South Carolina 1115 Mediciad Waiver

January 22, 2019

Joshua D. BakerDirectorSouth Carolina Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202Re: South Carolina 1115 Demonstration Waiver Application –South Carolina Medicaid Community EngagementSubmitted via EmailDear Mr. Baker: The Global Healthy Living Foundation (GHLF) appreciates the opportunity to submit comments on the South Carolina 1115 Demonstration Waiver Application –South Carolina Medicaid Community Engagement. GHLF is a 20-year-old 501(c)(3) patient organization representing chronically ill patients and their caregivers across the country. We work to improve the quality of life for patients living with chronic disease by making sure their voices are heard and advocating for improved access to care at the community level. The patients we represent suffer from chronic conditions including arthritis, psoriasis, gastrointestinal disease, cardiovascular disease and migraine.GHLF is committed to ensuring that Medicaid provides adequate, affordable and accessible healthcare coverage. Several 1115 waiver proposals submitted to and approved by the Centers for Medicare and Medicaid Services (CMS) in recent months have jeopardized patients’ access to quality and affordable healthcare coverage.1The purpose of the Medicaid program is to provide affordable healthcare coverage for low-income individuals and families. Unfortunately, South Carolina’s application does not meet this objective and will instead create new administrative barriers that jeopardize access to healthcare for patients with serious and chronic diseases. GHLF urges the South Carolina Department of Health and Human Services (SCDHHS) to withdraw their Section 1115 Demonstration Waiver. The proposed South Carolina 1115 Demonstration Waiver seeks to add new barriers to accessing coverage. Individuals between the age 19 and 64 would be required to either demonstrate that they work at least 80 hours per month or meet exemptions. One major consequence of this proposal will be to increase the administrative burden on all patients. Individuals will need to attest that they meet certain exemptions or have worked the required number of hours on a monthly basis. The proposal does not specify how often individuals would need tovalidate their community engagement activities in order to remain in compliance.Increasing administrative requirements will likely decrease the number of individuals with Medicaid coverage, regardless of whether they are exempt or not. Arkansas is currently implementing a similar policy requiring Medicaid enrollees to report their hours worked or their exemption. During the first six months of implementation, the state has terminated coverage for over 18,000 individuals and locked them out of coverage until January 2019.2In another case, after Washington state changed its renewal process from every twelve months to every six months and instituted new documentation requirements in 2003, approximately 35,000 fewer children were enrolled in the programby the end of 2004.3Battling administrative red tape in order to keep coverage should not take away from patients’ or caregivers’ focus on maintaining their or their family’s health.2Failing to navigate these burdensome administrative requirements couldhave serious –even life or death –consequences for people with serious, acute and chronic diseases. If the state finds that individuals have failed to comply with the new requirements for just one month, they will lose their coverage. People who are in the middle of treatment for a life-threatening disease, rely on regular visits with healthcare providers or must take daily medications to manage their chronic conditions cannot afford a sudden gap in their care.GHLF is also concerned that the current exemption criteria may not capture all individuals with, or at risk of, serious and chronic health conditions that prevent them from working. Additionally, South Carolina’s “case specific basis” exemption as “determined by SCDHHS” is vague and does not provide sufficient detail on how this exclusion would be implemented. Individuals with chronic disease, women, African Americans and those living in rural communities will be disproportionally impacted by the community engagement requirement. The outlined exemptions are not sufficient to protect patients. In Arkansas, many individuals were unaware of the new requirements and therefore unaware that they needed to apply for such an exemption.4No exemption criteria can circumvent this problem and the serious risk to the health of the people we represent. Regardless of system integration, administering these requirements will be expensive for South Carolina. States such as Michigan, Pennsylvania, Kentucky and Tennessee have estimated that setting up the administrative systems to track and verify exemptions and work activities will cost tens of millions of dollars.5These costs would divert resources from Medicaid’s core goal –providing health coverage to those without access to care.Ultimately, the requirementsoutlined in this waiver do not further the goals of the Medicaid program or help low-income individuals improve their circumstances without needlessly compromising their access to care. Most people on Medicaid who can work already do so.6A study published in JAMA Internal Medicine, looked at the employment status and characteristics of Michigan’s Medicaid enrollees.7The study found only about a quarter were unemployed (27.6 percent). Of this 27.6 percent of enrollees, two thirds reported having a chronicphysical condition and a quarter reported having a mental or physical condition that interfered with their ability to work. In another report looking at the impact of Medicaid expansion in Ohio, the majority of enrollees reported that that being enrolled in Medicaid made it easier to work or look for work (83.5 percent and 60 percent, respectively).8The report also found that many enrollees were able to get treatment for previously untreated health conditions, which made finding work easier. Terminating individuals’ Medicaid coverage for non-compliance with these requirements will hurt rather than help people search for and obtain employment. GHLF opposes the proposed South Carolina Medicaid Community Engagement demonstration program. GHLF believes everyone should have access to quality and affordable healthcare coverage. The South Carolina 1115 Demonstration Waiver Application does not meet that standard. Thank you for the opportunity to provide comments. Sincerely, Steven NewmarkDirector of Policy and General CounselGlobal Healthy Living Foundation391American Lung Association, A Coordinated Attack: Reducing Access to Care in State Medicaid Programs, July 2018. Accessed athttp://www.lung.org/assets/documents/become-an-advocate/a-coordinated-attack.pdf. 2Robin Rudowitz, MaryBeth Musumeci, and Cornelia Hall, “A Look at November State Data for Medicaid Work Requirements in Arkansas,” Kaiser Family Foundation, December 18, 2018. Accessed at: https://www.kff.org/medicaid/issue-brief/a-look-at-november-state-data-for-medicaid-work-requirements-in-arkansas/; Arkansas Department of Health and Human Services, Arkansas Works Program, December 2018. Available at:http://d31hzlhk6di2h5.cloudfront.net/20190115/88/f6/04/2d/3480592f7fbd6c891d9bacb6/011519_AWReport.pdf. 3Tricia Brooks, “Data Reporting to Assess Enrollment and Retention in Medicaid and SCHIP,” Georgetown University Health Policy Institute Center for Children and Families, January 2009.4Jessica Greene, “Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement,” Health Affairs, Sept. 5, 2018. Accessed at: https://www.healthaffairs.org/do/10.1377/hblog20180904.979085/full/. 5Michigan House Fiscal Agency, Legislative Analysis of Healthy Michigan Plan Work Requirements and Premium Payment Requirements, June 6, 2018, http://www.legislature.mi.gov/documents/2017-2018/billanalysis/House/pdf/2017-HLA-0897-5CEEF80A.pdf; House Committee on Appropriations, Fiscal Note for HB 2138, April 16, 2018, http://www.legis.state.pa.us/WU01/LI/BI/FN/2017/0/HB2138P3328.pdf; Misty Williams, “Medicaid Changes Require Tens of Millions in Upfront Costs,” Roll Call, February 26, 2018, https://www.rollcall.com/news/politics/medicaid-kentucky. 6Rachel Garfield, Robin Rudowitz, and Anthony Damico, “Understanding the Intersection of Medicaid and Work,” Kaiser Family Foundation, February 2017, http://kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/. 7Renuka Tipirneni, Susan D. Goold, John Z. Ayanian. Employment Status and Health Characteristics of Adults With Expanded Medicaid Coverage in Michigan. JAMA Intern Med.Published online December 11, 2017. doi:10.1001/jamainternmed.2017.7055.8Ohio Department of Medicaid, 2018 Ohio Medicaid Group VII Assessment: Follow-Up to the 2016 Ohio Medicaid Group VIII Assessment, August 2018. Accessed at: http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Final-Report.pdf.

April 3rd, 2019

Joshua D. BakerDirectorSouth Carolina Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202Re: South Carolina 1115 Demonstration Waiver Application –South Carolina Medicaid Community EngagementDear Mr. Baker: The Global Healthy Living Foundation appreciates the opportunity to submit comments on the South Carolina 1115 Demonstration Waiver Application –South Carolina Medicaid Community Engagement.The Global Healthy Living Foundation (GHLF) is a 20-year-old 501(c)(3) patient organization reaching millions of chronically ill patients and their caregivers across the country through social media, community events and our online support and education. GHLF works to improve the quality of life for patients living with chronic disease by making sure their voices are heard and advocating for improved access to care at the community level. Our patients suffer from chronic conditions including arthritis, psoriasis, gastrointestinal disease, cardiovascular disease and migraine. As a result, these patients incur significant financial burden due to the high cost of the treatments that are necessary to manage their disease. And, it is on behalf of the patients we represent that we provide this information for your consideration.The purpose of the Medicaid program is to provide affordable healthcare coverage for low-income individuals and families, and GHLF is committed to ensuring that Medicaid provides adequate, affordable and accessible healthcare coverage. However, several 1115 waiver proposals submitted to and approved by the Centers for Medicare and Medicaid Services (CMS) in recent months have jeopardized patients’ access to quality and affordable healthcare coverage.iIn January 2019, GHLFsubmitted comments urging the South Carolina Department of Health and Human Services (SCDHHS) to withdraw its previous Section 1115 waiver application as it would create new administrative barriers that jeopardize access to healthcare coverage for patients with chronic pain. Unfortunately, South Carolina’s revised application continues to threaten patients’ access to care, and GHLF urges SCDHHS to withdraw its Section 1115 waiver application. Under the revised application, individuals between the age 19 and 64 would be required to either demonstrate that they work at least 80 hours per month or meet exemptions. One major consequence of this proposal will be to increase the administrative burden on individuals in the Medicaid program. Individuals will needto demonstrate that they meet certain exemptions or have worked the required number of hours, and the proposal does not specify how often individuals would need to submit this information in order to remain in compliance. Increasing administrative requirements will likely decrease the number of individuals with Medicaid coverage, regardless of whether they are exempt or not. Arkansas is currently implementing a similar policy requiring Medicaid enrollees to report their hours worked or their exemption, andalso attempted to exempt certain enrollees through data matching as South Carolina proposes in its application. Still, during the first six months of implementation, the state terminated coverage for over 18,000 individuals and locked them out of coverageuntil January 2019.iiIn another case, after Washington state changed its renewal process from every twelve months to every six months and instituted new documentation requirements in 2003, approximately 35,000 fewer children were enrolled in the program by the end of 2004.iiiBattling administrative red tape in order to keep coverage should not take away from patients’ or caregivers’ focus on maintaining their or their family’s health.Failing to navigate these burdensome administrative requirements could have serious –even life or death –consequences for people with serious, acute and chronic diseases. If the state finds that individuals have failed to comply with the new requirementsfor three months, their coverage could be suspended for up to three months. People who are in the middle of treatment for a life-threatening disease, rely on regular visits with healthcare providers or must take daily medications to manage their chronic conditions cannot endurea sudden gap in their care.GHLF is also concerned that the current exemption criteria may not capture all individuals with, or at risk of, serious and chronic health conditions that prevent them from working. Additionally, South Carolina’s “case specific basis” exemption as “determined by SCDHHS” is vague and does not provide sufficient detail on how this exclusion would be implemented. Individuals with chronic disease, women, African Americans and those living in rural communities will be disproportionally impacted by the new requirements. The outlined exemptions are not sufficient to protect patients. In Arkansas, many individuals were unaware of the new requirements and therefore unaware that they needed to apply for such an exemption.ivNo exemption criteria can circumvent this problem and the serious risk to the health of the people we represent. Regardless of system integration, administering these requirements will be expensive for South Carolina and burden SCDHHS staff as well as Medicaid beneficiaries. States such as Michigan, Pennsylvania, Kentucky and Tennessee have estimated that setting up the administrative systems to track and verify exemptions and work activities will cost tens of millions of dollars.vThese costs would divert resources from Medicaid’s core goal –providing health coverage to those without access to care.Ultimately, the requirements outlined in this waiver do not further the goals of the Medicaid program or help low-income individuals improve their circumstances without needlessly compromising their access to care. Most people on Medicaid who can work already do so.viA study published in JAMA Internal Medicine, looked at the employment status and characteristics of Michigan’s Medicaid enrollees.viiThe study found only about a quarter were unemployed (27.6 percent). Of this 27.6 percent of enrollees, two thirds reported having a chronic physical condition and a quarter reported having a mental or physical condition that interfered with their ability to work. In another report looking at the impact of Medicaid expansion in Ohio, the majority of people onMedicaid found it easier to work or look for work (83.5 percent and 60 percent, respectively).viiiThe report also found that many enrollees were able to get treatment for previously untreated health conditions, which also made finding work easier. Terminating individuals’ Medicaid coverage for non-compliance with these requirements will hurt rather than help people search for and obtain employment. For these reasons, GHLF opposes the proposed 1115 Demonstration Waiver Application. The revised application also includes some targeted changes in income levels for certain eligibility groups. While GHLF appreciates these efforts to expand coverage, South Carolina would be better served by expanding its Medicaid program to 138 percent of the federal poverty level ($17,236 for an individual in 2019) which will make coverage available to 240,000 low-income individuals and families in the state.ixThis coverage will help patients access medications to manage chronic conditions, preventive services like cancer screenings, and many other treatments needed to stay healthy. GHLF believes everyone should have access to quality and affordable healthcare coverage. The South Carolina 1115 Demonstration Waiver Application does not meet that standard, and we urge the state to withdraw the application. Thank you for the opportunity to provide comments. Please do not hesitate to contact me [email protected] we may be of further assistance with this proposed rule or if you have questions on our comments.Sincerely,Corey GreenblattManager, Policy and AdvocacyGlobal Healthy Living FoundationiAmerican Lung Association, A Coordinated Attack: Reducing Access to Care in State Medicaid Programs, July 2018. Accessed at http://www.lung.org/assets/documents/become-an-advocate/a-coordinated-attack.pdf.iiRobin Rudowitz, MaryBeth Musumeci, and Cornelia Hall, “A Look at November State Data for Medicaid Work Requirements in Arkansas,” Kaiser Family Foundation, December 18, 2018. Accessed at: https://www.kff.org/medicaid/issue-brief/a-look-at-november-state-data-for-medicaid-work-requirements-in-arkansas/; Arkansas Department of Health and Human Services, Arkansas Works Program, December 2018. Available at: http://d31hzlhk6di2h5.cloudfront.net/20190115/88/f6/04/2d/3480592f7fbd6c891d9bacb6/011519_AWReport.pdfiiiTricia Brooks, “Data Reporting to Assess Enrollment and Retention in Medicaid and SCHIP,” Georgetown University Health Policy Institute Center for Children and Families, January 2009.ivJessica Greene, “Medicaid Recipients’ Early Experience With the Arkansas Medicaid Work Requirement,” Health Affairs, Sept. 5, 2018. Accessed at: https://www.healthaffairs.org/do/10.1377/hblog20180904.979085/full/. vMichigan House Fiscal Agency, Legislative Analysis of Healthy Michigan Plan Work Requirements and Premium Payment Requirements, June 6, 2018, http://www.legislature.mi.gov/documents/2017-2018/billanalysis/House/pdf/2017-HLA-0897-5CEEF80A.pdf; House Committee on Appropriations, Fiscal Note for HB 2138, April 16, 2018, http://www.legis.state.pa.us/WU01/LI/BI/FN/2017/0/HB2138P3328.pdf; Misty Williams, “Medicaid Changes Require Tens of Millions in Upfront Costs,” Roll Call, February 26, 2018, https://www.rollcall.com/news/politics/medicaid-kentucky. viRachel Garfield, Robin Rudowitz, and Anthony Damico, “Understanding the Intersection of Medicaid and Work,” Kaiser Family Foundation, February 2017, http://kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.viiRenuka Tipirneni, Susan D. Goold, John Z. Ayanian. Employment Status and Health Characteristics of Adults With Expanded Medicaid Coverage in Michigan. JAMA Intern Med.Published online December 11, 2017. doi:10.1001/jamainternmed.2017.7055viiiOhio Department of Medicaid, 2018 Ohio Medicaid Group VII Assessment: Follow-Up to the 2016 Ohio Medicaid Group VIII Assessment, August 2018. Accessed at: http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Final-Report.pdfixRachel Garfield, Kendal Orgera and Anthony Damico, “The Coveage Gap: Uninsured Poor Adults in State that Do Not Expand Medicaid,” March 2019, https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.