Medicaid Expansion: States are Avoiding the Elephant in the Room--Waiting Lists
In the mad rush to expand health coverage to over 28 million able-bodied individuals, Medicaid seems to have lost its original focus. The Medicaid program is failing those it was designed to serve leaving more than 650,000 actually needy people languishing on Medicaid waiting lists.[i]
Congress created the Home and Community-based (HCBS) Waiver program in 1981[ii] Under this waiver states may choose to extend home and community-based services to beneficiaries that would potentially otherwise qualify for care in an institution or nursing home. The objective of the waiver is to allow a needy Medicaid beneficiary to receive the care they require for survival at home without being placed in an institution. Among other things, the program provided home health services, habilitation, adult day care, personal care services, and psycho-social rehabilitation to eligible individuals. Most of the eligibles are folks with spinal cord injuries, severe intellectual disabilities, traumatic brain injury, or dehabilitating developmental disabilities. This is the precise population that Medicaid was designed to support. These services were designed to keep people out of institutional care and at home.[iii]
The HCBS waiver is usually operated through the states' Medicaid program. Since these are waiver programs, it is optional so states can limit enrollment. When the enrollment hits the designated capacity, individuals are placed on a waiting list. The problem is that for some individuals the wait can be years or, in the case of some New Mexico beneficiaries, decades.[iv] In fact, nearly 250,000 eligible individuals languish on waiting lists in "Affordable Care Act" Medicaid expansion states. At the same time these states have added over eight million able-bodied individuals to their Medicaid rolls through program expansion.[v]
Perhaps more serious is the fact that over 21,000 waiting list deaths have occurred since expansion began.[vi] While it is true that many of the deaths would have happened anyway as individuals waited, the staggering number begs the question of how many could have been prevented were these people provided the support they needed.
Even now, states like North Carolina struggle over Medicaid expansion. Nonetheless, the argument seems to be based on ideological grounds while not even considering the financial obligation to the over 12,000 beneficiaries on the State's waiting lists. [vii] In fact, Medicaid has gradually become a "catch-all, open-ended" welfare program rather than considering the original intent of focusing on the most vulnerable populations. Spending on the nondisabled population has now grown to over $157 billion annually, creating an almost 700 percent increase since the Affordable Care Act was passed.[viii]
The solution to funding the needy waiting-list population appears to be limited by the stratospheric growth of the Medicaid program for able-bodied individuals. Any change seems difficult because once an entitlement is in place, it is politically impossible to take it away. Nonetheless, a rational consideration of the work requirement for able-bodied recipients is reasonable. Our national objective is not to make healthy Medicaid recipients dependent on government welfare. Keep in mind that the Medicaid program is not the same program that started in 1965, since the original vulnerable population has expanded to include millions of well, able-bodied individuals that were never considered originally.[ix]
A rising national debt of $22 trillion should make controlling the Medicaid budget a national emergency. Managing fraud and abuse, applying high-powered analytics such as New York's Salient Interactive Miner (SIM), and confirming regularly appropriate eligibility is just the beginning of productive change. Obama-era regulations limiting the states' ability to frequently evaluate eligibility appears to be compounding the problem.
The well, able-bodied-adult expanded Medicaid population needs a more standard health insurance program. They do not require the "correct or ameliorate" standard designed specifically for the complex population Medicaid was originally designed to support. This is the population that is dying while waiting for the financing that the expansion population is consuming. Our policymakers and legislative leadership must move the elephant out of the room or it will take more that a big shovel to clean up the mess.
Craigan L. Gray, MD, MBA, JD
[i] Mary O'Malley Watts and MaryBeth Musumeci, "Medicaid Home and Community-bases Services: Results from a 50-state survey of enrollment, spending, and program policies." Kaiser Family Foundation (2018), http//files.kff.org/attachment/Report-Medicaid-Home-and Community-Based-Services.
[ii] Section 1915 (c) of the Social Security Act.
[iii] Cliff Binder, "Medicaid's Home and Community-Based Services State Plan Option: Section 6086 of the Deficit Reduction Act," Congressional Research Service (2008). https://digital.library.unt.edu/ark:/67531/metadc809234/m2/1/high_res_d/RS22448_2008Jan31.pdf.
[iv] Nicholas Horton, "Waiting for Help: The Medicaid Waiting List Crisis, March, 2018, https://thefga.org/research/medicaid-waiting-list/
[vii] Community and Work Disparities: A Program of the ADA participatory Action Research Consortium, https://centerondisability.org/ada_parc/utils/indicators.php?id=9
[viii] Nicholas Horton, "Waiting for Help: The Medicaid Waiting List Crisis, March, 2018, https://thefga.org/research/medicaid-waiting-list/
[ix] Medicaid Program History, https://www.medicaid.gov/about-us/program-history/index.html