At least two Republican-led states want to temporarily ease their Medicaid waiver requirements and make it easier for residents to get and keep coverage under Medicaid and the Children's Health Insurance Program during the coronavirus pandemic.
Meanwhile, two other Republican-led states, Oklahoma and Utah, are pushing ahead with Medicaid waiver changes intended to tighten eligibility for expanded coverage to low-income adults under the Affordable Care Act, including work requirements.
The sharply different directions these states are taking illustrate the pull between pragmatic and ideological pressures in the midst of the COVID-19 outbreak, which experts say requires making testing and treatment as accessible and affordable as possible to limit the spread of the epidemic.
Congress is considering allowing states to broaden Medicaid to cover uninsured people for COVID-19 testing, treatment, and recovery.
"Work requirements and premiums are precisely the kinds of policies that are dangerous now and divert energy for state government staff, who are under enormous stress," said Joan Alker, executive director of the Center for Children and Families at Georgetown University. "They need to focus on facilitating as many people's access to care as they can."
The Arizona Health Care Cost Containment System's request would help them mitigate any disruption in care for their members during the emergency declaration, the agency said in a March 17 letter to CMS Administrator Seema Verma.
Arizona also wants to use Medicaid money to provide temporary housing for beneficiaries who are homeless or at risk of homelessness and have tested positive for COVID-19.
Iowa asked to temporarily waive premiums and copays and permit continuous eligibility for adults and children. That runs counter to the Trump administration's effort to test beneficiaries for eligibility more often to ensure program integrity, which has led to hundreds of thousands of people being disenrolled.
Going in the other direction, the Oklahoma Health Care Authority on Monday published its Medicaid Section 1115 waiver application and announced the start of a 30-day public comment period. The waiver would include a work requirement, premiums and co-pays.
Oklahoma wants to expand Medicaid coverage by July 1, but the state also wants to impose conservative-friendly features on the expansion under the Trump administration's Healthy Adult Opportunity demonstration program.
"At this time, we don't anticipate changing our timeline for the submission of the Healthy Adult Opportunity demonstration waiver," an Oklahoma Health Care Authority spokesman said. "However, we are in communication with CMS discussing flexibility with the public comment period and evaluating all options available."
Utah is proceeding with its plan to require Medicaid expansion enrollees report at least 48 job searches in the first 90 days of eligibility, as well as to complete an online job readiness survey.
"At a time when the job market is collapsing, the absurdity of that requirement is even more apparent," Alker said. "I hope good-faith leaders in Utah will drop that requirement, which is a threat to public health."
A spokeswoman for Utah's Republican Gov. Gary Herbert could not immediately respond to requests for comment because the administration is focused on the major earthquake that hit the Salt Lake City area Wednesday.
Indiana, another Republican-led state that established premiums and other restrictive conditions on coverage through a Section 1115 waiver, did not respond to requests for comment on its plans in light of the pandemic.
A handful of states have limited Medicaid's traditional 90-day retroactive eligibility when people seek care. Experts warn that may put a heavy financial burden on hospitals serving lots of uninsured, low-income coronavirus patients.
Arizona and Iowa, which want to ease coverage requirements, have restricted retroactive eligibility under 1115 waivers. That's also true for Florida, which received an emergency Section 1135 waiver this week to loosen provider payment and certification rules.
Some experts want the CMS and the states to do what they've done in past emergencies and implement fast-tracked waivers temporarily extending Medicaid coverage to those affected, as happened following Hurricane Katrina and other catastrophes.
"Our state has moved toward the proper response to this pandemic, bringing more people into coverage," said Siman Qaasim, CEO of the Children's Action Alliance in Arizona. "This is really promising. It will be interesting to see if CMS approves it."