Three waivers states can use to reduce the ObamaCare mess

ObamaCare has created a mess in healthcare. Care is less available, insurance is unaffordable, and the country is heading toward bankruptcy. With Washington hopelessly gridlocked, how can Americans get in to a doctor’s office before they die waiting in line?

There is a way to get relief from ObamaCare’s expensive mandates. States can apply for waivers, which temporarily and partially suspend federal healthcare regulations, allowing the states to design their own demonstration projects. Each waiver has its own process and restrictions, and is generally identified by the number of its section within the law.

{mosads}Three waivers can significantly improve state Medicaid management: Sections 1115 and 1915 of the Social Security Act of 1965, and Section 1332 of the Affordable Care Act of 2010.

Section 1115

Section 1115 waivers allow states to waive any federal mandate pertaining to Medicaid. The waiver can be as broad or narrow in scope as a state chooses. 

Forty-two states currently have one or more 1115 waivers active or pending. When states have multiple waivers, one waiver is usually broad, such as activating managed care for all Medicaid recipients, and one is narrow, serving a specific population, such as family planning services to young mothers.

On August 1, 2017, Maine submitted a Section 1115 waiver request that aims to return MaineCare, the state Medicaid program, to the original 1965 Medicaid target population: “those unable to support their medical needs.” Maine’s goal is to infuse personal responsibility into what has become a government give-away.

Maine’s waiver expects able-bodied adults to “show evidence of employment, job-training, enrollment as a student, job search activities, community service, receipt of unemployment benefits, or compliance with the work requirements of SNAP [Supplemental Nutrition Assistance Program] or TANF [Temporary Aid to Needy Families].” 

The waiver request also includes the following initiatives:

• Point-of-service cost sharing, particularly for non-emergency care in an ER
• Asset assessment for Medicaid applicants, modeled after the SNAP program
• Elimination of retroactive eligibility coverage, except for long-term care recipients
• Disenrollment for noncompliance
• Premium reductions for those who earn at the top of their income brackets 

Maine’s waiver would reverse the current perverse incentive by which people lose coverage if they increase their income. This approach encourages both hard work and wealth creation.

At its core, Maine’s Section 1115 waiver intends to “prioritize limited resources for children, elderly, and the disabled, instead of turning Medicaid into an entitlement program for working-age, able-bodied adults,” and to “promote individual responsibility.”

Section 1915

The Social Security Act of 1965 has a second waiver process under Section 1915(c). This waiver is limited to Home and Community Based Services, meaning it cannot be applied to acute or preventative care.

Under a Section 1915 waiver, states still receive federal funding for Home and Community Based services, but they have increased freedom from federal regulations in how to provide these services.

States such as Colorado, Florida, Wisconsin, and Texas have used Section 1915 waivers to direct more Medicaid spending to pay for care for their tribal and elderly populations.  In fact, 38 states have one or more 1915 waivers.

Section 1332

The Affordable Care Act of 2010 has a waiver process in Section 1332, similar to Medicaid Sections 1115 and 1915. Under a Section 1332 waiver, a state may request variance from virtually any component of ObamaCare. However, it does not exempt the state from “accomplishing the aims of the ACA.”

By law, a Section 1332 waiver must “provide coverage at least as comprehensive,” be “at least as affordable,” and cover “at least a comparable number” of eligible individuals as ObamaCare.

Thus, the built-in constraints of a 1332 waiver hamper the states in any serious attempt to innovate, and make it harder to meet their population’s specific needs. 

Conclusion

President Trump’s first executive order, on January 20, 2017, urged federal agencies and departments to “exercise all authority and discretion available to them to waive, defer, [and] grant exemptions” from mandates associated with the Affordable Care Act.  If CMS honors the President’s order, waiver requests under Sections 1115, 1915, and 1332 should be viewed favorably.

Even those failed attempts by the 114th Congress to reform healthcare intended to offer the states greater flexibility in their Medicaid programs.  

In the absence of effective national healthcare reform, reform at the state level with waivers can circumvent oppressive federal mandates and allow the states, who know local needs and constraints best, to allocate resources optimally. With waivers, Americans are more likely to get into a doctor’s office before it’s too late. 

Dr. Deane Waldman, MD, MBA, is a retired pediatric cardiologist and director of the Center for Health Care Policy at the Texas Public Policy Foundation. Jennifer Minjarez is a policy analyst in the Center for Health Care Policy at the Texas Public Policy Foundation.