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Podcast: ‘What The Health?’ Tax Bill Or Health Bill?

November 17, 2017


Republican efforts to alter the health law, left for dead in September, came roaring back to life this week as the Senate Finance Committee added a repeal of the “individual mandate” fines for not maintaining health insurance to their tax bill.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the other health implications of the tax bill, as well as the current state of the Affordable Care Act.

Among the takeaways from this week’s podcast:

  • The tax bill debate proves that Republicans’ zeal to repeal the Affordable Care Act is never dead. The new congressional efforts to kill the penalties for the health law’s individual mandate could seriously wound the ACA since the mandate helps drive healthy people to buy insurance.
  • One of the most overlooked consequences of the tax debate is that it could trigger a substantial cut in federal spending on Medicare.
  • A $25,000 MRI? That’s what one family paid to go out of their plan’s network to get the hospital they wanted for the procedure for their 3-year-old. Such choices are again drawing complaints about narrow networks of doctors and hospitals available in some health plans.
  • Although they don’t likely say it in front of cameras, many Democrats are relieved at President Donald Trump’s choice to head the Department of Health and Human Services, former HHS official Alex Azar.
  • Federal officials have given 10 states and four territories extra money to keep their Children’s Health Insurance Programs running but it’s not clear what couch they found the money hidden in.
  • And in remembrance of Uwe Reinhardt, a reminder that he always stressed that a health care debate was about more than money — it was about real people. Email Sign-Up

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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner:’s “This Tennessee insurer doesn’t play by Obamacare’s rules — and the GOP sees it as the future,” by Erin Mershon.

Also: Georgetown University Health Policy Institute’s “What’s Going on in Tennessee? One Possible Reason for Its Affordable Care Act Challenges,” by Kevin Lucia and Sabrina Corlette.

Sarah Kliff: Bloomberg Businessweek’s “How to Make a Fortune on Obamacare,” by Bryan Gruley, Zachary Tracer, and Hannah Recht.

Joanne Kenen: Politico Magazine’s “How Bourbon and Big Data Are Cleaning Up Louisville,” by Arthur Allen.

Alice Ollstein: Talking Points Memo’s “Trump’s Abrupt Policy Shift Fuels Misleading Obamacare Renewal Info,” by Alice Ollstein.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Despite ACA Cost Protections, Most Adolescents Skip Regular Checkups

November 17, 2017

As children move through adolescence, some face health hurdles like obesity, sexually transmitted infections, depression and drug abuse. Regular checkups could help families address such problems, and the Affordable Care Act paved the way by requiring insurers to fully cover well-child visits, at no charge to patients.

But, both before and after the ACA was established, fewer than half of kids ages 10 to 17 were getting routine annual physical exams, according to a recent study.

“Most adolescents are pretty healthy, but a lot of them are headed for trouble with obesity” and mental illness and substance use, said Sally Adams, a research specialist on adolescents and young adults at the University of California-San Francisco, the study’s lead author. “These are things that can be caught early and treated, or at least managed.”

For the study, published online this month in JAMA Pediatrics, researchers analyzed data from the federal Medical Expenditure Panel Survey, which tracks health insurance coverage and health care use and spending. Researchers used data from 25,695 people who were caregivers of adolescents ages 10-17. About half were surveyed from 2007 to 2009 and the rest from 2012 to 2014.

Before the health law passed in 2010, caregivers reported that 41 percent of children had a well-child visit in the previous year. After the ACA’s preventive services protections became effective, typically in 2011, the rate climbed to 48 percent, a “moderate” increase, Adams said. The increase was greatest for minority and low-income groups.

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Still, more than half of children in the survey didn’t go to the doctor for routine care over the course of a year, even though many families gained insurance and wouldn’t have owed anything for the visits.

That’s cause for concern, Adams said. A primary care provider can screen youngsters for risky behaviors and treat them if necessary. A checkup is also an opportunity to educate patients on health.

“The behaviors they pick up as adolescents have a strong influence on their adult health across their life course,” she said. For example, she noted, “if you can keep them from starting to smoke, then they probably won’t smoke.”

Young children typically have regular pediatrician visits for recommended vaccines, hearing and vision tests as well as school checkups. But those needs may change as children get older, and state requirements that kids get physicals before entering school vary. Some may require a checkup every year, others only at intervals.

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“Healthcare professionals have told us that rates of well-child visits tend to be lower after the early childhood years,” Adams said.

The ACA required that most health plans cover preventive services recommended by four medical and scientific expert groups without charging consumers anything out-of-pocket. For children, many of these services are spelled out in the Bright Futures project guidelines, sponsored by the American Academy of Pediatrics and supported by the federal government, and by the U.S. Preventive Services Task Force, an independent group of medical experts that evaluates the evidence for clinical care.

About a fifth of adolescents ages 12 to 19 are obese, and between 13 and 20 percent of children have a mental disorder in any given year, according to the Centers for Disease Control and Prevention.

Some research has shown that parents may believe that adolescents do not need to go to the doctor unless they’re sick and that they can’t afford to pay for checkups, Adams said.

“What we would like is for families to understand that this is a right families have and that these are valuable services that can help their children,” she said.

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

About A Third Of Americans Unaware Of Obamacare Open Enrollment

November 17, 2017

While the Affordable Care Act’s fifth open enrollment season is off to a surprisingly good start, many uninsured people said they weren’t even aware of it, according to a survey released Friday.

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Nearly a third of people overall — including a third of people without health insurance — said they had not heard anything about the sign-up period for individuals who buy health plans on their own, according to the survey by the Kaiser Family Foundation (KFF). (Kaiser Health News is an editorially independent program of the foundation.)

Open enrollment started Nov. 1 and runs through Dec. 15 in most states. Advocates fear enrollment will decline this year because President Donald Trump has been repeatedly saying the health law is “dead,” and his administration severely cut funding for publicity and in-person assistance.

Nonetheless, nearly 1.5 million people have enrolled on the federal health insurance exchange, which handles coverage in 39 states, federal officials reported Wednesday.

One factor that could be pushing more people to sign up earlier this year is the open enrollment season was cut in half from three months to 45 days for the states relying on the federal exchange. Some state exchanges allow enrollment into January.

Several state health insurance exchanges have also said early sign ups are running higher than last year. The Colorado insurance exchange on Thursday said it has enrolled more than 22,000 people in the first two weeks — a 33 percent jump from last year’s first weeks.

In the previous open-enrollment season, 12.2 million people nationwide selected individual market plans through the marketplaces. The number dropped off during the year because not everyone paid and some found coverage elsewhere.

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Forty-five percent of all respondents to the KFF survey and 52 percent who said they were uninsured said they have heard less about open enrollment this year compared to previous years.

Insurers are trying to pick up some of the challenges of publicizing enrollment, and some of those ads are getting noticed.

The percentage of survey respondents who said they saw ads attempting to sell health insurance increased from 34 percent to 41 percent between the October and November KFF tracking polls. The share who say they saw ads that provided information about how to get health insurance under the ACA increased from 20 percent to 32 percent.

The poll found that nearly 8 in 10 Americans were aware the Affordable Care Act was still in effect.

The survey of 1,201 adults, which was conducted Nov. 8-13, has a margin of error +/-3 percent.

Medicaid Expansion Takes A Bite Out Of Medical Debt

November 17, 2017

As the Trump administration and Republicans in Congress look to scale back Medicaid, many voters and state lawmakers across the country are moving to make it bigger.

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News. It can be republished for free. (details)

On Nov. 7, Maine voters approved a ballot measure to expand Medicaid under the Affordable Care Act. Advocates are looking to follow suit with ballot measures in Utah, Missouri and Idaho in 2018.

Virginia may also have another go at expansion after the Legislature thwarted Gov. Terry McAuliffe’s attempt to expand Medicaid. Virginia voters elected Democrat Ralph Northam to succeed McAuliffe as governor in January, and Democrats made inroads in the state Legislature, too.

An exit poll of Virginia voters on Election Day found that 39 percent of them ranked health care as their No. 1 issue. More than three-quarters of the Virginians in this group voted for Democrats.

study from the Urban Institute may shed light on why Medicaid eligibility remains a pressing problem: medical debt. While personal debts related to health care are on the decline overall, they remain far higher in states that didn’t expand Medicaid.

In some cases, struggles with medical debt can be all-consuming.

Geneva Wilson is in her mid-40s and lives outside of Lowry City, Mo. She has a long history of health problems, including a blood disorder, depression and a painful misalignment of the hip joint called hip dysplasia.

She’s managed to find some peace living in a small cabin in the woods. She keeps chickens, raises rabbits and has a garden. Her long-term goal is to live off her land by selling what she raises at farmers markets.

Her health has made it hard to keep a job and obtain the insurance that typically comes with it. And Missouri’s stringent Medicaid requirements — which exclude nondisabled adults without children — have kept her from getting public assistance.

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Since graduating from college more than 20 years ago, Wilson has mostly had to pay out-of-pocket for medical care, and that’s left her with a seemingly endless pile of medical debt.

“As soon as I get it down a little bit, something happens, and I have to start all over again,” Wilson said.

Right now her medical debt stands at about $3,000, which she pays down by $50 a month. She desperately needs a hip replacement, but she canceled the surgery because, even with a deeply discounted rate from a nearby hospital, she couldn’t afford it.

“Approximately $11,000 is what would come out of my pocket to pay for the hip. That’s my entire pretax wage from last year,” Wilson said. “So it’s kind of on hold, but I don’t know if I can survive the year without going ahead and trying to get it done.”

For many people like Wilson, medical debt can be nearly as problematic as an illness. In 2015, 30.6 percent of Missouri adults ages 18 to 64 had past-due medical debt, the seventh-highest rate in the country. Kansas, at 27 percent, had the 15th-highest rate. In Maine, which voted to expand Medicaid this week, it was 27.7 percent.

Researchers Aaron Sojourner and Ezra Golberstein of the University of Minnesota studied financial data from 2012 to 2015 for people who would be eligible for Medicaid where it was expanded.

They found that in states that didn’t expand, the percentage of low-income, nonelderly adults with unpaid medical bills dropped from 47 to 40 percent within three years.

“The economy improved and maybe other components of the ACA contributed to a 7-percentage-point reduction,” Sojourner says. “Where they did expand Medicaid, it fell by almost twice as much.”

Those states saw an average drop of 13 percentage points, from 43 to 30 percent.

In Kansas, the rate of medical debt for nonelderly adults fell by 4 percentage points to 27 percent. In Missouri, the rate dropped 4 points to 31 percent, according to the Urban Institute. In Maine, it dropped only 1.4 percentage points from 2012 to 2015.

Medicaid, as opposed to private insurance, is the key, said the Urban Institute’s Kyle Caswell, because it requires little out-of-pocket costs.

Even if Medicaid patients need lots of care, they aren’t on the hook for big out-of-pocket costs in the same way someone with private insurance might be.

“We would certainly expect their risk to out-of-pocket expenses to be much lower, and ultimately the risk of unpaid bills to ultimately be also lower,” Caswell said.

But Medicaid’s debt-reducing advantages over private insurance could disappear under the leadership of the Trump administration.

Shortly after Seema Verma was confirmed as the administrator for the Centers for Medicare & Medicaid Services, she and Tom Price, then head of the Department of Health and Human Services, sent a letter to the governors outlining their plans for Medicaid.

The letter encouraged states to consider measures that would make their Medicaid programs operate more like commercial health insurance, including introducing premiums and copayments for emergency room visits.

Verma said that by giving recipients more “skin in the game,” they will take more responsibility for the cost of care and save the program money.

Republican proposals in Congress to repeal and replace the Affordable Care Act would have eliminated or limited Medicaid expansion. And that would have affected the last few years’ downward trend in medical debt.

“Anything that reduces access to Medicaid most likely would have the reverse effect of what we’re seeing in our paper,” Caswell said. “Reduced access to Medicaid would likely increase exposure to medical out-of-pocket spending and ultimately unpaid medical bills.”

As Geneva Wilson tends to her chickens, she said, she tries not to think too much about her medical debt or how she’ll pay for that hip replacement.

“It’s going to the point where, if I were to go shopping at Walmart, I would have to get one of the carts you drive because I can’t manage,” she said.

Wilson has already sold her jewelry, some furniture and a wood stove to pay down her debts. Now there’s not much left to sell except her cabin and her land.

“Probably the homestead and garden that I want, that I’ve been wanting and trying to work for, I don’t think they are a viable dream either,” Wilson said. “It’s hard losing your dreams.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

Trump Administration Plan to Add Medicaid Work Requirement Stirs Fears

November 15, 2017

The Trump administration’s recent endorsement of work requirements in Medicaid and increased state flexibility is part of broader strategy to shrink the fast-growing program for the poor and advance conservative ideas that Republicans failed to get through Congress.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, laid out her vision for the state-federal program in two appearances last week, saying her new course give states wide latitude over eligibility and benefits.

In a speech Nov. 7 to state Medicaid directors, Verma said the program needs to give people “hope that they can achieve a better future for themselves and their families, hope that they can one day break the chains of generational poverty and no longer need public assistance.”

She has noted other government assistance programs such as food stamps, have similar requirements.

But her outline scares advocates who see the changes as a way for states to kick millions of adults off the program and undermine its mission of providing health coverage to the poor. They note most nondisabled adults on Medicaid already work. Many who don’t are either too sick, go to school or care for relatives.

“Medicaid coverage is not something that should be earned,” said Robert Doherty, senior vice president at the American College of Physicians. “Medicaid is not a welfare program. It is a health care entitlement program, and anyone who meets the requirements should be able to have coverage.”

Verma’s plan to greenlight work requirements is only just the beginning of dramatic changes, these advocates said. They expect that she would allow more states to charge monthly premiums, as Indiana has proposed; approve drug testing of enrollees, as Wisconsin has requested; and putting a time limit on coverage, as Arizona has asked.

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Katherine Howitt, associate director of policy at the Community Catalyst, a consumer health advocacy group that backs the federal health law and  expansion of Medicaid, said Verma has thrown open the door to allowing states to add more restrictions on coverage.

“This new approach is not really about promoting work or improving care or improving state flexibility,” she added. “At the end of the day, it is making it harder for low-income people to access health coverage.”

Nearly 75 million people are covered by Medicaid, including 16 million added since 31 states and the District of Columbia expanded their programs under the Affordable Care Act.

Verma said her goal for Medicaid is to move people out of the program by getting them into jobs that offer coverage or provide enough income so they buy it on their own.

“Her comments show she doesn’t understand the reality that many low-wage jobs don’t offer benefits,” Howitt said.

Several states, including Arkansas, Kentucky and Maine, have asked CMS to allow them to require Medicaid recipients to work or do volunteer work as a condition of enrollment. The Obama administration turned down such proposals.

Even some right-leaning pundits say work requirements could backfire because taking away health coverage could make individuals sicker and less likely to hold down jobs.

“This could run counter to the goal of Republicans to help put people to work,” said Jason Fichtner, a health policy expert at the conservative Mercatus Center at George Mason University in Fairfax, Va.

But Josh Archambault, senior fellow for the conservative Foundation for Government Accountability, said he was encouraged by Verma’s approach.

“I think the intent of the program depends on different populations it serves,” he said. “For someone in a nursing home, it’s a health program. But for people in the Medicaid expansion, it is more like a welfare program where able-bodied people are expected to move back into the workforce.”

Congress, with the blessing of President Donald Trump, tried earlier this year to make substantial changes to Medicaid as part of the bills to replace the ACA. Those efforts stalled.

The changes included offering states more flexibility, but federal funding would not be as generous. The nonpartisan Congressional Budget Office said millions fewer people would eventually be covered.

Verma, a former health consultant who helped Indiana expand Medicaid in 2015 under Obamacare, said the law should never have allowed so-called able-bodied adults into the program. That’s because Medicaid already had too many problems, including not enough doctors and wait lists for some people seeking coverage, she said.

Before the ACA, Medicaid mainly covered children, disabled people and pregnant women.

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The health law broadened Medicaid to all low-income people, opening up the program to cover nondisabled adults without children with incomes up to 138 percent of the federal poverty level (about $16,600 for an individual).

“We put people on the Medicaid program — able-bodied individuals — in a program that is essentially designed for people that are going to be on the program for the rest of their lives,” Verma said Nov. 9 at an event sponsored by The Wall Street Journal.

Two-thirds of people on Medicaid are disenrolled within three years, according to a U.S. Census Bureau report.

Verma’s pointed criticism of Medicaid, the Affordable Care Act’s expansion and even state officials who helped implement that effort drew rebukes from state Medicaid directors.

Critics said her remarks were misguided and showed she doesn’t understand the program she runs.

Doherty said that by law Medicaid allows states to conduct experiments in how they run the program, but not by making it harder for people to get covered.

Nothing stops states, he added, from offering job training and other programs to help people on Medicaid get back to work. “But we can’t deny them access to health care just because they happen to be poor,” he said.

Robin Rudowitz, a Kaiser Family Foundation policy analyst, said Verma appears willing to let states experiment as never before.

“Some proposals [like work requirements] could create barriers to coverage for eligible beneficiaries and result in losses of coverage for Medicaid enrollees,” she said. (Kaiser Health News is an editorially independent program of the foundation.)

Some health experts said they see many contradictions in Verma’s approach. They said she wants Medicaid to focus only on the most needy — but she has been unwilling to criticize Congress for failing to reauthorize the Children’s Health Insurance Program (CHIP) that covers 9 million children. Federal CHIP funding ran out Sept. 30.

Verma also questioned why some states spend significantly more per enrollee than other states on Medicaid. But the reason, these experts note, is because states have flexibility to vary their benefits, eligibility rules and payments to providers.

As Medicaid has grown to cover more than 1 in 5 Americans, it has become more popular among beneficiaries, health care providers and even among some Republican governors who agreed to expand it. Howitt said the Trump plan would take Medicaid back to the 1980s when it was often linked to cash assistance welfare and carried a stigma.

Joan Alker, director of the Georgetown University Center for Children and Families, said backing work-requirement proposals helps the Trump administration further its ideological message that Medicaid is a welfare program and not a health program.

Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities, which supports the ACA, said Verma’s vision is simple: to undo the health law’s coverage gains.

“In 2010, Congress decided to expand Medicaid as the vehicle for low-wage workers to have coverage as part of health reform,” she said. “That is still the law and she [Verma] doesn’t get to disagree with that, she has to follow the law not sabotage it.”

Brokers Are Reluctant Players In A Most Challenging ACA Open-Enrollment Season

November 13, 2017

Lee Nathans, like insurance brokers in many states, expects to be crazy busy for the next several weeks, fielding calls from “people who are not going to be happy.”

Open enrollment for Affordable Care Act coverage started Nov. 1, and the approximately 10 million people who buy their own health insurance are only now getting a look at what’s being offered. It’s daunting.

“There will be a lot of people who will need to use a broker,” said Nathans, of Columbus, Ohio.

The enrollment period is also shorter than in previous years, ending Dec. 15.

In many places, there are fewer health insurance carriers offering coverage — and those that remain have sharply raised prices and changed their networks of doctors and hospitals.

More perplexing for people sifting through these options is the fact that this year there’s less on-the-ground assistance to help decode those complexities because of Trump administration funding cuts.

This KHN story also ran on NBC. It can be republished for free (details).

All that means brokers are coping with what may be the most challenging sign-up period since the ACA marketplaces, also known as exchanges, debuted in 2014.

When the ACA became law, some thought the days of brokers were numbered.

The ACA’s rules and online state and federal exchanges were supposed to make comparing plans and purchasing health insurance easier.

But for many consumers — particularly those who have never bought insurance before — having help is vital.

“Yes, health insurance is complicated,” said Lisa Hamler-Fugitt, executive director for the Ohio Association of Foodbanks, which provided such help for the past four years through federal grant-funded navigator programs in the state. Navigators are trained individuals or groups that guide consumers and small businesses through the process, for free.

“[Customers] didn’t turn to us just during open enrollment, but also when they had questions about how to use their plan, about deductibles and copayments.”

This year is different.

The Trump administration, criticizing the navigator effort nationwide, slashed funding. The Ohio program learned it would get a 71 percent cut and reluctantly closed its doors for this enrollment season.

There were also cuts to other states, which varied, but averaged 40 percent nationally. In Tennessee, for example, navigator funding was reduced by 16 percent, while in Indiana it fell 82 percent.

The Department of Health and Human Services appears to be turning to brokers to fill this gap. It announced in late October that the federal online marketplace,, has a new resource under its “Find Local Help” tab. Consumers can enter their contact information in the “Help On Demand” feature — and get a call back from a state licensed broker.

It isn’t known how many brokers signed up to participate, but agent John Dodd thinks it’s a good idea.

“This move of working more with brokers will help make up some of the difference [from losing the navigator program], although anytime you remove help, that’s not a positive step,” said Dodd, president-elect of the Ohio Association of Health Underwriters and owner of his own agency in Westerville.

But growing pressure on brokers — from smaller commissions to increased complexity of the health offerings — means they may be harder to find.

Last year, several big Blue Cross Blue Shield insurers cut or reduced their commissions, citing it as a cost-cutting move, following a similar action in 2015 by UnitedHealthcare. Some brokers then began charging a fee to help people enroll, while others stopped entirely.

When insurers pay commissions, the amounts are included in premiums and can be between 2 and 5 percent, depending on the carrier.

This year, “I’m still going to help my clients, but I’m not doing direct enrollments,” said Nathans. He will refer customers who need this assistance to a colleague.

There are reasons why the enrollment process is a heavy lift.

Licensed insurance broker John Jaggi of Forsyth, Ill., said he and his daughter, Anne Petri, also a broker, often spend the first 35 minutes of appointments just helping clients figure out the math to determine if they can get a premium subsidy. People who qualify earn less than 400 percent of the federal poverty level ($48,240 for an individual) and don’t have other coverage.

By that point, clients are exhausted and don’t even want to talk about the details of the plan, Jaggi said. And he’s paid “almost nothing” for his efforts.

Still, Jaggi and Petri plan to continue helping individuals with this year’s enrollment.

A Trump administration decision in October likely has created even more demand for these services. President Donald Trump said then that he was stopping federal “cost-sharing reduction” payments to insurers. These payments were used to offset the costs of coverage for certain low-income policyholders by reducing their deductibles and copayments.

Even without the federal assistance, insurers are still required to provide these cost reductions. To make up for them, insurers boosted premiums, particularly in middle-level “silver” plans. Because the cost of these plans is also the benchmark used to set the tax-credit subsidy many people receive to help pay their premiums, eligible consumers will likely receive more federal assistance this year and have more affordable options from which to choose.

In other words, people who receive the tax credits are not likely to feel a financial pinch. People who don’t, though, will likely take a hit.

“You have to feel bad for them,” said Petri. “How can they afford another $100 to $200 a month in premium?”

The individual market has always been volatile, but brokers say the situation is bad this year.

Dodd, the Westerville, Ohio-based broker, said he hopes Congress acts to stabilize the market. And soon.

Without that, “2019 could be Armageddon, off-the-charts bad,” he said.

Podcast: ‘What The Health?’ We Have Numbers!

November 10, 2017

Democrats won some unexpectedly large victories in Tuesday’s off-off-year elections, putting health care squarely back on the political map. Meanwhile, enrollment was unexpectedly high in the insurance exchanges’ opening days, according to the Department of Health and Human Services.

In this episode of “What the Health?” Julie Rovner of Kaiser Health News, Sarah Kliff of, Joanne Kenen of Politico and Alice Ollstein of Talking Points Memo discuss the potential political impact of Tuesday’s voting, including the success in Maine of a referendum to expand the Medicaid program, as well as the latest news from Washington, D.C.

Among the takeaways from this week’s podcast:

— Voters in exit polls cited health care as a major voting issue — and in Virginia the vast majority of those who said health care was a top issue voted for the Democrat. But some Republicans continue to insist that voters are angry that they did not repeal the Affordable Care Act and are doubling down on efforts to make that happen before the congressional midterm elections in 2018.

— Tuesday’s results in the Maine Medicaid referendum might prompt voters in other states that have yet to expand the program to try the direct-ballot route. But Maine’s governor has said he will continue to try to block implementation, which could lead to lawsuits.

— Despite the Trump administration’s efforts to undermine the Affordable Care Act, open enrollment for 2018 has seen a spike in sign-ups in the first few days. Some suggest one reason is that many people who qualify for tax credits are getting an unexpected windfall this year because of the way states have addressed federal cuts in subsidies for low-income enrollees. People who earn just over the cutoff for federal help, however, are facing frequently unaffordable rates.

— Federal Medicaid chief Seema Verma this week suggested the Trump administration will be approving state requests to require Medicaid recipients to work or perform community service in exchange for their benefits. Work requirements would be a major change for the program, and one several states are seeking.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Kaiser Health News and Climate Central, “Breathing Fire: Health Is A Casualty Of Climate-Fueled Blazes,” by John Upton and Barbara Feder Ostrov.

Sarah Kliff: Kaiser Health News, “Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs,” by Fred Schulte and Elizabeth Lucas.

Joanne Kenen: The New Yorker, “Faces of an epidemic,” by Philip Montgomery and Margaret Talbot.

Alice Ollstein: Reuters, “Exclusive: FBI agents raid headquarters of major U.S. body broker,” by John Shiffman and Brian Grow.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Obamacare Shopping Is Trickier Than Ever. Here’s A Cheat Sheet.

November 10, 2017

Health care is complicated. Shopping for an individual health plan just got even more so, with President Donald Trump’s decision last month to block $7 billion in Affordable Care Act subsidies.

Known as cost-sharing reduction payments (CSRs), these federal funds had helped insurers offset the costs of the discounts they are required to offer to some lower-earning customers to help them pay for deductibles and copays.

We’ll spare you the details. But because of how state regulators responded to the chaos and how insurers are trying to recover the money through higher premiums, common-sense rules of shopping may no longer apply.

This KHN story also ran on NBC. It can be republished for free (details).

A high-coverage “gold” plan in many states might now be cheaper than a medium-coverage “silver” plan. The reported 15 or 20 percent premium spikes resulting from Trump’s move might nail you right in the wallet. Or, weirdly, it could save you hundreds of dollars next year if you play your cards right.

Experts’ advice, in brief, is: SHOP AROUND. Play with different options on or state marketplaces. Don’t just renew this year’s plan. More than ever, for 2018 that might not be the best deal.

Find your situation here:

Household income is between $12,060 and $30,150 for an individual, $16,240 and $40,600 for a couple and $24,600 and $61,500 for a family of four.

By law, insurers still must pass along the cost-sharing reductions, even though Trump cut off the reimbursement. And you are probably eligible for them.

But to qualify for the cost-sharing reductions, which lower deductibles and copays when you seek care, you must purchase a silver plan on the marketplace. People buying the other metal levels — the more comprehensive gold or platinum plans or less generous “bronze” plan — cannot get this benefit. So unless you hardly ever see a doctor, get a silver plan.

However, if you’re healthy and at the lower end of these income ranges, a bronze plan might make the most sense.

That’s because of the other Obamacare subsidy, which reduces premiums.

These subsidies are paid directly to qualifying consumers in the form of tax credits. The premium subsidy is so generous for 2018 (we explain why, below) that, for many people, they could cover the entire cost of bronze plans.

Cost-sharing reductions help only if you expect to pay out-of-pocket costs for docs and hospitals. If you don’t — and if you feel like gambling that you won’t need expensive care — a free or super-cheap bronze plan might be better.

At the lower ranges of this income group, you might be eligible instead for Medicaid — in states that expanded that program under the ACA. This online subsidy calculator can help you figure it out.

Household income is between $30,150 and $48,240 for individuals, $40,600 and $64,960 for a couple and $61,500 and $98,400 for a family of four.

You’re eligible for subsidies to reduce premiums but not the cost-sharing reductions. Even so, Trump’s decision to cut them may affect you — in a good way.

To recover the missing $7 billion, most insurers are jacking premiums for silver plans — an estimated 20 percent extra.

The good news is that higher premiums don’t hurt most marketplace consumers. Obamacare caps how much eligible consumers are expected to pay for health insurance — even if premiums go to the moon. The federal premium subsidies cover the difference.

But that’s not all. Trump’s move makes the premium subsidy more generous. Here’s how.

The level of premium subsidy you receive is based not just on your income but also on silver-plan prices, and now silver premiums are going up a lot. The higher the silver premiums, the more generous the subsidies. But that subsidy is not limited to use on a silver plan.

Anybody eligible can take those subsidies and shop for any kind of plan on the marketplace. That’s why in Texas, Pennsylvania, Michigan and other states a high-benefit gold plan might be less expensive next year or not much more than a silver plan. It’s why many consumers could see their premium bills fall in 2018 — in some cases, to zero.

To repeat: Shop around. Shop early. The plan you have now probably won’t be cheapest next year.

Household income is more than $48,240 for individuals, $64,960 for a couple and $98,400 for a family of four.

More than 7 million of these folks buy individual health insurance plans through or outside the ACA’s online marketplaces.

If this is you, you’re ineligible for any Obamacare subsidies. That means your chances of getting slammed by premium increases for 2018 are high. Silver-plan premiums are soaring by 35 percent or more because of high claims and Trump’s decision to stop cost-sharing reimbursement to insurers.

But there are ways to limit the pain. Generally avoid silver plans and look at bronze and gold. Those premiums are probably rising less.

However, California and about a dozen other states allowed insurers to sell a separate class of silver plans without the cost-sharing money built into premiums. These may be available only outside the official, online ACA marketplaces, so to find them you have to ask a broker or check websites of insurers or online brokers such as eHealth or GetInsured.

Household income is less than $16,643 for an individual, $22,411 for a couple and $33,948 for a family of four.

You may qualify for Medicaid, the federal and state health program for low-income people. However, 19 states, mostly in the South, did not expand the program under the health law.

Medicaid eligibility in those places is much narrower, especially for adults, than in the rest of the country. That accounts for many of the 28 million uninsured Americans.

The subsidy calculator shows whether your income makes you eligible for Medicaid and whether your state has expanded Medicaid.

Maine Voters Greenlight Medicaid Expansion, But Governor Says Whoa

November 09, 2017

Just hours after Maine voters became the first in the nation to use the ballot box to expand Medicaid under the Affordable Care Act, Republican Gov. Paul LePage said he wouldn’t implement it unless the Legislature funds the state’s share of an expansion.

“Give me the money and I will enforce the referendum,” LePage said. Unless the Legislature fully funds the expansion — without raising taxes or using the state’s rainy day fund — he said he wouldn’t implement it.

LePage has long been a staunch opponent of Medicaid expansion. The Maine Legislature has passed bills to expand the insurance program five times since 2013, but the governor vetoed each one.

That track record prompted Robyn Merrill, co-chair of the coalition Mainers for Health Care, to take the matter directly to voters Tuesday.

The strategy worked. Medicaid expansion, or Question 2, passed handily, with 59 percent of voters in favor and 41 percent against.

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“Maine is sending a strong and weighty message to politicians in Augusta, and across the country,” Merrill said. “We need more affordable health care, not less.”

Medicaid expansion would bring health coverage to about 70,000 people in Maine.

As a battle now brews over implementation in Maine, other states will likely be watching: groups in Idaho and Utah are trying to put Medicaid expansion on their state ballots next year.

With passage of the ballot measure, Maine is poised to join the 31 states and the District of Columbia that have already expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level. That’s about $16,000 dollars for an individual, and about $34,000 for a family of four.

Currently, people in Maine who make too much for traditional Medicaid and who aren’t eligible for subsidized health insurance on the federal marketplace fall into a coverage gap. It was created when the Supreme Court made Medicaid expansion under the Affordable Care Act optional.

That’s the situation Kathleen Phelps finds herself in. She’s a hairdresser from Waterville who has emphysema and chronic obstructive pulmonary disease. She said she has had to forgo her medications and oxygen because she can’t afford them. “Finally, finally, maybe people now people like myself can get the health care we need,” she said.

Medicaid expansion would also be a win for hospitals. More than half of those in Maine are operating in the red. Across the state, hospitals provide more than $100 million a year in charity care, according to the Maine Hospital Association. Expanding Medicaid coverage will bolster their fiscal health and give doctors and nurses more options to treat their formerly uninsured patients, said Jeff Austin, a spokesman with the association.

“There are just avenues of care that open up when you see a patient from recommending a prescription drug or seeing a counselor,” he said. “Doors that were closed previously will now be open.”

But voter approval may not be enough. Though a legislative budget analysis office estimates Medicaid expansion would bring about $500 million in federal funding to Maine each year, it would also cost the state about $50 million a year.

The fate of the Medicaid expansion will now be in the hands of the Legislature, where lawmakers can change it like any other bill. Four ballot initiatives passed by Maine voters last year have been delayed, altered or overturned.

But state Democratic leaders pledge to implement the measure. “Any attempts to illegally delay or subvert the law … will be fought with every recourse at our disposal,” Speaker of the House Sara Gideon said. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

This story is part of a partnership that includes Maine PublicNPR and Kaiser Health News.

Election Night Surprise: Health Care Galvanizes Voters

November 08, 2017

Health care appears to have played an unexpectedly robust role in Tuesday’s off-year elections, as Democrats swept statewide races in Virginia and New Jersey and voters told pollsters it was a top concern.

The health headline of the night came in Maine, where voters by a large margin rebuked Republican Gov. Paul LePage and approved a referendum  expanding Medicaid under the Affordable Care Act. Maine is one of 19 states that has not expanded the program to people with incomes up to 138 percent of the federal poverty line, or about $16,600 for an individual. An estimated 70,000 to 90,000 Mainers could gain insurance under the expansion.

The Legislature has passed similar bills five times, but LePage vetoed each one. And despite Tuesday’s outcome, he held firm in his opposition. The governor announced Wednesday that he would not implement the expansion, which he said would be “ruinous” for the state’s budget, unless it is fully funded by the Legislature.

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Medicaid expansion might also be back in play in Virginia. Voters there not only elevated Democratic Lt. Gov. Ralph Northam to the governorship, they may have steered Democrats to a takeover of the state House of Delegates, which has been the primary source of opposition to Gov. Terry McAuliffe’s efforts to expand Medicaid. As of Wednesday morning, Democrats had picked up 15 of the 17 seats they would need to take over the majority with several races too close to call or requiring a recount.

And while it was not a headline issue in the governor’s race, health care proved decisive to Virginia voters, according to exit polls funded by a pool of media organizations.

Health care was by far the top issue for voters, according to the poll, which asked voters which of five issues mattered most to them. Nearly 4 in 10 said health care was the issue most important to their vote, followed by gun policy at 17 percent, taxes at 15 percent, immigration at 12 percent and abortion at 8 percent. Among those voters who cited health care, 77 percent voted for Democrat Northam, making it his strongest issue by a wide margin.

Pollsters were quick to add, however, that at least some of health care’s prominence in the poll was due to the fact that voters were not given the chance to choose issues that are typically more popular, such as the economy or education.

The fallout will depend on who holds which views, said Rodney Whitlock, a former GOP Senate staffer. If health care is a top concern for Democrats, “that doesn’t have a lot of meaning for Republicans,” he said. But if independents are the ones who see health as a salient voting issue, “that means much more.”

But Robert Blendon, a professor of health policy and political analysis at Harvard University, said the election results suggest that health care has again become a positive for Democrats. “You don’t have to say you love the ACA, but that you don’t want to drop millions of people” from coverage, he explained.

In New Jersey, voters said they were more concerned with state issues, with property taxes and corruption topping the list of topics they told exit pollsters drove their votes. But health care was third.

Still, the election results likely hinged on a host of concerns, warned Drew Altman, president and CEO of the Kaiser Family Foundation. Health issues are still strongly viewed through partisan lenses, he said, and the voting probably was more of a referendum on President Donald Trump than on health care. But the results in the Maine referendum could have repercussions beyond that state, showing that Medicaid expansion is “far more popular” than Republicans have acknowledged. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

In Ohio, voters defeated what some called a confusing ballot measure aimed at limiting prescription drug prices to no more than the amount paid by the Department of Veterans Affairs. A similar measure was voted down in California last year.

Update: This story was updated on Nov. 8 to add more detail about the exit polling.

Estados podrían imponer el requisito de estar trabajando para tener Medicaid

November 07, 2017

La administración Trump señaló el martes 7 de noviembre que permitiría a los estados imponer requisitos de trabajo a algunos adultos inscriptos en el Medicaid, una meta que los conservadores desearon por largo tiempo, y a la que se oponen demócratas y defensores de los más pobres.

Esta decisión marcaría un giro importante en la política federal. La administración del presidente Barack Obama dictaminó en repetidas ocasiones que los requisitos de trabajo eran inconsistentes con la misión del Medicaid de proporcionar asistencia médica a personas de bajos ingresos.

El anunció lo realizó Seema Verma, directora de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), quien se dirigió a través de un video a los directores estatales del Medicaid durante una reunión. En un comunicado de prensa lanzado antes del discurso, se explicó que esta decisión es parte de un plan para que los estados tengan más flexibilidad para modificar sus programas locales del Medicaid.

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La idea de que un programa diseñado para nuestros ciudadanos más vulnerables deba usarse como un vehículo para servir a los adultos sanos en edad de trabajar no tiene sentido, pero la administración anterior luchó contra las reformas impulsadas por los estados que habrían permitido que el Medicaid evolucionara”, dijo Verma en una copia de sus comentarios publicados momentos antes de que hablara.

“Para las personas que viven con discapacidades, los CMS siempre han creído que un trabajo acorde es esencial para su autosuficiencia económica, la autoestima, el bienestar y la mejora de su salud”, dijo. “¿Por qué no creer lo mismo para los beneficiarios del Medicaid en edad de trabajar y sanos?”

Ocho estados -Arizona, Arkansas, Indiana, Kentucky, New Hampshire, Maine, Utah y Wisconsin- han enviado solicitudes a los CMS para que se les permita exigir a las personas bajo Medicaid que trabajen o presten servicios a la comunidad.

El comunicado no indicó cuándo Verma se pronunciaría sobre las solicitudes pendientes, pero un funcionario de los CMS dijo que probablemente sería antes de fin de año.

Sin embargo, estudios demuestran que la gran mayoría de las personas que reciben Medicaid ya están trabajando, buscando empleo, yendo a la escuela o cuidando a un familiar.

Alrededor del 59% de los adultos sin discapacidades en el Medicaid, que son menores de 65 años, tienen trabajo, según un análisis de la Kaiser Family Foundation. (Kaiser Health News es un programa editorialmente independiente de la fundación).

Verma enfatizó el compromiso de la agencia de considerar propuestas que darían a los estados más flexibilidad para poner a prueba los esfuerzos para sacar a los beneficiarios de la pobreza.

“Todos los estadounidenses merecen la dignidad y el respeto de tener altas expectativas, y como funcionarios públicos debemos ofrecer programas que despierten la esperanza y le digan a cada beneficiario que creemos en su potencial”, dijo Verma.

Los estados y el gobierno federal se dividen los costos del programa Medicaid, que suman $575 mil millones, para cubrir a 74 millones de personas. Los estados pueden establecer beneficios y reglas de elegibilidad dentro de amplias pautas federales.

Desde la década de 1990, el gobierno federal ha permitido cada vez más a los estados que renuncien temporalmente a las reglas que rigen el Medicaid para que puedan experimentar cómo administran el programa. Los estados han usado esas opciones para esfuerzos tales como agregar primas mensuales o personalizar su expansión del Medicaid según la Ley de Cuidado de Salud Asequible (ACA) de 2010.

Dos requisitos a largo plazo de estas exenciones son que no aumenten los costos federales y que se mejore la cobertura de salud de los más pobres.

Los CMS dijeron el martes que ampliar el acceso ya no es un objetivo clave de las exenciones federales del Medicaid. Esta declaración representa un cambio filosófico en el programa que abriría la puerta para aprobar requisitos de trabajo que, reconocen los mismos estados, reduciría el número de personas inscriptas.

“Esto me indica que la agencia se está preparando para negar un objetivo central de la ley federal y, en cambio, tratar de lograr exactamente lo que la ley no permite, es decir, una reducción en el nivel de asistencia disponible para los estadounidenses más pobres y médicamente más vulnerables”, opinó Sara Rosenbaum, profesora de derecho y políticas de salud en la Universidad George Washington, en Washington, DC

Ya se esperaba este anuncio de Verma. Antes de ser nombrada como titular de los CMS, fue consultora de atención médica y ayudó a los programas del Medicaid de Indiana y Kentucky a redactar sus solicitudes de exención, incluidos los requisitos de trabajo. Para evitar un conflicto, los CMS aclararon que Verma no participará en las decisiones sobre esos dos estados.

La decisión de apoyar los requisitos laborales probablemente terminará en una batalla judicial, dijo Jane Perkins, directora legal del Programa Nacional de Ley de Salud, un grupo de defensa. Perkins dijo que los CMS tienen poder para permitir que los estados experimenten con el programa del Medicaid, pero no restringiendo la elegibilidad.

“Esto es realmente un cambio, con los CMS diciéndoles a los estados: ‘vengan a decirnos lo que quieren hacer y si quieren recortar el programa, les daremos el visto bueno'”, dijo Perkins. “Eso es inconsistente con la intención del Congreso sobre las exenciones del Medicaid”.

El video de Verma dirigido a la Asociación Nacional de Directores del Medicaid marca una de sus pocas apariciones públicas desde que asumió el cargo. A pesar de supervisar tanto al Medicaid como al Medicare, programas que impactan a más de 120 millones de estadounidenses, ha concedido pocas entrevistas o discursos públicos.

Los gobernadores republicanos defienden los requisitos de trabajo, diciendo que tal mandato proporcionará “dignidad” a los afiliados y los estimulará a no contar con el programa de derechos del gobierno.

“Este programa ofrece oportunidades para que las personas tomen el control de sus vidas”, dijo el gobernador de Kentucky el republicano Matt Bevin, al revisar su propuesta de requisitos de trabajo en julio.

Quienes se oponen a los requisitos de trabajo afirman que muchos inscriptos en el Medicaid ya trabajan y que un mandato es contraproducente. Negar a las personas el acceso a la atención médica podría evitar que se mantengan saludables y que puedan conseguir empleo, argumentan.

El discurso de Verma ocurrió después que los CMS anunciaran el lunes que agilizarían el proceso, a menudo arduo, para obtener exenciones al Medicaid. Ofreció acelerar algunas solicitudes y dijo que permitiría a los estados obtener exenciones de hasta 10 años, cinco años más de lo que actualmente se permite.

Verma también dijo que el gobierno federal dará a conocer información que muestran los resultados del Medicaid, pero no dio detalles sobre qué medidas se evaluarían.

La mayoría de los inscritos en el Medicaid se encuentran en planes privados de atención administrada, que son evaluados cada año por los estados, analizando todo: desde las tasas de vacunación para niños hasta las tasas de detección del cáncer para adultos.

Más de 16 millones de personas se han sumado al Medicaid desde 2013, principalmente porque 31 estados ampliaron la elegibilidad para el programa, siguiendo la línea del Obamacare.

Medicaid Chief Says Feds Are Willing To Approve Work Requirements

November 07, 2017


The Trump administration signaled Tuesday that it would allow states to impose work requirements on some adult Medicaid enrollees, a long-sought goal for conservatives that is strongly opposed by Democrats and advocates for the poor.

“Let me be clear to everyone in this room: We will approve proposals that promote” employment or volunteer work, Seema Verma, the head of the Centers of Medicare & Medicaid Services (CMS) said in a speech to the nation’s state Medicaid directors.

Such a decision would be a major departure from federal policy, and critics said it would lead to a court fight. President Barack Obama’s administration ruled repeatedly that work requirements were inconsistent with Medicaid’s mission of providing medical assistance to low-income people.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve the working-age, able-bodied adults does not make sense, but the prior administration fought state-led reforms that would’ve allowed the Medicaid program to evolve,” Verma said.

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“For people living with disabilities, CMS has long believed that meaningful work is essential to their economic self-sufficiency, self-esteem, well-being and improving their health,” she added. “Why would we not believe that the same is true for working-age, able-bodied Medicaid enrollees?”

Verma also blasted the Affordable Care Act, saying the health law’s efforts to give coverage to so-called able-bodied adults was a mistake because it resulted in “stretching the safety net for some of our most fragile populations,” such as children, pregnant women and people with disabilities. It also has added to the problems for Medicaid enrollees getting access to care, she said.

The speech got a cool reception from the state directors. None of her comments brought immediate clapping from the nearly 1,000-person audience, but there was polite applause at the end.

Eight states — Arizona, Arkansas, Indiana, Kentucky, Maine, New Hampshire, Utah and Wisconsin — have submitted requests to CMS seeking to require nondisabled Medicaid enrollees to either work or provide community service.

The proposed work requirement rules vary by state. Arizona calls for enrollees to be working, seeking work or attending school or job training for at least 20 hours a week.

New Hampshire would require enrollees to work, engage in job training or acquire education for more hours the longer they are in Medicaid. For example, they would put in 20 hours a week the first year they were enrolled, 25 hours the second year and at least 30 hours in their third year.

Verma did not say when she would rule on the pending applications, but one CMS official said it would likely be before the end of the year.

The Medicaid chief said she wants to give states more flexibility as CMS officials “reset the federal-state relationship, and restore the partnership,” so that Medicaid “is sound and solvent and helps all beneficiaries reach their highest potential.”

Kentucky expects to get a green light from CMS and plans to implement the mandate by July, said Stephen Miller, the state’s Medicaid director. “We were in sync with what she had to say” about work requirements, he said.

He said that even though the state’s Medicaid rolls have soared to cover 33 percent of residents, Kentucky still has high rates of cancer, smoking and obesity. “We have to try something else,” he said. “We need to do more than just help people access health care.” The move would also help the state save money, he added.

Allison Taylor, Indiana’s Medicaid director, said a work requirement would help the state find the nearly 1 million workers it is estimated to need by 2025.

Studies show the vast majority of Medicaid enrollees are already working, looking for work, going to school or caring for a relative.

About 59 percent of nondisabled adults on Medicaid who are under 65 do have jobs, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Verma said the Obama administration was wrong when it denied states’ requests to implement work requirements, also known as community engagement mandates. “Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said. “Those days are over.”

New York Medicaid Director Jason Helgerson said the speech created an “us vs. them” scenario. “To suggest that the work we do is some form of bigotry is disgusting,” he said.

While he welcomed more flexibility from CMS toward states, Helgerson said the ACA has been a boon to New York and there is no evidence of people having longer waits for care since the expansion.

Verma decried the Obama administration’s emphasis on Medicaid enrollment. “While many responded to this expansion with celebration, we shouldn’t just celebrate an increase in the rolls, or more Medicaid cards handed out,” she said. “For this population, for able-bodied adults, we should celebrate helping people move up, move on and move out.”

Several Medicaid directors said they were upset that Verma suggested they care only about adding people to Medicaid rolls. “We do so much more than that,” said one Medicaid director, who refused to be named because of concerns about working with CMS.

More than 16 million people have been added to Medicaid since 2013, mostly as a result of 31 states and the District of Columbia expanding eligibility under the federal health law.

States and the federal government split the costs of the $576 billion Medicaid program, which covers 74 million people. States are allowed to set benefits and eligibility rules within broad federal guidelines.

Since the 1990s, the federal government has increasingly allowed states to temporarily waive Medicaid rules to give states the ability to experiment with how they administer the program. States have used those options for efforts such as adding monthly premiums or customizing their expansion of Medicaid under the 2010 Affordable Care Act.

Two long-term requirements of such waivers are that they do not increase federal costs and they improve health coverage of the poor.

CMS said Tuesday that expanding access is no longer a key purpose of federal Medicaid waivers. That would be a philosophical change in the program that would open the door to approve work requirements, which states acknowledge would reduce the number of people enrolled.

“It tells me that the agency is preparing to disavow a central objective of federal law and instead will attempt to accomplish exactly what the law does not countenance, namely, a reduction in the level of assistance available to the poorest and most medically vulnerable Americans,” said Sara Rosenbaum, a health policy and law professor at George Washington University in Washington, D.C.

Verma’s decision had been widely expected. Before being appointed to CMS, she was a health care consultant, and she helped the Indiana and Kentucky Medicaid programs draw up their waiver requests, including work requirements. To avoid a conflict, CMS said Verma will not be involved in decisions on those two states.

A decision to support work requirements would likely end up in a court battle, said Jane Perkins, legal director of the National Health Law Program, an advocacy group. Perkins said CMS has power to allow states to experiment with the Medicaid program but not by curtailing eligibility.

“This is really a change in the complexion of the Medicaid program, where CMS is saying to states, ‘Come tell us what you want to do and if you want to cut back the program, we will give you the go ahead,’” Perkins said. “That is inconsistent with congressional intent” of Medicaid waivers.

Verma’s address to the National Association of Medicaid Directors meeting in Arlington, Va., marks one of her few public appearances since taking office. Despite overseeing both Medicaid and Medicare — programs that affect more than 120 million Americans — she has given few interviews or public speeches.

She has frequently been mentioned as a possible replacement for Health and Human Services Secretary Tom Price, who resigned in September following allegations of wasteful travel spending.

Verma’s speech came after an announcement by CMS on Monday that it would streamline the often-arduous process to get Medicaid waivers. It offered to fast-track some requests and said it would allow states to get waivers for up to 10 years — five more years than currently allowed.

Verma also said the federal government would release scorecards showing Medicaid outcomes, but she gave no details on what measures would be evaluated. Some state officials fear CMS will use the new grading measure to lower their federal funding.

Most Medicaid enrollees are in private managed care plans, which get evaluated each year by states, looking at everything from vaccination rates for children to cancer screening rates for adults.