Seema Verma is administrator of the Centers for Medicare & Medicaid Services.
President Trump called on Congress earlier this year to give governors around the country “the resources and flexibility they need with Medicaid to make sure no one is left out.” As administrator for the Centers for Medicare and Medicaid Services, I share the president’s vision: to ensure that Medicaid works for those it was designed to serve.
Americans have a duty to make certain that quality care and services are available for Medicaid’s important core populations: individuals with disabilities, older Americans in need, pregnant women and children. The Affordable Care Act shifted the program’s focus to enrolling more able-bodied, working-age adults, but a top aim for the Trump administration is refocusing Medicaid on the nation’s most vulnerable populations in order to provide a more robust level of care and a strengthened program overall.
U.S. policymakers have a rare opportunity, through a combination of congressional and administrative actions, to fundamentally transform Medicaid to measurably improve lives for decades to come. That can only be achieved by tapping into the program’s great potential and state-level innovation, which cannot be realized under its current structure and operation.
First and foremost, we must redouble our efforts to improve care for those on Medicaid in those core populations. The Medicaid program has justifiably taken a lot of heat in recent years after a number of studies called its effectiveness into question.
For example, a 2013 study published in the New England Journal of Medicine examined Oregon’s expansion of its Medicaid program to able-bodied adults and concluded “that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years.” In a 2010 study published in the Annals of Surgery, researchers examined the results of 800,000 surgeries and found that, after adjusting for other factors, Medicaid and uninsured patients had increased risk of mortality.
Medical outcomes can be better for Medicaid recipients, and progress depends on having a much richer understanding of what’s working and what isn’t. Medicaid’s current capacity for data collection and evaluation is weak, especially for a program of its size and importance. That needs to be corrected in any redesign of the program.
We also need a complete reset of the state-federal Medicaid partnership. In my own experience working directly with states on Medicaid for more than 20 years, far too much of states’ time is spent mired in a maze of one-size-fits-all federal laws, regulations and processes that often do not translate to better health outcomes. Federal administrative burdens force states to shelve cost-efficient ideas to improve health in order to comply with mandates.
That dynamic would change under House and Senate proposals in which the federal government’s role would shift from micromanaging Medicaid in each state to primarily monitoring the fiscal integrity of the program and improved health, quality and access.
State-led innovation in Medicaid is key. Trump not only supports Medicaid innovation — he encourages it. For instance, different payment and service delivery models have been proved effective in the commercial market to both improve care and lower cost. States should be able to leverage these models with more flexibility and less hassle from the federal government.
If we give states more control and curtail top-down directives from Washington, health outcomes will improve. That was my experience in Indiana, where we tailored our Medicaid expansion under the ACA to include coverage spending accounts for beneficiaries, who also made minimal monthly contributions based on their incomes. We saved taxpayer money and achieved better outcomes.
Finally, Medicaid needs to be on sounder fiscal footing so that it is available for future generations. Currently, the more money a state contributes, the more money that state receives in federal matching. Total federal Medicaid costs have ballooned by more than $100 billion since the ACA was implemented in 2013.
The Congressional Budget Office — which released its score of the Senate health-care bill on Monday — has not accurately predicted how health-care legislation would effect Medicaid enrollments in the past. Initiating a per-capita cap financing structure, now under consideration in Congress, would restore much-needed order to Medicaid’s financing. The proposal would provide a fixed amount to states for each enrollee that would increase each year based on a formula that would take into account average medical expenses. Moving to this type of system would provide stability and predictability for both state and federal budgets. Most important, it would protect future beneficiaries by ensuring the Medicaid program’s long-term viability.
Taken together, these common-sense steps will help Medicaid produce better results for recipients and ensure the program’s fiscal sustainability for beneficiaries for many years to come.