Looking Ahead at Medicaid: Work Requirements and Other Big Changes
In a pilot Emerging Scholars Exchange Program presentation at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), Renuka Tipirneni of the University of Michigan's Institute of Healthcare Policy and Innovation (IHPI), reviewed the latest scholarly findings related to the rapidly changing Affordable Care Act's Medicaid expansion programs.
Tipirneni, MD, MSc, is an Assistant Professor in Michigan's Department of Internal Medicine, Co-Investigator on IHPI's evaluation of Michigan's Medicaid expansion, and Principal Investigator evaluating Michigan's Medicaid Health Homes program. Her visit to Penn is part of a test collaboration exchange program by LDI, IHPI and UCSF's Lee Institute designed to provide development opportunities for early career faculty.
Entitled "What happens to patients after Medicaid expansion? Changes in health care access, health behaviors, and work," Tipirneni's presentation looked at her own research findings as well as those of other health services researchers investigating a Medicaid program undergoing historic sorts of change.
Twice as many enrollees
In Michigan, as in many other states, the 2014 launch of the Affordable Care Act's insurance exchanges and Medicaid expansion resulted in 320,000 people signing up for the former and 680,000 for the latter -- more than twice the initially expected number of enrollees in both categories. Today, ten percent of the state's population is covered by one of the two programs.
This trend raised concerns about whether the flood of new patients would reduce the availability of new patient appointments throughout the state or greatly extend the waiting time for such appointments.
Tipirneni noted that as she began a "secret shopper" longitudinal study of appointment availability, she assumed availability would go down and waiting time would go up. But her hypothesis was proved wrong on both counts by her data. Appointment availability for Michigan Medicaid patients actually went from 49% to 55% and wait times remained stable.
"What really surprised me in this analysis," she said, "was the dramatic increase in the number of appointments that were offered specifically with non-physician providers. It doubled for both Medicaid and privately insured patients. That really led me to think that practices were hiring more nurse practitioners and physician assistants in anticipation of this policy change or utilizing them in different ways. The exact details were not clear to me but it seemed like there was something important going on there."
She said her own and other Medicaid studies generally found that:
- Access for health care was improved by the Medicaid expansion
- Appointment availability for new Medicaid patients increased
- Wait times remained stable
- Medicaid patients reported being able to get the care they needed.
The new wildcard in Medicaid is the Trump administration's approval of a variety of Section 1115 waivers that enable states to modify their own programs, often in ways that may decrease costs as well as the level or nature of care available to their populations of Medicaid enrollees.
Medicaid work requirements
Approved by the Centers for Medicare & Medicaid Services (CMS) in January, the most controversial waiver would limit Medicaid eligibility to those individuals who can prove they have a job, are in training for a job, or volunteer in community service programs. The linking of Medicaid eligibility to work is a historic change for the 53-year-old program originally designed to provide safety net care for low-income individuals and families that otherwise couldn't afford medical care. Kentucky is the first state preparing to implement this requirement.
Tipirneni and her IHPI team have been doing contract research work for the State of Michigan surveying and interviewing 2015 and 2016 Medicaid expansion enrollees about their health status, ability to work, and ability to seek a job.
"We found that most Medicaid enrollees were already working or in school," she said. "And enrollees who were unable to work reported significant barriers to employment such as poor health, chronic health conditions or other functional limitations. In our Michigan survey we also found individuals on expanded Medicaid coverage have an association with improved health, ability to work and improved ability to seek employment."
The bottom line
"The bottom line," Tipirneni said, "is that work requirements (in Michigan) would likely only apply to a small group of enrollees but may disrupt care for many chronically ill individuals, depending on how the work rules are implemented."
"One thing that is clear," she said, "is that there is an increasing CMS emphasis on flexibility for states to pursue modifications, including section 1115 waivers. In many statements in the past year, CMS Director Seema Verma has said her agency is going to give states an 'unprecedented level of flexibility' and that community engagement (work requirement) emphasis is one example of the flexibility being promoting right now."