Like many states, Utah has been working to redesign its
Medicaid program in an effort to contain costs–the state submitted a Section
1115 demonstration waiver application to CMS earlier this month. As my
colleague Joan Alker has blogged about in the past, waivers are often adopted
with little public transparency even though the stakes are very high for
Medicaid beneficiaries. Utah is
the perfect example of why children’s advocates need to speak up when a state
starts taking about pursuing a Section 1115 waiver. And we’re asking national kids’ advocates to do just that on
the Utah application–read on to find out how you can add your voice to a letter
urging CMS not to approve waiver provisions that will limit children’s access
to needed care.
As a bill moved through Utah’s legislature to authorize
the waiver, much of the public discussion focused on reforming provider
payments and the incentives they create.
The formal waiver application, however, reveals that the state is also
seeking to remove important protections for children enrolled in Medicaid. In
particular, the state seeks to impose unprecedented levels of cost-sharing on
children with the lowest incomes and to limit children’s benefits when the
state hits an arbitrary spending target.
Utah’s waiver application seeks to move its Medicaid
payments closer to an accountable care organization model, where payments to
health plans are based on the number and health of enrollees and the quality of
care they receive, rather than on the volume of services providers
perform. Since the waiver does not
apply to Utah’s Primary Care Network or to Medicaid beneficiaries who reside in
nursing homes, most of the beneficiaries impacted by the changes will be children. Kids make up 57% of all Utah Medicaid
enrollees and a substantially higher percentage when nursing home residents and
PCN beneficiaries are excluded.
But they account for less than a third of Utah’s Medicaid spending. So while kids are a large majority of
those affected by the waiver, most of the program’s spending is elsewhere.
As Say Ahhh! readers know, EPSDT is the Medicaid benefit
for children that assures they have access to medically necessary
services. Utah proposes to waive
the requirement that it provide children with EPSDT whenever growth in the
state’s per capita Medicaid costs exceeds growth in its general fund
spending. This means children
would be on the hook for losing benefits if either state spending grows slowly
(as in recessions) or per person Medicaid spending grows quickly, whether that
spending is on behalf of children or not (and most of it is not). EPSDT is a key foundation of Medicaid’s
commitment to serving children’s unique needs–Utah should not be permitted to
waive this vital protection.
In addition to putting some benefits at risk, the Utah
proposal would also give health plans authority to impose co-pays, deductibles,
or other cost-sharing on services for children in Medicaid. Medicaid law largely protects the lowest-income
children from cost-sharing, but Utah proposes to remove those protections and
substitute cost-sharing amounts up to its CHIP cost-sharing limits–some of the
highest in the nation. We’re not
aware of any other states that charge anywhere near this level of cost-sharing
for kids in families with such low incomes (below 133% of the federal poverty
level), nor has the federal government ever approved such a request.
Utah’s application states that the reason for this change
is to give plans the ability to encourage healthy behavior among
enrollees. When thinking about
kids, though, this idea makes little sense–are kids expected to alter their
behavior and make healthier choices because their parents have to pay more for
them to see the doctor or get an x-ray?
Removing these protections seems unlikely to bring about the desired
result, at least for kids, again the majority of those affected by the waiver
To raise these concerns with CMS, we here at CCF have
drafted a letter to Secretary Sebelius and
we hope your organization will sign on, as well. Right now, we’re looking for national groups to sign on to
show their support by August 3.
You can use this web form to add your
organization to the list. Thanks
for considering it and stay tuned for more info as Utah’s proposal is
negotiated with CMS.