FEATURED STORY

What to Watch in the States in 2019 – State Medicaid Trends

Legislative sessions have begun in all but four states (Alabama, Florida, Louisiana and Nevada begin sessions in the months ahead).  As lawmakers begin to tackle the numerous issues they need to address in the coming months, let’s look at what to expect regarding Medicaid.
Things to keep in mind:
There are 20 new governors across the U.S. They began 2019 focused on building their new administrations. Because of this, if you are in a state with a new governor it may seem that things are off to a slow start. But make no mistake, first-term as well returning governors and those whose seats aren’t up until 2020 are hard at work figuring out how to fulfill their campaign promises and do something to protect access to healthcare.
Additionally, there are hundreds of new legislators getting oriented. They are learning legislative processes and rules, and learning about the work of the different state agencies as well as their own policy and budgetary responsibilities. They are setting up their offices, and in some cases hiring staff. They will be joining those incumbents who watched the 2018 midterm elections with great care. All are keenly aware that the voters have called on them to protect pre-existing conditions and address other healthcare coverage issues.
Medicaid
While some states are working to expand access to meaningful, affordable healthcare, others are implementing policies and practices designed to further erode coverage options and limit access to care.
Expanding Access
Last November, three states passed ballot initiatives to expand Medicaid as provided for through the Affordable Care Act – Idaho, Nebraska and Utah. Additionally, the new governor of Maine made it her first order of business to implement the state’s voter-approved Medicaid expansion, and the governors of Kansas and Wisconsin have also indicated their interest in expanding Medicaid.  Montana failed in 2018 to pass a tobacco tax that was intended to fund their current expansion, giving rise to some concern that Montana’s expansion might sunset. However, there are talks underway to find other funding for Montana’s expanded Medicaid program. HFA will continue monitor the efforts in these states and keep our eyes open for additional states advancing this positive trend.
Legislation has been introduced in four states (Hawaii, Missouri, Montana and Oklahoma) to create a Medicaid buy-in option for consumers who need additional options for accessing health insurance coverage. A buy-in plan would likely be offered on a state’s health insurance marketplace as an additional (and more affordable) option for people who don’t qualify for Medicaid and find Marketplace plans out of reach for reasons such as disability, affordability or limited access to Marketplace plan options. There are numerous states beyond the four listed above are investigating their options for broadening access to care. We are tracking their progress.
Restricting Access
The Centers for Medicare and Medicaid Services has approved Section 1115 waivers limiting Medicaid eligibility in seven states. Arkansas, Arizona, Indiana, Kentucky, New Hampshire, Michigan and Wisconsin have won approval from CMS to impose new reporting and work requirements on some of their Medicaid enrollees. Decisions are pending for Alabama, Mississippi, Ohio, Oklahoma, South Dakota, Tennessee, Utah and Virginia. HFA is concerned that these requirements create barriers to access. Earlier this January, the Kaiser Family Foundation released an issue brief on the impact work requirements has had in the state of Arkansas. According to numbers reported by the Arkansas Department of Human Services, over 18,000 Arkansans were disenrolled from Medicaid between September and December of 2018, due to failure to satisfy the work and/or reporting requirements. Consumers who are disenrolled are locked-out of coverage for the remainder of the plan year, and then have to reapply for coverage.
In the coming months, the Washington Wire will investigate state proposals for utilization management of pharmacy benefits.
Quick Hits:

• The 35-day partial shutdown of the U.S. government ended – at least for now – when the President and Congress agreed to a three-week stopgap spending bill on Jan. 25. President Trump and Congressional lawmakers have until Feb. 15^ to resolve their differences on border security and agree on a long-term funding bill.
• The U.S. House of Representatives filed a motion seeking to intervene as a party in the Texas v. United States lawsuit, where a district court judge has issued a stayed ruling striking down the Affordable Care Act. Proceedings in that litigation were stayed during the government shutdown but should begin again shortly.
• One phase of the patent litigation between Genentech and Baxalta has concluded. The parties agreed to the entry of a final judgment establishing that, under the district court’s interpretation of the patent terms, Genentech’s Hemlibra product does not infringe Baxalta’s patent. Genentech also agreed to drop its counterclaim against Baxalta. The entry of this final judgment allows Baxalta to proceed to the appellate stage to appeal the court’s interpretation of the patent terms.
• HFA filed comments with the U.S. Department of Health and Human Services on HHS’s proposed Healthy People 2030 framework. HFA expressed appreciation for the Healthy People objectives relating to bleeding disorders, as well as the more general objectives regarding access to coverage and care. HFA suggested possible refinements to the bleeding disorders objectives, with the aim of (a) promoting earlier diagnoses of von Willebrand’s disease, and (b) focusing on the preservation of joint health and mobility in hemophilia care, as well as other metrics important to the patient community.
• HFA joined with NHF to file comments on proposed rules for Medicaid managed care programs. Our comments emphasized that people with bleeding disorders need robust provider networks and timely information about changes to those networks that might impact their access to care. HFA and NHF also filed joint comments opposing proposed rules that would allow some Medicare plans to implement step therapy for Part B drugs (including clotting factor) and limit access to “protected class” Part D drugs (including antiretrovirals and immunosuppressants).