Keeping Care Affordable: CMS Stands up for California Kids – Say Ahhh! A Children’s Health Policy Blog

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By Michael Odeh, Children Now

Earlier this month the federal Centers for Medicare and
Medicaid Services (CMS) made an important ruling that truly embraces the “AFFORDABLE” in the Affordable Care Act (ACA).

Health care services and economics research over
the past four decades has clearly
shown that unaffordable cost-sharing in health care can be a barrier to
children and their families accessing and utilizing the care they need. And for
low-income families, even modest
co-payments can be unaffordable and the ultimate effect is that patients reduce
their use of both essential and less-essential services.

The California plan passed as part of last year’s budget
sought to impose, for the first time ever, mandatory co-payments for children
and other Medicaid enrollees – no exemptions for any of the most vulnerable
populations. The following mandatory co-payments were proposed:

* $50 for emergency room services;

* $50 for non-emergency use of an Emergency Room;

* $100 for an inpatient hospital stay (with a maximum of
$200 per stay); and

* $5 per for each doctor’s office visit, clinic visit,
dental visit, and brand name prescription drug ($3 for generic prescriptions).

Furthermore, the burden to collect the required co-pays
was to be put on Medicaid providers. These providers, who have already been hit
hard over the
past couple years, could either make the decision to refuse patients for
non-payment (i.e., deny services) or provide services at the lower
reimbursement rate paid by the state without collecting the co-payment from
their patient, which is precisely why this plan was effectively just another
cut to providers.

A number of California and
national children’s
groups expressed their strong opposition to the state’s proposal, which was
submitted as an amendment to California’s $10 billion Medicaid 1115 waiver
approved in 2010 (as the “bridge” to health reform in 2014).

Despite the state’s attempt to tie the co-payment
proposal to the waiver and health reform, let’s make no mistake that the
Medicaid co-payment proposal was purely for purposes of achieving $575 million
in budget savings.

That’s why it is completely appropriate that CMS denied the
, stating that they were “unable to identify the legal and policy
support” for the state’s request. CMS directly cites section 1916(f) of
Title XIX of the Social Security Act, which allows changes to Medicaid cost-sharing
protections only if they demonstrates a unique and untested use of co-payments, are limited to two years or less, will provide benefits to recipients, and are voluntary. California’s request on its face clearly did not meet the 1916(f)
criteria and nothing in the state’s rationale suggested the proposal would
improve patient care and quality.

The action and reasoning by CMS is consistent with the
year by the 9th U.S. Circuit Court of Appeals on co-payments for childless
adults in Arizona’s Medicaid program. Budget savings are clearly no
justification for imposing co-payments on the lowest-income and most vulnerable

There’s a reason why Affordable is in the title of the
ACA, which itself is all about making coverage and care affordable and
accessible for all families. Keeping Medicaid affordable is clearly in line
with that vision, and denial of California’s ill-conceived Medicaid co-payment
request is an important step in making the ACA a reality.

Note: The author would like to acknowledge the assistance
of his 100% Campaign  colleagues.

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