Our State Medicaid Director Tony Keck was called to
Washington this week by the US House Energy and Commerce Committee to testify
at a hearing that was entitled: “The
Need for Medicaid Reform: A State
Perspective.” Here you can view the written comments that he submitted along with the video of the
entire hearing, which lasted almost two hours.
Keck testified alongside two other invited guests, including
Dr. Joe Thompson, the Surgeon General of Arkansas, and Seema Verman, a health
policy expert who helped with much of Indiana’s Medicaid reforms.
So was he there to beat the drum against Medicaid
expansion?
Not at all, and in fact
Medicaid expansion wasn’t even really discussed, except for a few passing
remarks by House members who were asking questions. Instead, the focus was on this question: “What changes need to be made to the Medicaid
program in order to ensure its long-term sustainability without breaking the
federal or state budgets?” Keck’s
primary answer to that question is revealed in his opening remarks:
“I believe there is a developing bi-partisan
interest among states for flexibility to manage programs locally in exchange
for more accountability for improved health and more predictability in
expenditures at the state and federal level.”
In other words, more local control of Medicaid and less federal
interference in how the states run their programs.
Much of the discussion centered on the role that the
Medicaid recipient should play in controlling their health care costs. Talk about empowering Medicaid beneficiaries
to make health care decisions centered on the lack of flexibility states have
had to wield either the carrot or the stick when it comes to patient benefit
design. Keck testified that South
Carolina is pursuing some aggressive goals when it comes to what’s known as
Value Based Insurance Design, but that “Medicaid is all carrots and no sticks,
and sometimes you need sticks.” He said
that South Carolina wants to go much further than the federal government has
with respect to requiring patients to take an active and responsible role for
their care, and that he will be approaching CMS in the next few months with
waiver requests.
Speaking of waiver requests, that was a major bone of
contention during the hearing. Keck
responded to the first question of the day, which was from the Republican
chairman, about things that he would do to remove roadblocks in the Medicaid
system by suggesting that the waiver process needs to move much quicker. Keck brought up a waiver that South Carolina
requested 5 years ago that was just now being approved after taking up
“hundreds if not thousands of hours of staff time,” even though the waiver was
regarding an issue that only cost $3 million.
The first Democrat to ask questions brought up a different perspective
on the waiver issue, eliciting a response from Arkansas’ Surgeon General that
Arkansas’ latest Medicaid waiver had only taken CMS two months to grant (though
further questioning from the next Republican revealed that Arkansas had other
waivers that had taken much longer than two months).
Block grants also came up.
Not surprisingly, the questions and comments landed safely within the
party lines, with Republicans making statements for and Democrats against block
grants. During this line of questioning Keck
agreed that if a state could be given more flexibility within the constraints
of a capped block grant amount, then better Medicaid outcomes would result. What about payment reform? According to Keck, “Fee for service is not
universally the cause of all our problems…”, but he and the others testifying
made it clear that payment reform was necessary and would be coming. In a nod to the hospital community, Keck also
testified that EMTALA reform was necessary to address the abuses of emergency
room visits.
All in all, if you are interested in the continued fight
about Medicaid expansion, this hearing will disappoint. But, if you are interested in three top
Medicaid experts and their thoughts on the reforms that need to be made to the
Medicaid program, and if you enjoy some occasionally snarky back and forth
between US House Republicans and Democrats when asking (loaded) questions, then
take a few hours and watch the hearing.
Whether you end up agreeing with Keck or not, you will be hard pressed
to disagree with the fact that further changes in South Carolina are coming – whether it be the way that physicians are
paid or patients are held responsible (unless CMS denies the waiver!).
Therefore, South Carolina’s physicians need to continue to
be the Voice of Health Care when it comes to treating the Medicaid population,
and this means we need to be involved in these significant policy discussions,
which also means we need to be thinking deeply from our front-line perspective
of how best to care for the neediest in our great state.
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