Is a new wave of health care “waivers’’ coming? Georgia and many other states may seek federal approval soon to make changes to their... Health care ‘waivers’ get new attention in Georgia, Washington

Is a new wave of health care “waivers’’ coming?

Georgia and many other states may seek federal approval soon to make changes to their health care programs through waiver requests, lawmakers and experts say.

Opening the door Tuesday to one particular waiver idea was the head of the federal Centers for Medicare and Medicaid Services. Seema Verma, the CMS administrator, told state Medicaid directors that the feds would be receptive to allowing work requirements for non-disabled adults covered in the government program.

Verma, a President Trump appointee, called the Obama administration’s opposition to these requirements “soft bigotry.” Several states already have asked for these work requirements.

She also announced changes to speed the review of requests for “waivers” to the federal Medicaid law, which would allow states more flexibility with the program.


In Georgia, the talk about requesting federal health care waivers has picked up momentum.

Republican leaders on health care in the Georgia General Assembly recently have voiced a willingness to consider creating ideas to tackle state health care challenges.

What isn’t clear yet is what type of waiver – or a combination of them – that Georgia would pursue.

One concern of policymakers is that the state has one of the highest rates of uninsured people in the country.

Georgia political leaders have declined to pursue Medicaid expansion under the Affordable Care Act or other major initiatives to bring coverage to more Georgians.

Maine voters, in a referendum Tuesday, approved expanding the state’s Medicaid program, the first such direct vote on the issue. But Maine’s governor, a longtime critic of expansion, suggested he will fight it.

Expansion, as undertaken in 31 states, also has paid for treatment of many low-income adults with opioid addiction, a growing problem in Georgia and across the nation.

Another concern is the financial squeeze faced by many rural hospitals in the state, which are serving a large number of uninsured – often non-paying – patients.

A waiver proposal can come in many forms. One involves Medicaid “demonstration’’ projects, such as one that Atlanta’s Grady Health System has proposed.

Years ago, Georgia obtained a waiver to put most Medicaid beneficiaries under HMO-like insurance.

“What they do is allow a state to alter the rules of their Medicaid program to achieve certain ends,’’ said Bill Custer, a health insurance expert at Georgia State University.

Other waiver plans were aimed at tailoring a Medicaid expansion to suit a state’s preferences.

Indiana and Arkansas, for example, gained approval for their own versions of expansion. A task force created by the Georgia Chamber of Commerce came up with such a plan, but it was not taken up by the state Legislature.

Approvals for such Medicaid waivers are based on not costing the feds more money than under conventional expansion as outlined by the ACA, Custer said.

Currently states have many waiver requests pending, such as requiring Medicaid beneficiaries to pay a monthly premium, along with the work mandate, he added.


Lowering the insurance risk


Another type of waiver, called 1332, is related to the ACA. Several states have sought such waivers to adopt a “reinsurance’’ program for their exchanges offering coverage to individuals and families.

A reinsurance program aims to stabilize health insurance premiums by capping the cost that insurers incur in covering people with high medical costs.


Federal health officials have approved such programs in Alaska, Minnesota and Oregon.

Alaska’s and Minnesota’s exchange premiums have stabilized as a result of the changes.

But requests for similar revisions in Oklahoma and Iowa did not get federal approval in time for the 2018 exchange year and were withdrawn.

Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, said the Trump administration’s record on approving these 1332 waivers “is a bit of a mixed bag.”

Nevertheless, she said, “We’re hearing that a lot of states will submit [waiver] applications in January.”


A little late to the game?


In Georgia, Lt. Gov. Casey Cagle formed a Health Care Reform Task Force to come up with a way to restructure how the state delivers health care services. He said the task force will bring forth its reform ideas in January.

Sen. Chuck Hufstetler, a Rome Republican, said recently that the task force is looking at different types of proposals to help uninsured Georgians keep their health problems from escalating into chronic or serious conditions, the Rome News-Tribune reported recently.


Hufstetler said that, in hindsight, waiver requests should have been formulated during the last 40-day session of the Georgia General Assembly.

“We may have made a mistake in thinking the ACA would be repealed,” he said, according to the News-Tribune. “We said we have to wait and see what the federal government has done, but they haven’t done anything.”

Congressional Republicans planned for years to push through repeal of the ACA once there was a GOP president to sign such a measure. But they have failed to agree on a repeal bill to send to President Trump.

Meanwhile, state Sen. Renee Unterman (R-Buford), told WABE recently that Georgia should “put everything on the table” when it comes to covering more people.

“If you ask me what keeps me awake at night, it is that uncompensated care,’’ said Unterman, chair of the Senate Health and Human Services Committee.

“When you’re in the middle of the crisis, you have to look at everything, you have to be amenable, and I believe you have to compromise.”

Unterman told the AJC’s Jim Galloway that her ideas do not include a full-blown Medicaid expansion. She has narrower targets: Young people with behavioral problems, and those who are dealing with opioid addiction.

“It’s not opening up the door for a million people. It’s opening up the door for a hundred thousand [frequent patients] who you know you’re spending a lot of money on,” Unterman said, according to the AJC. “Let’s bring the cost down. Let’s give them a better quality of life. To me, it’s just compassion.”


Meanwhile, one waiver idea is already on the table: the Grady idea – which did not get off the ground when first proposed in 2015.

The waiver proposal focuses on using federal matching Medicaid dollars to help set up pilot sites that would give coverage to the uninsured, then manage their care and potentially improve their health.

Grady in Atlanta, Memorial Health in Savannah, and a small group of rural hospitals were seen as the initial sites in the coverage plan.

Here’s a 2015 GHN article on the Grady idea, as proposed.

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Andy Miller

Andy Miller is editor and CEO of Georgia Health News

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