United States: Blogging Live From AHLA: A Review Of Recent Trends In Medicaid Waivers
Last Updated: March 23 2018

Good morning from snowy Baltimore! Myself, along with my colleagues Tom Barker, Sean Ahern, and Erik Schulwolf are excited to be here here at AHLA's Institute on Medicare and Medicaid Payment Issuers. Over the next few days we plan on blogging about our insight, key sessions, and other fun tidbits and developments as we take in all of the great information at this annual gathering of the health bar. Not to sell ourselves short- we will start with a session I was lucky enough to put together with several of my colleagues from other organizations entitled, "The Changing Face of the Medicaid Program: A Review of Recent Trends in Medicaid Waivers."

I was joined in this session by the following wonderful individuals:

  • MaryBeth Musumeci, Associate Director for Kaiser Family Foundation's Program on Medicaid and the Uninsured
  • Leo Cuello, Director of Health Policy for the National Health Law Program, and
  • Matt Salo, Executive Director of the National Association of Medicaid Directors

The session was dynamic and a learning experience for all involved. I began with 2-hours session with a deep dive into the history of section 1115 waivers, the uses of such waivers, and a review of the legal constructs of section 1115 of the Social Security Act. I concluded by taking a look at how courts have previously viewed the Secretary's discretion regarding waiver approvals, and the 2012 process adopted in regulations to guide waiver approvals. You can see my slides here:

MaryBeth presented some fantastic data on current waiver approvals, including the growing number of states request waiver authority never before requested. MaryBeth took us deep into the recent approvals of waivers in Indiana and Kentucky, and pointed out some of the key research Kaiser has done already in evaluating the success (and failures) of these state-led efforts. MaryBeth's slides are here:

Next, Leo Cuello of the National Health Law Program walked us through ongoing litigation by aggrieved recipients in Kentucky challenging CMS' approval of its 1115 waiver. Leo engaged in a deep dive of the underlying statutory authority granted to the Secretary in section 1115, including: (1) what is an experiment or demonstration project?; and (2) what are the "objectives" of the Medicaid program for purposes of determining whether or not a particular waiver is approval or not. Leo's slides are here:

Finally, Matt Salo of NAMD gave us the unique perspective of the state Medicaid directors as the Trump Administration works to ease the process for 1115 waiver approval – and as states increasingly seek waiver authority never before granted. Matt's perspective is a unique one – as he represents 50+ very different and unique Medicaid programs with different goals and political ideologies. Matt argued that the underlying Medicaid statute is antiquated and broken – and that 1115 waivers are now such an integral part of the program that focusing on the objective of a single waiver within a very narrow context really misses the point (Matt gave the good example of Arizona, which has only ever operated its Medicaid program under an 1115 waiver.) Matt's slides are here:

It was certainly an engaging discussion and one that I think will only continue as we watch what this administration does with the many more waivers coming down the pipeline.

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