Margaret Murray is the founding CEO of the Association for Community Affiliated Plans, which represents 61 not-for-profit plans that cover people in Medicaid managed care and the Affordable Care Act exchanges. She previously served as New Jersey's Medicaid director and as senior budget analyst for the U.S. Office of Management and Budget. Murray recently spoke with Modern Healthcare reporters Shelby Livingston and Harris Meyer about the challenges of the 2018 open enrollment, prospects for congressional action to stabilize the individual market and fund federal healthcare programs, and what's needed to address the opioid addiction crisis. The following is an edited transcript.
Modern Healthcare: How are your members doing overall in their niche as safety-net plans and how are they faring with the consolidation of the commercial market?
Margaret Murray: Our plans cover almost half of all people in Medicaid managed care. They typically are in only one state and are committed to the Medicaid program and their main client, the Medicaid enrollee. So they're here to stay.
MH: How does the 2018 open enrollment look for your member plans?
Murray: Sixteen of our member plans will be in Affordable Care Act marketplaces. Their premiums are going up about 20% more than they would have otherwise because of non-payment of the federal cost-sharing reductions and general policy uncertainty. They're kind of waiting to see what happens.
MH: What is the financial impact of President Donald Trump halting the federal CSR payments?
Murray: Our plans are taking a huge hit for the last three months of 2017, and some of them are considering lawsuits. But the big issue will be in 2019. Will plans stay in the marketplace at that point? It will depend on what happens with open enrollment this year, how many people sign up, and how the Trump administration enforces the ACA's individual mandate and other rules. Our plans will have to start thinking about that decision fairly early in 2018. We'll see if our plans are willing to put up with the increased policy uncertainty. A lot will depend on what happens with a proposal by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) to fund CSRs and stabilize the individual market.
MH: What could your organization support in an eventual market stabilization bill, and what could you not support?
Murray: Our main point, in addition to funding the CSRs, is to make sure there is either a carrot or a stick that is sufficient to get people to enroll. We commissioned a paper that suggested the individual mandate is the most effective method. But we'd be open to other suggestions, whether it's increased marketing or some type of auto enrollment. Our concern about an alternative by Sen. Orrin Hatch (R-Utah) and Rep. Kevin Brady (R-Texas) to the Alexander-Murray bill is it offers no carrot or stick. That would be very hard for us to support.
MH: What about the Hatch-Brady provisions to expand state flexibility and short-term health plans?
Murray: We're very concerned about short-term plans. We were pleased when the Obama administration limited them. We are concerned those types of plans will suck some of the better risks out of the marketplace. Our plans don't want to compete against plans that aren't subject to any of the ACA's consumer protections or requirements for essential health benefits.
MH: Do you see CSR funding and funding for the Children's Health Insurance Program and federally qualified health centers all getting rolled into one big package toward the end of the year?
Murray: We hope they don't all kind of come crashing together at the end of December. We're also concerned about reauthorizing dual-eligible special needs plans (D-SNP). We'd like to see them reauthorized permanently, but even a five-year reauthorization would be good. It's proven that it's a good program. One of our mantras is the insurance industry needs stability, and allowing the D-SNP to be permanently reauthorized would offer more stability.
MH: Your organization has been more consistently outspoken in opposition to Republican repeal-and-replace bills than other insurance trade groups. Why is that?
Murray: We like to say that nobody cares more about Medicaid than our plans. Rolling back the expansion or making such dramatic cuts to Medicaid was really an existential threat to a program that our plans support, so our plans were very vocal. Our plans developed a $1 million campaign called Medicaid Is Us to support Medicaid and encourage people who care about the program to write to their senators and representatives. It ended up producing over 51,000 communications with members of Congress.
MH: Do you have discussions behind closed doors with the other insurance trade groups about positioning and lobbying on these issues?
Murray: We're always in discussion with them, and in many cases we do have agreements. We certainly encourage them to be vocal about Medicaid. But ultimately, each association has to think about the primary focus of its members.
MH: How would the Republican proposals for Medicaid affect your member plans?
Murray: First, rolling back the ACA's Medicaid expansion could cost 16 million to 32 million people their Medicaid eligibility. Second, we were concerned the annual growth rate for the proposed per capita payments to the states was not realistic. I'm concerned about new pharmaceuticals that the states and plans would not be able to cover with those low growth rates.
MH: What would be acceptable and unacceptable in new Medicaid 1115 waivers under the Trump administration?
Murray: We're concerned about waivers limiting people's access, because one of our mantras has been to get more people covered. We wouldn't want to see people not getting Medicaid because states impose drug testing, when that's the actual moment they really need Medicaid.
MH: How would some of these waivers limit access?
Murray: Some of the waiver requests call for work requirements. We know in many areas there are limited jobs. If people can't get a job to begin with, then they can't get Medicaid, they're double penalized. Having Medicaid enhances people's ability to get jobs.
MH: Republican proposals want to move low-income people off Medicaid and into private plans. Do you have concerns about that?
Murray: Private plan copayments are much higher than they are in Medicaid. So one of our concerns is whether people would be able to get the treatment they need if they are facing copayments.
MH: What are your member plans doing to address the opioid addiction crisis?
Murray: First, we have a collaborative helping the plans train their providers to do screenings and brief interventions and referrals to treatment during office visits. Also, our plans have changed some of their prior-authorization policies to make it harder to get opioid prescriptions, while continuing to allow cancer patients to get them. They have created alternative therapies such as acupuncture and chiropractic care so people have alternatives to opioids for pain management. We're also trying to facilitate access to medication-assisted treatment.
MH: How would rolling back the Medicaid expansion affect your plans' ability to treat opioid addiction?
Murray: For people who are currently addicted, there are not many places they can go for treatment if they don't have insurance. The Medicaid expansion population has greater need for drug treatment than the higher-income population. Rolling back the expansion at the time of this substance abuse crisis is extremely counterproductive.
MH: Is President Trump's declaration that the opioid epidemic is a public health emergency going to help your plans address the epidemic?
Murray: We applaud his statement as a first step. But we think the country needs to go much further. We would encourage all states to take up the Medicaid expansion. We think the Medicaid payment exclusion for inpatient care should be waived or eliminated by Congress. We'd also like to see some changes to the rules around privacy, so that if you go to see your primary-care doctor, the doctor knows you have prior substance abuse issues and can talk to you about it. And, of course, there should be more funding.