On November 1, 2021, the New York State Assembly Committee on Health held a public hearing entitled “Medicaid Program Efficacy and Sustainability” (originally scheduled for October 26). The Committee was seeking input on key topics related to Medicaid, including the New York’s Medicaid spending cap and the Medicaid Managed Care program. The hearing notice can be found here.
Medicaid Matters was represented at the hearing by consumer advocate and coalition member Maggie Sanchez. Medicaid Matters’ written testimony is below and here.
Testimony to the New York State Assembly Committee on Health
Medicaid Program Efficacy and Sustainability
November 1, 2021
Thank you for the opportunity to provide testimony on New York’s Medicaid program. Since 2003, Medicaid Matters New York has been bringing the interests of people who are served by Medicaid to the table in Albany. Our coalition includes individuals and organizations across the state unified around the goal of making sure consumer interests are included, understood and met in any and all policy and budget discussions on Medicaid in New York.
Medicaid Matters has actively raised several significant issues and concerns related to the initiatives advanced through the Medicaid Redesign Team (MRT) in 2011, as well as the MRT II in 2020. The Medicaid Matters Coordinator served on the original MRT as the only consumer advocate, and several Medicaid Matters members participated in issue-specific workgroups that grew out of the MRT. Many side-bar meetings took place with the Governor’s office and Department of Health officials, excluding consumer advocates and at the cost of public discourse. While there were a few improvements that came to fruition as the result of consumer advocacy, dozens of Medicaid changes aimed at curbing cost were made as a result of the MRT. Medicaid Matters supports the notion that Medicaid funding should be spent wisely and in ways that honor the intent of the program. We do not believe, however, the administration kept the interests of people at the core of the implementation of most of these initiatives.
Of the dozens of initiatives that resulted from the original MRT, there are two that have been particularly problematic for the program and its enrollees: expansion of Medicaid Managed Care and the creation of the Medicaid Global Cap.
The Medicaid global cap was presented in 2011 as a mechanism to limit growth in Medicaid spending and instill discipline in Medicaid budgeting. The cap was set at an arbitrary, fixed moment in time and not designed to keep pace with program growth. In February 2021, Medicaid Matters issued a one-page fact sheet entitled “Why New York Should Repeal the Medicaid Spending Cap.” The document provides detailed justification for our support for repeal of the cap, laid out in the provisions of a bill by the Assembly and Senate Health Committee Chairs (A.226, Gottfried / S.5255, Rivera). The one-pager makes the following points:
- The cap is not designed to be responsive to increases in the number of people covered by the program or the cost of health care services.
- The cap was set arbitrarily and has not been adjusted to account for growth in the program. A certain amount of growth should be expected and predictable, for example, to accommodate an aging population that will turn to Medicaid to cover long-term services and supports, particularly in home- and community-based settings.
- Due to the economic downturn and job loss associated with the COVID-19 pandemic, over 700,000 new enrollees turned to Medicaid between March and November of 2020. This demonstrates the benefit of Medicaid being responsive and flexible, assuring that people did not lose access to health care when they lost employer-based health insurance. That is exactly how Medicaid should respond to economic downturns.
- The cap provides a platform for the Executive to frame Medicaid growth as a problem that requires austerity, when in fact, a strong Medicaid program provides a system that allows people to have access to health care when they need it.
- The statute that created the cap grants authority to the Division of the Budget to unilaterally cut the Medicaid budget mid-year to keep spending under the cap. The Legislature has no oversight over those cuts.
- Significant sums of public funds have been distributed outside the annual budget process at the Governor’s discretion and determined to be ‘cap neutral,’ without explanation, to justify the expenditures.
- State Medicaid spending draws a federal match; it is the State’s largest source of federal funding. By capping state spending, the global cap also effectively caps the amount of federal funding the state can receive for its Medicaid program, which is illogical during a health and financial crisis.
- Medicaid cuts that the Executive claims essential for remaining under the cap disproportionately impact:
- People with disabilities and older adults reliant on community-based services and supports;
- Safety-net hospitals and community-based providers, like community health centers providing primary care and community mental health centers; and
- Historically under-resourced communities of color.
- It has been argued that if the cap were repealed, an alternate fiscal mechanism would be necessary to provide structure and discipline in Medicaid spending. No alternative is necessary. The Medicaid budget would once again be negotiated and enacted through the annual budget process set forth by the State Constitution.
Medicaid Matters, along with other partners, believes Medicaid must be a vehicle for reaching greater equity by investing in the program rather than embracing austerity. To that end, New York State should:
- Provide eligibility equity for older adults and people with disabilities by raising the Medicaid income level for those age 65+ and adults with disabilities from 84% of the FPL to 138%, eliminate the asset limit for Medicaid for age 65+ and adults with disabilities, and increase the income limit for the “QMB” Medicare Savings Program from 100% of the FPL to 200%;
- Provide Essential Plan coverage for immigrants with incomes up to 200% of the FPL;
- Extend post-pregnancy Medicaid coverage from 60 days post-pregnancy to one year;
- Guarantee consumer and community priorities are included in the next 1115 Waiver;
- Ensure access to home- and community-based services by enhancing the wages of people who provide them;
- Allocate Indigent Care Pool funds to the safety-net hospitals that actually provide a higher proportion of services to people covered by Medicaid and people who are uninsured; and more.
The original MRT initiated a plan for expansion of Medicaid Managed Care. One of the unique things about New York’s Medicaid Managed Care program at the start was the important role played by New York-based managed care plans. Originally called Prepaid Health Services Plans (PHSPs), these public health plans were established in New York State law and set up by groups of providers that had a history of serving the Medicaid population, and who were committed to providing better care. Importantly, they were all not-for-profit and frequently mission-driven groups including community health centers and public hospitals. In the early years of Medicaid Managed Care, public health plans provided coverage for two-thirds of Medicaid enrollees. Over the years, national for-profit managed care plans (such as Centene and Amerigroup) saw the size of the New York Medicaid market, and the potential profitability of coming into the market. When Molina Healthcare completes its acquisition of Affinity Health Plan (which was one of the earliest and most mission-driven of Medicaid Managed Care plans in its early incarnation as the Bronx Health Plan), two-thirds of Medicaid Managed Care enrollees will be in for-profit plans whose primary accountability is to their shareholders, and whose mission is maximizing profit.
Referred to as “Care Management for All,” the expansion of Medicaid Managed Care in 2011 was centered around the goal to eliminate all remaining exemptions and exclusions from mandatory managed care enrollment over the course of a complex, multi-year implementation plan. Medicaid Matters created an extensive chart for advocates to provide an easy-to-read reference guide to the state’s implementation plan, because nothing the state presented was comprehensive of the entire roll-out schedule. More importantly, however, Medicaid Matters issued a document outlining the necessary elements that must be included in any care management model to ensure people’s rights and access to services are preserved in the context of Medicaid Managed Care.
Among several critical points, the paper included a call for:
- Culturally-competent outreach and engagement;
- Compliance with Early Periodic Screening, Diagnostic, and Treatment (EPSDT) for children;
- Meaningful behavioral health care coordination; and
- Compliance with Olmstead v LC, which requires people with disabilities be provided services in the most-integrated setting.
The paper also called for strong consumer protections in all contractual obligations, including:
- Consumer and provider education and training to minimize auto-assignment and disruptions in services;
- Full, clear disclosure of managed care plan policies;
- Accessible, plain language consumer notices;
- Person-centered planning;
- Clear and responsive grievance and appeals process; and more.
Sadly, and perhaps not surprisingly, almost every component of the paper – issued in February 2011, when the MRT was still deliberating – is still relevant.
We know from experience Medicaid can be administered through managed care models in ways that focus on the needs, rights and choices of enrollees. For example, New York has a home-grown managed care product designed to meet the needs of individuals with complicated health and social needs, specifically for individuals with HIV. Medicaid HIV Special Needs Plans (SNPs) were the result of relentless advocacy by the HIV community to assure that the Medicaid program responded to the unique needs of HIV+ individuals. Advocates worked closely with the Department of Health, particularly the AIDS Institute, to establish the HIV SNPs. HIV SNPs provide each enrollee with a medical team with expertise in HIV care. They also provide care coordination, including counseling, legal support and help navigating public benefits. The HIV SNP model, shaped in coordination with HIV advocates, is one that could be replicated for other groups with high health and social care needs.
Above all and no matter the model, people who are served by New York’s Medicaid program deserve access to services, protection of their rights, and clear understanding of how to navigate a complex system. It is incumbent on New York State to provide enough oversight of managed care plans and any other entity it contracts with to ensure people, their rights and services are protected. Medicaid Matters believes people should have the right to comprehensive public insurance coverage, no matter their circumstances. To that end, New York should enact the New York Health Act to provide universal coverage to all New Yorkers. Until such time the New York Health Act comes to fruition, we must continue to work toward a Medicaid program that responds to the needs of consumers and promotes access to care and services that keep people well.