Nebraska could pave the way forward for Medicaid work requirements
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • Pandemic raises questions about impact of Medicare payment restructuring in post-acute
      Perrigo sells generic drug business for $1.55 billion
      Proposed overhaul of Arkansas Medicaid expansion unveiled
      Tensions over vaccine equity pit rural against urban America
    • Pandemic raises questions about impact of Medicare payment restructuring in post-acute
      Tensions over vaccine equity pit rural against urban America
      States easing virus restrictions despite experts' warnings
      Average nursing home nursing staff turnover exceeds 100%, report finds
    • The Check Up: Dr. Marc Boom
      The Check Up: Dr. Marc Boom of Houston Methodist
      Dr. Marc Boom
      Q&A: Houston Methodist CEO praises staff efforts to keep vaccine efforts going during ice storm
      Charles-Shor_160x200 1_i.jpg
      Cleveland Clinic receives $15.5 million donation for new neurological institute
      The Check Up: Dr. Imran Andrabi
      The Check Up: Dr. Imran Andrabi of ThedaCare
    • Highmark, HealthNow finalize affiliation, creating fourth-largest Blues plan
      Low 2020 utilization could affect insurer profits for the next two years, analysts say
      CMS: Group health plans must cover COVID-19 diagnostic testing
      High MLRs inspire insurers to focus on quality improvements
    • Pandemic raises questions about impact of Medicare payment restructuring in post-acute
      Proposed overhaul of Arkansas Medicaid expansion unveiled
      States easing virus restrictions despite experts' warnings
    • UPMC's patient volumes stabilize, boosting 2020 profits
      Genomics firms taking advantage of SPACs trend to go public faster
      COVID-19 could dent hospital revenue by at least $53 billion in 2021, AHA says
      deloitte GDP image chart graph going up
      Sponsored Content Provided By Deloitte
      Breaking the cost curve
    • Teladoc reports $383.3M in fourth-quarter revenue, up 145%
      man and woman looking at ipad wearing face masks stock image
      Sponsored Content Provided By Surescripts
      Improvements to benefits data can enhance ePrescribing and the patient experience
      Oscar Health's $1B IPO sets the stage for more health tech exits in 2021
      A map of the U.S. with images of the coronavirus.
      The digital divide becomes a new social determinant of health
    • Tensions over vaccine equity pit rural against urban America
      Utah cancels vaccine appointments after registration error
      Connecticut is doling out vaccines based strictly on age. It's simpler, but is it fair?
      Great-granddaughter of Tuskegee study victim gets vaccine
    • Alicia Wilson
      Q&A: Emerging leader Alicia Wilson on staying close to home
      Michael Jordan, Novant team up to address health equity
      Former Ascension CEO, the first to lead the health system, passes away
      Biden's pick to head CMS would be first Black woman to hold post
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • Dr. John Fischer
      Patient-reported outcomes tool for hernia surgery helps physicians improve care
      New care model helps primary-care practices treat obesity
      doctor with patient
      COVID-19 treatment protocol developed in the field helps patients recover
      Rachel Wyatt
      Project to curb pressure injuries in hospitals shows promise
    • What's next for on-demand telehealth companies?
      A CalOptima PACE vaccination clinic.
      Will COVID-19 be the catalyst for creating a more sustainable healthcare system?
      A map of the U.S. with images of the coronavirus.
      The digital divide becomes a new social determinant of health
      Ascension’s St. Mary’s Hospital Surgery Center at Towne Centre and Allegheny Health Network’s Bethel Park surgery center
      Hospitals see opportunity, risk in ambulatory surgery centers
    • Dr. Daniel Hall
      UPMC pilots machine learning, telehealth to inform patient transfers
      A woman being recorded using her inhaler on a smartphone.
      Digital check-ins, connected inhalers help control asthma
      A phone screen showing the question, "Mary we hope this information was helpful and we'd like to keep guiding you. Are you interested in knowing when it's your turn to receive the vaccine?"
      Chatbots, texting campaigns help manage influx of COVID vax questions
      A woman with a wearable sensor talking to her provider.
      Wearable sensors help diagnose heart rhythm problems in West Virginia
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • What's next for on-demand telehealth companies?
      Rising prescription copays drop adherence, spike mortality, research shows
      Dr. John Fischer
      Patient-reported outcomes tool for hernia surgery helps physicians improve care
      Highmark Health inks six-year cloud, tech deal with Google
    • Hospitals' Medicare billing practices suggest upcoding, OIG says
      California hospitals prepare ethical protocol to prioritize lifesaving care
      Amazon, JPMorgan Chase, Berkshire Hathaway disband Haven
      Digital pathways poised to reshape healthcare continuum in 2021
    • Dr. Daniel Hall
      UPMC pilots machine learning, telehealth to inform patient transfers
      A woman being recorded using her inhaler on a smartphone.
      Digital check-ins, connected inhalers help control asthma
      Humana partners with in-home provider for 24/7 care
      A phone screen showing the question, "Mary we hope this information was helpful and we'd like to keep guiding you. Are you interested in knowing when it's your turn to receive the vaccine?"
      Chatbots, texting campaigns help manage influx of COVID vax questions
    • Bundled payments reduce surgery costs by 10.7%
      Coordinated payment policies could speed transition to value, experts say
      CMMI's geographic direct contracting model needs an overhaul, experts say
      Hospitals fight UnitedHealthcare policies over lab test, specialty drug payments
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Dr. Alan Kaplan
      The risks, rewards of taking organizations 'where they haven’t gone before'
      Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
    • Dr. Stephen Markovich
      Making sure we're aligned along the path to achieving inclusion
      Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
      Laura Lee Hall and Gary Puckrein
      Increased flu vaccination has never been more important for communities of color
      John Daniels Jr.
      Health equity: Making the journey from buzzword to reality
    • Mikelle Moore
      The promising future of rural healthcare, even amid the COVID-19 pandemic
      In-person visitation must be part of the national COVID-19 response
      We've lost so much to the pandemic, but we've also made gains that will endure
      Medical groups key to meeting president's vaccine pledge
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Best Places to Work in Healthcare Logo for Navigation
      Nominations Open - Best Places to Work in Healthcare
      Nominations Open - 50 Most Influential Clinical Executives
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Minorities in Healthcare
      • - Luminaries
      • - Top 25 Minority Leaders
      • - Minorities to Watch
    • Women in Healthcare
      • - Luminaries
      • - Top 25 Women Leaders
      • - Women to Watch
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • podium march webinar logo lockup
      Sponsored Content Provided By Podium
      Webinar: Critical Touchpoints for Every Patient’s Journey — How Technology Plays an Important Role
      scp health logo lockup march 2021
      Sponsored Content Provided By SCP Health
      Webinar: COVID’s call to action — Reset for success in 2021
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Healthcare Transformation Summit
    • Leadership Symposium
    • Virtual Briefings
      • - Hospital of the Future
      • - Mental Health
      • - Patient Safety & Quality
      • - Strategic Marketing
      • - Virtual Health
      • - Workplace of the Future
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Next Up Podcast: Educating patients on the COVID-19 vaccine with Tanya Andreadis
      Dr. Joseph Cacchione
      Next Up Podcast: Educating patients on the COVID-19 vaccine with Dr. Joseph Cacchione
      Dr. Karen DeSalvo
      Next Up Podcast: What to expect with telehealth and healthcare technology in the next four years
      Carter Dredge
      Next Up Podcast: Ready, set, innovate! Innovation and disruption in healthcare
    • Beyond the Byline: Insurers are betting on virtual-first plans as COVID-19 shifts care pathways
      Beyond the Byline: How residents' stories shape our coverage of the vaccination rollout in nursing homes
      Beyond the Byline: Regulators aim to boost value push with fraud and abuse law updates
      An older man wearing a mask receiving a vaccine.
      Beyond the Byline: Verifying information on the chaotic COVID-19 vaccine rollout
    • Outreach during COVID-19
      Leading intention promote diversity and inclusion
      Introducing Healthcare Insider Podcast
    • The Check Up: Dr. Marc Boom
      The Check Up: Dr. Marc Boom of Houston Methodist
      The Check Up: Dr. Imran Andrabi
      The Check Up: Dr. Imran Andrabi of ThedaCare
      The Check Up: Tanya Blackmon
      The Check Up: Tanya Blackmon of Novant Health
      The Check Up: Dr. Patrick Hwu
      The Check Up: Dr. Patrick Hwu of the Moffitt Cancer Center
    • ivana naeymi-rad one on one intelligent medical objects
      Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Medicaid
January 16, 2020 06:00 AM

Nebraska could pave the way forward for Medicaid work requirements

Michael Brady
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print
    AP
    A yard sign promoting Initiative 427, the Medicaid Expansion Initiative, is seen in Omaha, Neb. in Oct. 2018.

    Nebraska's two-tiered approach to Medicaid expansion has spawned interest among health wonks because its work requirement could stand up to legal scrutiny.

    The Trump administration has been pushing states to adopt a Medicaid work requirement, claiming that such policies can improve people's health outcomes by getting them to work more. Many red states were eager to pursue a work requirement because it aligns with the ideological commitments of conservative policymakers, but the courts have ruled against them so far.

    But Nebraska is tacking a new approach that circumvents one of the courts' most pressing concerns with work requirements: Medicaid enrollment.

    In November 2018, Nebraskans voted in favor of a ballot initiative that extended Medicaid coverage to most able-bodied adults ages 19 to 64 that earn up to 138% of the federal poverty level. Rather than pursue a conventional Medicaid expansion, Nebraska opted to request a Medicaid 1115 from the CMS last month that would allow it to create two tiers of Medicaid benefits for the newly eligible population. Comments on Nebraska's proposal are due January 17.

    The "Prime" tier will allow expansion enrollees to receive the same Medicaid benefits as Nebraska's traditional Medicaid population if they fulfill community engagement, personal responsibility and wellness activities. The "Basic" package would cover basic health services and prescription drugs, but drop coverage for dental, vision and over-the-counter drugs. Medicaid expansion enrollees would receive basic benefits even if they don't fulfill any of the activities required for prime benefits. Under the plan, the state would check every six months to determine whether a beneficiary was eligible for basic or prime benefits. Beneficiaries could be locked out of prime benefits for one year if they don't fulfill all of the reporting requirements.

    The state's community engagement requirement could be fulfilled through work, searching for a job, education, volunteering or other qualifying activities.

    Nebraska's Department of Health & Human Services claims the approach would improve the health of the expansion population, increase patient engagement, deliver a better experience for patients and providers, and slash healthcare spending. But many healthcare experts are skeptical of those claims.

    Though several experts are skeptical of those claims, they think it could pass muster with courts because it increases the number of people covered by Medicaid rather than curbing enrollment.

    Federal courts have shut down work requirements in Arkansas, Kentucky and New Hampshire because their policies could lower enrollment by denying coverage to otherwise eligible people if they failed to meet reporting requirements. Some states paused implementation of their work requirements until the courts settle the matter.

    "Does this comport with the objectives of the Medicaid program, which is to provide health coverage to vulnerable people?" said Joan Alker, executive director and a co-founder of the Center for Children and Families and a research professor at the Georgetown University McCourt School of Public Policy.

    It's a question the courts will eventually decide, according to Tiffany Friesen Milone, policy director for the OpenSky Policy Institute, a left-of-center Nebraska think tank.

    "I don't see how we (the state of Nebraska) don't get sued," she said.

    Integrity concerns behind work requirement support
    Conservative policymakers and researchers have increasingly supported additional Medicaid work and reporting requirements in recent years due to concerns about Medicaid's integrity. They're worried that states are enrolling ineligible people, said Aaron Yelowitz, a professor in the Department of Economics at the University of Kentucky and a senior fellow with the libertarian Cato Institute.

    Citing his academic research and recent reports from HHS and its Office of the Inspector General, Yelowitz said that "states are gaming the system by misqualifying people to get higher federal match rates" rather than steering them into programs they're eligible for, like non-expansion Medicaid enrollment.

    "There are people eligible under some pathway, but that pathway is one where the state bears some more expense and (the state is) ripping off the federal government," he said.

    But many Medicaid experts think that Yelowitz's concerns about the program's integrity are vastly overblown. They argue that he and other like-minded researchers and policymakers misunderstand or "grossly misrepresent" the data on Medicaid improper payments using faulty logic and research methods.

    Still, both sides agree that program integrity is a legitimate goal for states and the federal government.

    If people think the Medicaid program isn't run well, it could "undermine support for the program," Yelowitz added.

    During last month's Medicaid and CHIP Payment and Access Commission meeting, the commissioners requested that MACPAC's staff look into what's behind Medicaid's improper payment rates.

    Most of the commissioners were more concerned about misnomers being spread about Medicaid's program integrity than there being significant integrity problems.

    Better data could go a long way toward informing experts and the public about how concerned they ought to be about it. But most experts aren't worried about it for now.

    No evidence that work requirements work
    Red states have been enamored with Medicaid work requirements for the past couple of years because conservative policymakers think that they could boost workforce participation and trim state Medicaid expenditures by moving more people onto commercial insurance plans.

    But a 2018 study in the New England Journal of Medicine found that 18,000 people in Arkansas lost coverage when the state implemented its work requirement, and there was no significant bump in beneficiary employment. The state's employment rate went up during the demonstration period, which the state ended early.

    "Correlation has been confused with causality," Akler said. "Healthier people are more likely to work because they're healthier."

    Nebraska's waiver, if approved, would be a valuable opportunity to find out what works and what doesn't. Medicaid 1115 waivers were created for the purpose of researching and demonstrating new policy approaches.

    But the state didn't include an evaluation plan in its waiver proposal, saying that it would "work with an independent entity to develop a robust evaluation plan and methodology" to test its hypotheses. It's unclear how Nebraska or the CMS would learn anything from the demonstration because the state hasn't explained how it would know if the experiment was working or not.

    Critics of the proposal say that the lack of an evaluation plan suggests the underlying policy aim is to cut spending by denying people benefits rather than to experiment with new ideas to change how people behave.

    Diving deeper into Nebraska's plan
    Nebraska's proposal asks that the CMS waive Medicaid's 90-day retroactive eligibility requirement, which covers three months of medical services for Medicaid-eligible people that aren't enrolled. The state says that waiving the requirement would incentivize people to fulfill reporting requirements, maintain coverage and improve the continuity of care. It would also allow the state to avoid paying for medical expenses incurred during that period.

    The state's application carves out specific populations from the retroactive eligibility waiver, such as pregnant women, who would likely benefit from better care continuity and continuous coverage. Nebraska's proposal didn't detail why it doesn't want to include those populations in the demonstration.

    "Many low-income individuals may not know that they are eligible for Medicaid and may not seek care for a condition until the condition becomes unmanageable," the Nebraska Section of the American College of Obstetricians and Gynecologists said in a letter. "Ending retroactive eligibility may further encourage such self-imposed rationing of care as patients will likely try to avoid incurring medical bills they cannot pay."
    The reporting complexity of the proposal would likely interrupt enrollment, rather than improve maintenance of coverage, experts say.

    Nebraska would need to conduct an expensive, resource-intensive outreach campaign to ensure that Medicaid beneficiaries and providers understand the differences in benefits and eligibility and reporting requirements. That's especially difficult in a rural state like Nebraska.

    "The intent should not be to trip people up. It should not be to create a system that is so impossible that you need to have a Ph.D. to figure out what's going on," Yelowitz said.

    A "robust system" would make it easy for eligible people to enroll and maintain coverage and ensure program integrity by preventing ineligible people from receiving benefits, according to Yelowitz.

    Automated reporting could reduce the administrative burden on beneficiaries, making it is easier for them to maintain eligibility while achieving the goals of state policymakers. For example, if a Medicaid enrollee is working, information about their wages could be automatically collected and reported using existing unemployment insurance data.

    But there's a fundamental conflict between making sure that eligible people can enroll in and maintain Medicaid coverage, and preventing ineligible people from receiving benefits, Yelowitz said.

    Additional reporting requirements will likely lead to more eligible people losing some coverage, at least temporarily. And the evidence isn't clear that it's worth the tradeoff.

    The additional reporting would probably increase uncompensated care, said Andy Hale, vice president of advocacy for the Nebraska Hospital Association. That would hurt providers, especially in rural areas that are already struggling.

    The state would likely spend a huge sum of time and money administering the much more complex Medicaid expansion, which might not be worth the cost, Friesen Milone said. Kentucky's Medicaid administrative costs went up more than 40% when it implemented its waiver because the federal government doesn't provide matching funds for many implementation expenses.

    Correction: An earlier version of this story misstated the type of Medicaid waiver Nebraska sought. This error has been corrected.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    Proposed overhaul of Arkansas Medicaid expansion unveiled
    Proposed overhaul of Arkansas Medicaid expansion unveiled
    Aetna challenges exclusion from Oklahoma's new Medicaid managed-care program
    Aetna challenges exclusion from Oklahoma's new Medicaid managed-care program
    Sponsored Content
    Get Free Newsletters

    Sign up for free enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today

    The weekly magazine, websites, research and databases provide a powerful and all-encompassing industry presence. We help you make informed business decisions and lead your organizations to success.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Stay Connected

    Join the conversation with Modern Healthcare through our social media pages

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Minorities in Healthcare
          • - Luminaries
          • - Top 25 Minority Leaders
          • - Minorities to Watch
        • Women in Healthcare
          • - Luminaries
          • - Top 25 Women Leaders
          • - Women to Watch
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Healthcare Transformation Summit
        • Leadership Symposium
        • Virtual Briefings
          • - Hospital of the Future
          • - Mental Health
          • - Patient Safety & Quality
          • - Strategic Marketing
          • - Virtual Health
          • - Workplace of the Future
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing