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Maine asks Trump for permission to start charging Medicaid recipients premiums

The move doesn't require Congress.

President Donald Trump, center, speaks as he meets with Republican senators on health care in the East Room of the White House in Washington, Tuesday, June 27, 2017. Sen. Susan Collins, R-Maine, left, and Sen. Lisa Murkowski, R-Alaska, right, listen (AP Photo/Susan Walsh)
President Donald Trump, center, speaks as he meets with Republican senators on health care in the East Room of the White House in Washington, Tuesday, June 27, 2017. Sen. Susan Collins, R-Maine, left, and Sen. Lisa Murkowski, R-Alaska, right, listen (AP Photo/Susan Walsh)

Maine could be among the first states to fundamentally change its Medicaid program by requiring low-income adults to meet work requirements and pay monthly premiums, if the state’s requests are approved by the Trump administration.

The Maine Department of Health and Human Services filed an application to the Centers for Medicare and Medicaid Services (CMS) Wednesday evening, requesting core changes to its Medicaid program, dubbed MaineCare.

Historically, the state-federal program was prohibited from asking low-income people to pay premiums. Six states (Arizona, Arkansas, Indiana, Iowa, Michigan, and Montana) have approved waivers to charge premiums to adults when they expanded Medicaid eligibility to 133 percent of the federal poverty level (FPL).

Maine has not expanded Medicaid. (It’s on the ballot in November.) If its waiver is approved, Maine would be the first state to impose premiums to traditional Medicaid adults: adults who make up to 100 percent of FPL, former foster care youth, adults receiving transitional medical assistance, and people with breast/cervical cancer or HIV up to 250 percent of FPL.

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Additionally, no states have established work requirements. Four states (AZ, IN, KY, PA) have submitted waivers to CMS to add work requirements; to date, none have been approved.

ThinkProgress reached out to Senators Susan Collins (R-ME) and Angus King (I-ME), but has not heard back on whether they support these changes to the state’s Medicaid program.

The Senate failed to pass two different Affordable Care Act (ACA) repeal-and replacement bills — the American Health Care Act (AHCA) and the Better Care Reconciliation (BCRA). Both Republican bills gutted Medicaid, and would have left up to 15 million more people uninsured who would otherwise have been covered through Medicaid under current law. (Much to the chagrin of Maine’s Republican governor, the state’s senators voted against these bills, and Senator Collins in particular was a key reason the Republican health care plan failed in the Senate.) Because the Senate failed to curb Medicaid costs this legislative calendar, there is now an opening for moderate and conservative states to reform the program through waiver authority. Under 1115 waivers, the Department of Health and Human Services (HHS) can grant states permission to experiment as long as they promote the objectives of the program. That’s what Maine is trying to do now.

Approval is up to the discretion of HHS, and there is a bare-bone criteria set by the agency. Once waivers are submitted, HHS does not need to adhere to a hard deadline.

Under the Obama administration in 2016, HHS denied a Medicaid waiver to Ohio, which looked to impose monthly premiums. The federal agency cited concerns that Medicaid premiums would undermine access to affordable care.

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Jack Comart, litigation director of Maine Equal Justice Partners, said it’s hard to see how HHS could approve a waiver similar to one it rejected less than a year ago. Comart added that they would file a lawsuit if the agency approves Maine’s waiver.

“This administration has made it clear that they want to reduce Medicaid eligibility,” he said.

The evidence on Medicaid monthly premiums

There’s a longstanding research about the affects of premiums on low-income people. “Research shows barriers could lead to lower enrollment,” Marybeth Musumeci, an Associate Director at the Program on Medicaid and the Uninsured at the Kaiser Family Foundation (KFF), told ThinkProgress.

A recent KFF research review of 65 papers on Medicaid monthly premiums found that:

  • Premiums in Medicaid and Children Health Insurance Program (CHIP) lead to a reduction in coverage among children and adults.
  • Those with lower incomes who disenroll from Medicaid coverage following premium increases are more likely to become uninsured than opt for private or commercial insurance.
  • Potential state revenue from Medicaid premiums are offset by disenrollment. More expensive services, such as emergency room care, increase costs in other areas. (Maine is seeking to charge some Medicaid beneficiaries out-of-pocket costs if they seek non-emergency care at the ER.)

Many conservative health experts believe that Medicaid beneficiaries could and should transition to private or commercial insurance. But people who qualify for Medicaid disqualify for subsidies on the ACA marketplace, thus leaving these plans too expensive and unattractive without federal assistance.

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Maine’s premium would be based on the individual’s income bracket, and would be anywhere between $10 to $40 per month. Medicaid enrollees would have to decide whether to pay the premium, or opt out of insurance and pay the penalty for not having insurance. The Trump administration has threatened to weaken and not enforce the individual mandate.

The evidence on work requirements

Health Affairs wrote about various hangups with work requirements when an amendment to House Republicans’ AHCA looked to impose them on Medicaid beneficiaries.

Key takeaways are:

  • More than half of able-bodied people receiving Medicaid already work.
  • Any increases in employment following the requirement are small or short-lived.
  • The Temporary Assistance for Needy Families (TANF) program, which would be in charge of monitoring the work requirement, is already overtaxed. Adding an influx of Medicaid beneficiaries would overwhelm the system.

Among Maine’s goals for the waiver is to preserve finances for the state’s most needy, promote financial independence and transition the group to private insurance, and encourage individual responsibility for health care. But the research so far doesn’t reveal that monthly premiums or work requirements will help achieve those goals.

A handful of other states with Republican governors are looking to create similar changes to their Medicaid program, including Arkansas, Kentucky, Arizona, Wisconsin, and Indiana.