As the cost of operating Medicaid continues to grow, lawmakers wonder whether they're getting any useful policy advice from the panel responsible for advising Congress on Medicaid spending.
Word on Capitol Hill is that lawmakers feel the panel charged with making policy recommendations to Congress and the administration about Medicaid and the Children's Health Insurance Program (CHIP) offers advice that often is too generic, not backed by data and therefore not practical.
That means some recommendations, such as allowing children in families with incomes below 150% of the federal poverty level to avoid CHIP premiums, and eliminating wait periods to enter CHIP, are left on the table.
Last month, the Government Accountability Office, which selects commissioners for MACPAC (the Medicaid and CHIP Payment and Access Commission), received letters from both Republicans and Democrats raising questions about how it chooses panel members, most of whom are providers, consultants, consumer advocates, health plan representatives and state officials. Surprisingly, the panel lacks a Medicaid director, another criticism leveled at the office.
Sources close to Republican lawmakers who belong to the House Energy and Commerce Committee, which oversees Medicaid, say they wonder when MACPAC will have more useful and actionable recommendations. Former panel members, and not surprisingly, Democrats, are not taking the criticism lying down.
The scrutiny comes as Medicaid, the nation's largest insurer, is experiencing severe growing pains. The number of enrollees has jumped from around 50 million in 2010, the year the Affordable Care Act was signed into law, to more than 70 million today. Medicaid spending hit $495.8 billion in 2014, and is expected to grow to over $600 billion by 2020.
MACPAC was created in 2009. It is a nonpartisan legislative agency comprising 30 full-time employees, with an annual budget of $8 million. Panel members are given stipends to serve.
The commission is modeled after the Medicare Payment Advisory Commission, or MedPAC, which advises Congress on Medicare spending.
While Congress regularly adopts MedPAC recommendations, it has only adopted half of the 13 recommendations made by MACPAC since its inception, Energy and Commerce Committee staffers say, adding that generally the recommendations lack enough detail to act upon them.
Also, unlike MedPAC, when MACPAC makes a recommendation that will require additional spending, it does not typically provide spending offset suggestions, the staffers say.
In January, House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) and Health Subcommittee Chairman Joe Pitts (R-Pa.), sent letters to both the GAO and MACPAC inquiring how conflicts of interest among panel members are determined, and at what level does a conflict of interest allow them to recuse themselves from weighing in on commission topics.
The letters came after MACPAC Chairwoman Sara Rosenbaum, who was appointed in December to her position by the U.S. Attorney General, signed an amicus brief supporting the Obama administration in House v. Burwell. The lawsuit, brought forth by the Republican-led House of Representatives, alleges that the administration violated the law by creating subsidies under the Affordable Care Act that were not appropriated by Congress.
Democrat insiders on Capitol Hill say that only Republicans have questioned MACPAC's usefulness, and that only 50% of its recommendations have been enacted because Congress has been controlled by the GOP for the bulk of the panel's existence.
Still, some Democrats have raised their own concerns. Rep. Eliot Engel (D-NY), a senior member of the Energy and Commerce Health Subcommittee asked the GAO last month why it had not appointed a MACPAC commissioner with knowledge of women's health issues to represent the needs of low-income pregnant women. Engel argued the role has gone unfilled for two years, despite the panel's having received nominations from a number of qualified individuals, according to his letter.
However, Engel said the letter shouldn't be construed as a lack of support for MACPAC.
Criticism over the commission's makeup isn't only coming from Capitol Hill. State stakeholders have also wondered why the GAO has never appointed an active Medicaid director, despite receiving nominations, “if for no other reason than there's literally nobody who has a more in-depth and current understanding of the wide range of aspects of the program,” said Matt Salo, executive director of the National Association of Medicaid Directors. “I think that point does lead to legitimate questions and concerns around whether the membership of the commission undermines its ability to function as a policymaking and recommending entity.”
In regard to its selection process, a GAO spokesperson said the agency has a rigorous vetting process, and is always open to discussing congressional members' concerns.
MACPAC deferred comments about its commissioner selection process to the GAO, and declined to comment on statements made by Energy and Commerce Committee staffers on its usefulness. It did, however, release a letter from Rosenbaum, in which she said she would not pursue any further legal work that could be seen as a conflict of interest.
Founding MACPAC commissioners say their recommendations are highly data-driven, according to Trish Riley, whose term ended in December. She now serves as executive director of the National Academy for State Health Policy.
Others were dismayed by comparisons of MACPAC to MedPAC, in terms of recommendation output and adoption.
“MedPac's primary role is related to payment updates for a program that's 100% run by the federal government, so of course they'll make more recommendations to Congress,” said Dr. Patricia Gabow, a former MACPAC commissioner who also left in December. She is the retired CEO of the Denver Health and Hospital Authority.
Another question is whether Congress is offering MACPAC enough direction.
“We would repeatedly go to staff and ask, 'What would you like us to look at?' and we didn't get much,” said Dr. David Sundwall, a former co-chair of MACPAC who left in 2014. He is also a public health professor at the University of Utah School of Medicine.
“It was kind of a two-way street in that we weren't getting direction from the Hill, and as such, weren't forthcoming with recommendations,” Sundwall said.
No Hill sources have advocated to end MACPAC, which would take an act of Congress and the president.