When I began writing this blog entry, the American Health Care Act (AHCA), the Republicans’ proposed replacement for the Affordable Care Act (ACA), was still on the table. As we all know now, President Trump is moving on to focus on other issues.
So where does that leave us? We are still in the same state of uncertainty. With the failure of the AHCA, we are left not knowing what exactly the healthcare landscape will look like in Trump’s presidency. But, we can still be sure it will change.
I’ll use this blog to discuss the likely eventual changes to federal healthcare law in regard to Medicaid, and what you can do to prepare for them.
Medicaid expansion is not likely to last
Much of the push for the reform of the ACA came from GOP governors and Congressional leaders who were opposed to Medicaid expansion. Seema Verma, the new administrator of the Centers for Medicare and Medicaid Services (CMS), was the chief architect of Indiana’s Medicaid plan: The Healthy Indiana Plan. Considering Vice President Mike Pence is the former governor of Indiana and Verma is in the top spot at CMS, it’s safe to assume that the Trump Administration will likely deliver greater state control over Medicaid spending and rules. These will probably include work requirements and copays. The AHCA proposed a full repeal of Medicaid expansion by 2018. While the timeline may have changed, we can probably count on Medicaid expansion being on the chopping block in the future.
What are the risks of Medicaid reform?
Medicaid reform could spell big losses for the people we serve—those with complex behavioral health and medical conditions, and those with poor social determinants of health, such as unstable housing and limited access to providers. If the AHCA is any indication, two major changes may come to the behavioral health field. First, the essential health benefits (EBH) provision of the ACA may disappear under reform or repeal of the act. Put simply, this means that plans won’t be required to provide coverage of mental health and substance use treatment services. As such, state’s may choose not to cover behavioral health services in their Medicaid plans.
The second major risk is the possibility of losing progress on the Medicaid IMD exclusion. You may remember that the IMD exclusion prohibits states from covering treatment in inpatient facilities or institutions with more than 16 beds. This rule forced many people with major mental illnesses onto the streets, emergency rooms, and jails. IMD exclusion waivers have allowed states to use Medicaid money to cover stays in previously excluded settings for certain individuals and certain time frames, providing much-needed treatment.
What you can do about it now
There are some things you can do immediately to benefit the people you serve. Consider the following:
1. Speak up and advocate. Contact your state legislators and other decision-makers to let them know how important parity, EHBs, and the IMD exclusion waivers are to individuals with mental health and substance use disorders in your state. Ask your colleagues, friends, and other providers to do the same. Work with your provider and consumer associations and contact your local media.
2. Plan now for state managed care plans similar to Indiana’s. Think about how your program or organization can help people who will need to meet employment or cost sharing requirements. For example:
- How can you and your agency support your clients meeting employment requirements? You could provide in-house employment supports or partner with a job training center. Plan to make employment part of your treatment plans and a goal for most clients. This will require good client retention, robust treatment plans, and measures of success for “employability” to help your clients keep their Medicaid coverage. For the people who are truly unemployable, figure out how you can help them get SSDI.
- How can you help people get used to making copays? For people who are accustomed to not paying anything for their care, coming up with copays will represent a difficult change. Talk to your clients about saving, budgeting, and planning for payment. Copays will likely be based on percent of income, so clients with higher incomes will be expected to pay more; those earning no income probably won’t have to pay. Not collecting copayments—however well-intentioned— is not advised as contracts will require that you do and audits may uncover the pattern leading to real and serious consequences.
3. Remember that integrated delivery systems will prevail, no matter how the care they provide is ultimately paid for. Continue to plan strategically and tactically for ways an integrated approach can take care of the population health needs of the people you treat. For example, identify the model most apropos to your organization and the population you serve. Market yourself as a partner provider to larger systems in your areas, appealing to the gaps in the system of care and making your value-add as tangible to partners as possible. And continue to prepare for value-based reimbursement, by making sure that you are collecting detailed patient data, streamlining and creating efficiencies in your programs, and tracking outcomes.