Governors: Avoid Harmful Insurance Practices in Medicaid Waivers
While our nation’s governors recently gathered in Rhode Island for the summer meeting of the National Governors Association, most of the country’s political attention remained focused on the debate in Washington, D.C. over the fate of the Affordable Care Act. Less noticed, but also critically important, is that fact that each governor holds in their hands today the ability to radically reshape Medicaid for their state’s most vulnerable citizens regardless of the outcome of that debate.

While our nation’s governors recently gathered in Rhode Island for the summer meeting of the National Governors Association, most of the country’s political attention remained focused on the debate in Washington, D.C. over the fate of the Affordable Care Act. Less noticed, but also critically important, is that fact that each governor holds in their hands today the ability to radically reshape Medicaid for their state’s most vulnerable citizens regardless of the outcome of that debate.

This power is significant considering the 69 million Medicaid enrollees living across the country.

We are health care advocates who have come together to speak up for patients and health care consumers. We view it as our purpose to ensure patients are the first and most important stakeholder in any health care policy decision, whether that decision is made by a legislator, health insurance commissioner, insurance company CEO, president, or — as in this case — governor.

Recently, governors from every state received a letter from Tom Price, secretary of the Department of Health and Human Services, and Seema Verma, administrator of the Centers for Medicare and Medicaid Services. In that letter, the authors encouraged them to seek to “align Medicaid and Private Insurance Policies for Non-Disabled Adults.” While aligning state Medicaid policies with those of private insurance carriers is a policy goal that has merit, it also demands careful consideration.

Patients and policymakers alike can agree that Medicaid can look to private insurance for efficiencies in the system and ways of promoting well-coordinated care. We applaud those efforts, but caution that some efficiencies have come at the expense of patients. This year alone, we’ve seen too many private insurers take steps that may save them money, but leave patients with unreasonable — and in some cases, dangerous — burdens. For example:

Emergency coverage : Just this month, one insurer implemented a policy in which they can decide after the fact that they will not cover a patient’s visit to an emergency department, even when such emergency coverage is in the consumer’s policy. As of July 1, consumers in four states — Georgia, Missouri, New York, and Kentucky — were placed in the untenable position of having to assess whether their condition would later be determined sufficiently dangerous to warrant emergency coverage. Doctors should be assessing emergency situations, not patients.

: Just this month, one insurer implemented a policy in which they can decide after the fact that they will not cover a patient’s visit to an emergency department, even when such emergency coverage is in the consumer’s policy. As of July 1, consumers in four states — Georgia, Missouri, New York, and Kentucky — were placed in the untenable position of having to assess whether their condition would later be determined sufficiently dangerous to warrant emergency coverage. Doctors should be assessing emergency situations, not patients. High Deductibles: Studies show that low-income individuals and families with high-deductible plans often delay or forgo necessary doctor visits and emergency care because they just can’t afford it. Vulnerable Medicaid beneficiaries should not be effectively locked out of using their health care coverage because of excessive out-of-pocket costs.

Studies show that low-income individuals and families with high-deductible plans often delay or forgo necessary doctor visits and emergency care because they just can’t afford it. Vulnerable Medicaid beneficiaries should not be effectively locked out of using their health care coverage because of excessive out-of-pocket costs. Denials of lifesaving care: Cases of insurance companies taking on the role of doctor and denying patients life-saving medicines that have been ordered by physicians is also becoming all-too common. The Wall Street Journal recently detailed several cases in which patients were forced to go through countless hours of paperwork and appeals just to get vital cholesterol medication approved by their insurance carriers. As one cardiologist put it, “At the end of the day, you would like to do what is best for the patient. But you really don’t have the time to play the insurance games.”

Medicaid may have things it can learn and adopt from the insurance industry, but practices like these aren’t among them.

Americans rightly count on our governors to protect their state’s most vulnerable and uphold a standard for quality, affordable health care. As such, we implore each governor to keep Medicaid beneficiaries top of mind as they consider requesting waivers from federal Medicaid standards. We also strongly encourage each to adopt the following principles for assessing the scope and breadth of any potential waiver request:

High-quality, comprehensive health care should be available and affordable to all Americans;

Insurance design should be improved to better meet the needs of consumers; and

The health care delivery system should be modernized to put the patient at the center.

With these as standards for designing waiver requests, we believe Medicaid beneficiaries in every state can get the better-quality care we — and our nation’s governors — know they deserve.

Former Del. Donna Christensen (D) represented the U.S. Virgin Islands in the House of Representatives from 1997 to 2015. Jim Manley is a former senior adviser to Sens. Harry Reid (D-Nev.) and Edward Kennedy (D-Mass.) Scott Mulhauser is a visiting fellow at the University of Pennsylvania and former senior adviser to the Senate Finance Committee and Vice President Joe Biden. Jason Resendez is executive director of the LatinosAgainstAlzheimer’s Network and Coalition. They all serve on the board of directors of Consumers for Quality Care.

Clarification

Manley was added as an author.

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