being covered and furnishing care. And we can use the transportation example again. It is literally the opposite of furnishing somebody services to stop providing them with transportation services. We think about the work requirement, which is terminating people who do not comply with an administrative requirement. Terminations, not furnishing health services, not what the act says.


So your takeaway from this slide should be, these are not Leo’s standards; these are not standards that some court made up, these are the standards that are in the statute, passed by Congress. And states — and most particularly HHS, is not heeling to those standards.


Now I know some people will sometimes say, “How do we know what the legislature meant? They don’t know how to write statutes.” All kinds of things. Let’s look at the laws, right? In TANF, you have very clear language. The purpose is to end the dependence of needy parents on government benefits by promoting job preparation, work and marriage. Personally, I don’t think that language is Congress’s finest hour, but it’s in the statute. In SNAP, you have conditions of participation that include work requirements. It is undeniably in the statute. What does that language look like in the Medicaid statute? It’s not there. So again, your takeaway is, when Congress wants work requirements, it knows how to write work requirements. It has added to the Medicaid statute umpteen different times over the years. It has never added work requirements, including the times when it added those requirements to the other programs. Last year we had legislation to do work requirements in Congress that failed. What does that tell you? Most recently, as of last year, Congress says there shouldn’t be work requirements in Medicaid, and number two, if there are a bunch of people in the legislature trying to pass a law saying, “Let us do work requirements,” what does that tell you about the current status of the legality of work requirements.


We have a policy that does not comply with Medicaid law, it does not comply with 1115 law, and unfortunately that means the lawyers get involved. Party is over, everybody out of the pool, the lawyers are here, it’s no longer fun. So let’s talk about Kentucky first. In January, with our partners, we filed a lawsuit against HHS over the approval of the waivers in Kentucky. In June those waivers were vacated, in other words, shut down, by the D.C. district federal court. And the reasoning of the court was that HHS failed to consider the administrative record in the case. In other words, the evidence in front of them about whether these waivers were good or bad. Where that case is now, is that CMS reposted that same application for public comments and presumably they will be soon reapproving that same application and we may have a version two of Kentucky.


We also have Arkansas, where we filed litigation in August. That litigation will be proceeding in front of the same judge as the Kentucky case. The briefing will be running from November to January , meaning after mid-January at some point, we would expect a hearing, and at some point after that, some kind of decision. The key difference of course is that terminations in Arkansas begin in September, so I want to talk about that for a minute, because I know that’s what a lot of people are interested in, and I want to talk about it in two ways. I want to talk about the data, and then I want to talk about how you should think about the data.


So data first. The data is bad. It does what many of us predicted, including really respected policy experts. 8,462 people have lost their health insurance thus far, two months into the termination’s beginning. That size, the important thing for you to know about that size is there are not enough people in that cohort who are not working, not students, not parents, not with a disability, to have a number that large. So by definition there are workers, students, people with disabilities, et cetera, in that group. Very concerning. 507 people have recorded compliance with either work or volunteering, or some combination thereof. That 507 number, however, does not distinguish between people who were already working and people who are newly working. We suspect the majority are in fact people who are already working, not newly working. Additionally, of the people who are newly working, it doesn’t give us a baseline as to how many people every month are newly working. Because every month people on Medicaid, some amount of them, get jobs. So if, let’s say, there were actually only $200 people who were newly working, but the average is $175 a month in Arkansas to get work, then that means only 25 got it through this. So the upshot of this is, I think that 507 number is actually closer to 100. So now we just do a simple comparison: We have 8,5000 or so people who lost their health insurance, and we have some number, I think closer to 100, who may have gotten work through this process. And so obviously you have to ask yourself does that pass your smell test? But they are justifying this based on outcomes, so ask yourself a question:  If you had 8,500 people who did not have health insurance and you gave them health insurance, what would be the value for health outcomes of that, compared to the psycho social benefits that 100 people get from working? In addition, of course, you have the state spending a lot of money, making a lot of effort, and a lot of red tape to do this. So that’s where the data sits.


And I’ll close by talking about how you should think about that data. I think may surprise you a little bit here. I think there’s been a lot of public discussion, including in the media, criticizing Arkansas for their implementation. There are big mistakes in the Arkansas implementation. To be clear. This program was designed and approved by HHS with an online portal only system for reporting your hours. That’s how this was designed and approved, and was until very soon after the problem started. So just understand when we’re talking about a low income community in a rural state, that this was not designed in a way that was going to likely be successful for a lot of people. We have solutions like, you can drive 20 minutes to a place where you can then use the online portal if you are able to do an account successfully. If you know how to navigate it. And you have to do that every month to report in some cases. Again, big issues with implementation, but I actually want to say, we shouldn’t be thinking about this in terms of, Arkansas did a bad job. And I think of the Greek myth of Icarus, right? Puts on some wax wings and tries to fly towards the sun. The wax melts, he falls to the earth and dies. And you could take a really narrow lesson from that, which is: Don’t use wings made out of wax. Or, you could say to yourself, the sun is 20 million degrees Fahrenheit, don’t fly at it.  Right? And so my point is, the problem here is not Arkansas’ implementation, whether you think it was good or bad, because there are bad things about it, there are good things about too that we could talk about. I think Cindy talked about some, and they are really true. The problem here is the design. If you fly at the sun with wings of wood, or wings of paper, or wings of metal, it’s going to be the same result. This population includes people who are homeless, people who have serious mental illness. People who are victims of domestic violence aren’t allowed out of their house, aren’t allowed to communicate. People who have moved five times in the last month. The workers in this population include people who work part time, do shift work. People who are seasonal workers, who have four months off, and then eight months on. It includes tons of people who are self-employed, people who are paid cash, and many of them, right, a huge number of them, are legally below the threshold for you to be required to file taxes. So there is no reason why we would know about many of these people and their work status, much less their volunteer status. And there is no way to be tracking this all in real time on a month to month basis. So the headline here is not, “Arkansas is doing a bad implementation job”. The headline is, “This is a bad idea”. It is an idea that is not legal, is bad as a matter of health policy, and is not something that is feasible to do, considering the population that we are talking about.


SARAH DASH:  Well, thank you, Leo. So on that note first, I just want to say, this is what the Alliance is all about and that it takes a lot of courage to kind of come up and sit on a panel where there are such extremely different points of view, and different ideas about the intensions and the implementation of programs, so before we get to the end, I want to thank our panelists for being up here. So let’s kind of stick to this question for a moment. I want to turn to Cindy Gillespie first and see if you have anything you want to respond to as far as what Leo said. But I’m also curious, you mentioned you thought there was some good things. I wanted to see if you want to elaborate on that a little bit before Cindy responds.


LEO CUELLO:   Sure. So I think one of the good things is that we know from the data, a little bit more than 70% of the people are being identified for exemptions without having to do anything through a data match, right? So that is 70% of the population who doesn’t have to deal with all of the problems of figuring out how to report themselves, right? That is a good thing, that is not necessarily something that every state would have done, or will do. And that is dramatically reducing the scope of the problem. Without that, instead of talking about 8,500 people, we might be talking about 30,000 people. So that’s a good thing. I think some of the policies that Arkansas has put in place with respect to self-attestation are also better than policies we have seen in other states. So I think there are a lot of things about the implementation that are better, but I sort of think about it in terms of there are reasons why somebody might disagree about whether they prefer the firing squad or the electric chair. There are details that matter, but at the end of the day, huge numbers of people are getting terminated, and some of them are literally going to die. To me, that’s the story.


CINDY GILLESPIE:  You know, you said it well when you said the data at this point — it is early data, okay? And there is a lot that’s going on here. I think maybe most importantly is to step back and let me just remind you why we did this. People keep saying that we did this in order to reduce the rolls. The rolls in Arkansas in December of last year — 10 months ago — we had 330,000 people on the Arkansas Works Rolls. By the time we started this in June, that was down to about 270,000. We didn’t do this to reduce the rolls. Our rolls are going down, the economy is improving there, we have other efforts that are going on around keeping our rolls accurate. We have a lot going on. We are not doing it to reduce the rolls. We are doing it because we have a number of people that are in the program that we see not getting help from anywhere. We started with a group of 30 to 49 year old’s for a reason. When you are 30 to 49 years old, you don’t have a child, a dependent in your home, you’re not caring for an incapacitated person, you’re not in school, you’re not engaged in the community in any way, shape, or form, all evidence out there is that it does in fact lead to a healthier life, when you are engaged. If you can get your education and skill training up, you see that that is — I mean, one of the reasons people talk all the time anymore about social determinants of health, most of which go back to poverty, is because you really do have to move people up, help people move up the economic ladder. Our programs in the state are too siloed. The workforce programs are over in one place, you’ve got the education programs in another place, you’ve got the health programs in another place. And for us to actually help people, we have to bring those programs together around them. So our experiment — a demonstration, as you said, is an experiment. So our experiment is based on the idea of compassion. We want to identify that subset of people within this population, and between us, our insurance carriers, we are working with the homeless advocates, we are working with every group we can out there, begin to help those folks move to access the services that are available and paid for through all of the other federal programs that flow to the states. So that is our goal. And I do think it’s important to understand what the goal is, because as you said, we are collecting data, we will continue to collect it, we will evaluate the program as we are supposed to, because we are trying to learn how to make that difference and how to pull these things together.


The other thing is, it’s often talked about, this is the first few months of a new program, we are the first to do this. It’s often talked about like everything is black and white in the way this is being run. We have set up, in addition to the fact that, yes, there is an online portal, there is a self-service portal. Medicaid beneficiaries in general, we are hoping will move towards the self-service portal. To apply for Medicaid, you apply online, or you call someone and they apply for you online. I mean, it all happens online. So yes, our portal is online because that’s how you change your circumstance, that’s how you do this. But we have other ways for people who can’t do it themselves, to reach someone who can help them do it. We also have a good cause exemption. This is a new program, right? And people are learning as they find out, oh, wait this has to happen. So we have a way for people to call, have someone else call or email on their behalf, come into an office, whatever it is. Come in, tell us what’s going on, and our folks will work with them. So if in the case, as you’re talking about, we find out afterwards that there was a reason somebody wasn’t able to get to us and get their exemption, we grant it. So we’re trying to implement this — I love the way my head of county operations says it, she said, “Her directive to her people is when they are looking at this, if it’s a judgement call to be made, then err on the side of the client.” That’s the approach they are taking. So we’re in the beginning stages, and I think that the team there is doing a great job. They are doing it with compassion, and I’m very hopeful that we will continue to see success. We have individuals who are accessing services, who are getting training, who are going from making zero, to make $24 an hour. We have success stories. I’m hoping a year from now, we will have hundreds and hundreds of those. You have to start. I did like what Administrator Verma said, “I don’t think it’s compassionate to leave people in poverty.” And our goal is to help them.


SARAH DASH: Thank you, Cindy. We’ve already gotten a couple of questions on green cards, and they are on the topic, so I’m going to let — Rachel will ask those, and then we’ll switch gears. We actually have already had a robust discussion, so we only have about 20 minutes left in our briefing. If you do have another question, please write it on a card, and someone will come around and pick it up. Rachel?


RACHEL NUZUM:  Thank you. I just want to change gears for a second and bring Cynthia into the conversation. I thought it was interesting in your West Virginia example, you highlighted a bit of the classic good news/bad news situation. You over achieved your goals in terms of finding folks that were eligible and enrolling them. Obviously with that comes some costs that you weren’t expecting. I think as we talk to states, but also to federal folks, there is a lot of interesting concern about doing a really good job at outreach and enrollment, how do you make sure that you’ve got the resources to then be able to absorb and bring those people into the system, and how have you seen those costs balance out? Have you seen savings, or more balancing of those expenditures when you look at your ER reductions and other costs?


CINDY BEANE:   So in West Virginia we did. Our enrollment far exceeded our expectations. We have leveled out now around 165,000 individuals on expansion; at one time we were up to 185,000. Like Arkansas, we have seen a movement. Our numbers are down, and have leveled out. We have seen people — our economy in certain areas of the state is picking up, and we have seen people obtain employment and get off the rolls. But what we did is found efficiencies within the program. Initially, there was a lot of pent up demand. Fortunately for an expansion state, for those first couple of years, those were 100% federal dollars, so we are now to the point of where that match is going down. So we’re currently at the 94, and in 2020 it will go to 90. But with that, what we’ve found by finding other efficiencies, we found some efficiencies in our pharmacy program, and some efficiencies in some of our LTS services, and we basically have revamped our program in order to pay for these additional individuals on the rolls, because it’s important for West Virginia and its economy to have a healthy workforce. So West Virginia, we have historically been a coal state. Coal is not like it used to be. And our economy is changing, and we have to get our workforce healthy and in order to basically have our economy be more robust. And so it’s very important for West Virginia to continue those individuals on those roles. So yes, it was a concern, and yes, we had to find efficiencies in other parts of the program in order to continue to pay for the expansion population.


SARAH DASH:  Thank you. We also have a question, kind of switching gears again, around providers. And if you could all talk about how will the innovations that are being discussed effect the way that patients interact with their providers. We’ve talked about client-centered approach, patient-centered approach. Is there anything new that’s being done in these new arrangements to either attract physicians, to see Medicaid patients, or for innovations that are dealing with the so-called social determinants of health. Is there anything to help physician offices, or others for that matter, connect patients to the resources that they may need? And we’ve talked a lot about work in community engagement, but perhaps other resources as well. If you could comment on that. Calder, you’re nodding, I don’t know if you have a comment on that, and perhaps we’ll ask others as well.


CALDER LYNCH:  Yeah, I’ll just jump in quickly, and say that this is an issue that we know states are very interested in. We’ve heard this consistently, that there is a desire to understand how different issues are impacting the overall cost of care. And so we’re working with a few states, and some different approaches under 1115 or other authority, to think through that more. And we hope we’ll have some examples that we can begin sharing and learning from soon, but one of the things that we’re really — want to make sure we focus on in this, is that we’re linking those investments to outcomes, right? That they are linked to value. That if we’re going to begin thinking paying for things, new things, things in different ways, that we’re measuring the impact that that’s having on cost of care and outcomes, and we’re monitoring, and of course correcting over time. So look for a little bit more on that here very soon. I think we are working with a number of states, but it’s something we’re very interested in.


CYNTHIA BEANE:  In West Virginia, the health home model that we highlighted, that really encourages the practices to have that extra person in the office that can do that care management, that can outreach, that can call that member, or make sure they’re being adherence to the medications. And it gives the physicians office an additional hands on deck for some of the individuals, especially in our bipolar health home. Those aren’t the easiest clients. A lot of time they are non-compliant with their medications. And so it has helped them, and it has that additional payment, in order going to the office, and to pay for that support. Also our managed care companies have also offered, in different areas, where there is a particular need, an ObGyn practice that has a lot of high risk pregnancies, has a lot of pregnant women that are suffering SUD. They’ve offered additional care management in there to hook those women up to treatment during the pregnancy, and also making sure that the babies have support as soon as those babies are born and hooked up with, right from the start, an additional services. So I think there are different, unique aspects that Medicaid agencies can do to help give those physicians offices additional supports, because it’s not necessarily always the payment, it’s the additional support that they need to help manage the Medicaid member.


CINDY GILLESPIE:   I’ll just add a couple of quick ones, and it really just builds on what Cindy said. A couple of things we’re doing in Arkansas; we’ve had, like you, the health homes, patients that are in medical homes. It’s been very successful, and the state has been going for quite a few years. It’s voluntary, but over 80% of the practices are in. We are expanding that this year, down to practices with 500 or less patients, which will really allow us to move this more into the rural areas. So that’s been a tremendous benefit. An exchange of information that goes on between providers in that in these PCMHs has really helped improve the quality of care delivered in many areas. The other thing I’ll mention, even though this is not new in the rest of the country, it is new for us, we are beginning next year managed care for the first time in the state around the behavioral health population. Managed care is not popular in Arkansas, I think would be the way to say it, and so this is our first foray, really, into managed care in the health space. And so the behavioral health population high need will be in what we are terming “organized care”, but this year it began with care coordinators. So care coordination for the first time around this population, which is allowing us to finally have that connectivity about what’s going on between the behavioral health and the rest of the medical treatment. And so we’re very excited about that shift and change.


RACHEL NUZUM:  Thank you. We’ve got a number of questions, a vast majority of them actually that are really focused on the resources that are required to really connect the people that need the services in their given states and in different areas within in the states, with the services available. And kind of how much more critical that is now in the face of using some of these waivers where the inability to potentially reach out to someone and make them aware of requirements could lead to them coming off the rolls. So I was wondering, Calder, if you wanted to talk about it, and also Tom, and then turn to the states. What steps are you all taking, or how are you all thinking about as you are evaluating these new approaches, ensuring that appropriate steps are being made, especially in areas where maybe broadband is non-existent yet, or how are we kind of working to connect. And then maybe our state folks can talk a little bit about — I know we’ve talked a lot about that in Arkansas, but either way.


CALDER LYNCH:  Sure. So I think we all recognized both CMS and states, that these are weighty undertakings in terms of — and this is true, I think, for all types of 1115 demonstrations. So they take a lot of really thinking through and planning around effective implementation. And in terms of community engagement specifically, we really identified some key steps that states kind of need to go through in order to have a thought through all of the issues that are we recognizing or emerging through this. And they really center around three key issues, and those procedural operational changes that they need to make, staff retraining, policy development that needs to happen with their eligibility field workers, their health plans and other partners across the state government, developing the necessary systems capabilities. We heard the conversation about the work Arkansas has done to really do data linkages across the different programs that will be able to minimize some of the administrative work that beneficiaries need to do. Then really having an effective communication strategy to make sure folks understand what the requirements are, reaching out in the communities, working with the natural partners that already exist; that are already engaging with Medicaid beneficiaries. And so part of the learning collaborative I mentioned in my opening comments is really helping states identify what are the best practices across each of those steps and across each of those three areas, and letting them share with each other the lessons learned and the best practices that are emerging, because we are finding that to be some of the most valuable exchanges that are occurring. We brought states a few weeks ago in Baltimore, it was a lot of, I think, cards exchanging and conversations happening between states that are thinking about these policies. I know that Cindy can talk a lot about some of the work that they’ve done, but they are going to need to be unique and tailored to some of the unique aspects of each individual state.


CINDY GILLESPIE:  I’ll start, You know, one thing that we are learning, as he said, we’re taking this from the standpoint of, how do you — we continuously keep asking ourselves, what can we do to improve communication, what can we do to improve communication? And I think that’s very important for any state that sets out to do this. It is to realize that it should be a process of continuous improvement, continuous improvement. When we read something in the newspaper about when someone raises an issue and says, well, this person did not know, we go: How could we have gotten to them? How do we get to them? Where do we reach them? I think that is what’s incredibly important. Is not to say, this is the plan on communications, make it static and then go. It is to keep reassessing. We will be doing focus groups, we will learn from those focus groups, we will reassess, we will add to; we will continue to add to, and continue to add to. The more this has gone on over the few months, the more the community has become engaged, and I think that is incredibly important. The organizations that work with different populations, we have been doing training sessions for them, we have been doing webinars. The medical community, the carriers, are able to let the pharmacies know if someone has not been responding. There’s all kinds of ways to try to touch someone. We’ve even had the Laundromat Society Association in Arkansas willing to put posters up. Try to think about where people will be. We’ve worked with churches, we’ve worked with others. So communication is not static. Communication is something that you just keep layering on, and layering on, and layering on, and I think that’s an important lesson to learn.


SARAH DASH:   Cindy let me ask — did you have a comment, Tom?  Okay. In terms of — there are several questions and I will try to summarize them. If somebody does have their coverage terminated, what is next? Is there outreach to help them figure out how to get back on? Any kind of outreach to help them stay healthy enough to work, or otherwise engage in the community? There were several questions along those lines, if you could comment on that.


CINDY GILLESPIE:  Sure, I would be happy to. So if — in addition to the — you have required noticing you have to around everything in this program, so we do all the required noticing. But as I was talking about communications, part of it is we have been layering on additional communications. One of those is when someone does lose their coverage for non-compliance with the work requirement. We do then reach out to them and let them know partly where they still can receive healthcare, if they need healthcare services, if they think this has been done in error, if they would have had an exemption. If there is something else that was going on, we tell them how to reach us. That’s what I meant about this good cause exemption, they have a way to do that. So we try to make sure they know where there are services still available to them, and we try to make sure they know how to come back and communicate with us if they think this was in error. And this is different from the appeals process. This is just, come talk to us, give us a call, and let us look and see what’s going on. Then on top of that, as you know, we said they can come back into the program in the next plan year. The timing around this first one means that they will be able to go through open enrollment, which will start in November, to start coverage again back in January, or at any point during the year next year if they choose to come back that way.


SARAH DASH:  Thanks. So we have a few minutes left for questions. I want to turn to Tom and Leo, who haven’t had much of a chance to weigh in. Can you just talk broadly about what is next for these court cases? What can we be looking for? What should we be looking for in terms of the process, timing, outcomes, that kind of thing. As we know, there are several other big court cases that might affect healthcare in the near future. What are you looking at, and how might they affect Medicaid in general? Tom, do you want to go first?


TOM BARKER:  So I will defer to Leo on the community engagement lawsuits, the Arkansas case, and next steps in the Kentucky case. I would say that there is sort of — this is quite apart from the subject of waivers, there is sort of a burning issue in the courts right now over whether or not the entitlement to Medicaid is even enforceable via the federal court system. There are a couple of cases surrounding the free choice of provider requirement in the Medicaid statute that — and there is a split in the circuits on that issue, and that sort of typically would tee things up for a Supreme Court decision. The whole question of whether or not the Medicaid entitlement is enforceable in the federal court system is an issue that I think is worth keeping an eye on over the next year.


SARAH DASH:   Thank you. Leo, did you have any thoughts?


LEO CUELLO:  Sure. The litigation will move forward in Arkansas, will very possibly start up again in Kentucky. I think there will be some other new states approved. There are a couple of states that are approved that haven’t implemented yet. Those may start, and may also one day lead to litigation, so I think this is a topic that’s going to get richer and more complex over the next year. It’s not going to stop being a topic of conversation. One thing that I would say, that I would probably disagree a little bit with Tom on, is the notion that there is sort of a lot of history for courts to draw from in these cases. There is not a lot of waiver cases. It’s not like free speech where there is a million cases authored by the Supreme Court. There is not a lot of waiver cases out there. Even less that are waiver cases —


TOM BARKER:  I don’t disagree with that. I agree with you on that.


LEO CUELLO:   Yeah, okay. I misunderstood, I’m sorry. I do think — and there is even less that are Medicaid cases, and there aren’t many that are at a high level that would be binding on every court. So the court that heard the Kentucky case really didn’t have a lot of clear precedent and was sort of making it up as it went along. And I think courts are going to have to, as the judge did in Kentucky, take a look at, does what the state is doing match the record that was in front of the state? How does that look compared to the statute in the state? And I think we’ll see courts struggle with how to do that. I think the issue of deference will be a talking point. The courts should defer to their secretary. That is a very condensed description of a wide body of law, which basically says that sometimes the court should grant deference, other times it shouldn’t grant deference, and when it should grant deference, even there as we saw in Kentucky, there needs to be rational means to achieve something that comports with what the statute says the program is about. So I think these are going to get — it’s just going to keep going.


SARAH DASH:   It’s amazing, but we are actually almost out of time. So I want to ask a final wrap-up question, with apologies to those of you who didn’t get your specific question answered. Hopefully you can come up and check in with the panelists if they are available to stay for a few minutes. But as we wrap-up, first please don’t leave until you fill out your blue evaluation form. But I want to ask each of the panelists, and we’ll start with Leo and kind of go down the line. Just to wrap-up, can you just share your positive vision, what innovation or development do you see as most promising for Medicaid in the next year? If you could just briefly share that, that would be fantastic.


LEO CUELLO:  Sure. So I think we actually heard great examples from both states on the stage. Some of the interventions with respect to SUD are really important. The issues around social determents of health are really important. The notion that we can better connect our clinical system to some of the other social and non-medical support systems is really important. It’s a big challenge. It’s a statutory challenge in the sense that, how do you in Medicaid pay for certain things when the law says, here is what you’re allowed to pay for. That’s a challenges that CMS is working diligently with states to try and solve in a lot of places. Then it’s a challenge for states to implement. They have to get providers on board with new types of screening you have to do to get at the social determinants of health. You have to get providers on board with new types of treatment that are really important. So for example, trauma informed care for communities of color, communities that are victims of sex-trafficking, where you have to really address a lot of trauma that’s been there. So I think we’ve been talking about probably the lightening rod a lot. There are a lot of positive things out there. And the only thing I will close with is the interaction and the interaction is when you take away coverage, you destroy continuity of care for individuals who are going to be locked out for a nine month period. Right, that does not promote continuity of care. It doesn’t help you get at these social determinants of health. And so when you look at what will actually work with social determinants of health, whether it’s new screenings, or new ways of doing the therapy, or new connections, it’s always the addition of some new value. It’s not the taking away of something.


SARAH DASH: Thanks, Leo. Cindy Gillespie?


CINDY GILLESPIE:  I will say that I agree with most of what you said, except for right at the end. And I agree from the standpoint of, I think that is, for Medicaid, and for the population we serve, probably the most important thing. Is how do we begin to work with particularly those who are second, third, fourth generation poverty? How do we really begin to break that? And you break it by figuring out how we are going to in fact help the whole person, and not just help their medical. How do we really deal with this issue of all the social determinants of health, and how do we pull that together?


SARAH DASH:   Thank you. Cindy Beane?


CINDY BEANE:  I think one of the benefits of the ACA that brought to the Medicaid agency was that the Medicaid agency can’t expand and do these things alone just in the silo of Medicaid. Now I work closely with the Justice Department, because there is individuals coming out of the jails and prisons who are now on Medicaid. I work closely with our Bureau for Children and Families in order to basically get to those social determinants and what I think the next step for Medicaid is to actually blend some of these funding’s together, piled together with either our Bureau for Children and Families, looking at those kids, foster care kids, or kids that are involved in that system, our justice involved system. There is a plethora of systems out there that really work with those social determinants. They are willing to work with the Medicaid agency. We all have our own data pools, we are currently working on basically getting those feeds. So people know, what is that whole person? Because it is important, if they are homeless, and they can’t get healthcare — access to healthcare. They might have a medical card, but if they don’t know where to go, how do you outreach to that person? So that is the key. The key is for Medicaid agencies to realize we can’t do it alone. We have to have these partnerships with public health, Children and Families and Justice.


TOM BARKER:  I completely agree with the comments on social determinants of health. I think that’s a huge challenge for Medicaid. My other comment is I do think, and I realize that CMS is thinking about this right now, but I really do believe that Medicaid needs to think about how the new therapies — gene and [unintelligible] based therapies, for example, fit into the overall Medicaid prescription drug rebate program, and how the drug rebate program could deal with value-based purchasing arrangements for these new therapies, because it’s a completely different paradigm and they don’t work the same way that traditional drugs work in the drug rebate program. So I think that’s a challenge that needs to be addressed in the next couple of years.


CALDER LYNCH: We are real excited to see the work that states are doing on all of these fronts. I mean, obviously we’ve talked a lot today about the work in community engagement, and requirements. What that’s really driven to try to address, is what’s seen as a really emerging and growing problem when you look at work participation rates across the country, particularly among childless adults, have fallen pretty considerably over the last few decades, and we are now at a point where we have the lowest rate of unemployment in nearly 50 years, wages grew at the fastest rate they ever have in the month of August, and states are looking for opportunities to help reconnect individuals back into the workforce, and back into their communities, and this is one aspect of that. And we heard that the Medicaid program hasn’t historically had this as a purpose, and that’s true, but it’s also important to remember that before 2014, childless adults weren’t even eligible for Medicaid outside of a very few limited demonstrations. So the program has evolved and we’re having to evolve with it to help address the needs of the populations that it’s serving. And it’s not a policy that’s radical or on the fringes. Kaiser Health tracking poll last summer showed 74% of adults supported the policy of a worker community engagement requirement as a condition of eligibility. Obviously the devil is in the details and we continue to work with states around those implementations. But the evaluations will show what the results are, and we are really committed to making sure that those are thorough, and then we have good data to understand what’s working so that can be emulated, and best practices can emerge.


SARAH DASH:   Well, thank you. That is all the time we have. Please join me in thanking our panel for today’s discussion, thank you. Thanks to the Commonwealth Fund, and to Rachel for making this possible. Please fill out your blue evaluation, it really does help us, and come back to our next briefing. Thank you.