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March 10, 2011
TOPEKA Gov. Sam Brownback today made public a letter he sent to the federal government, essentially asking that it remove the strings attached to the Medicaid dollars it sends to Kansas.
Kansas will receive almost $2 billion in federal Medicaid assistance this year. That money, matched by about $790 million in state dollars, provides health coverage for poor children, the disabled and frail elderly.
The letter, sent to U.S. Secretary of Health and Human Services Kathleen Sebelius and dated March 9, sounded a plea first taken up several weeks ago by other GOP governors frustrated by "maintenance-of-efforts" requirements spelled out in the federal health reform law. Those so-called MOE requirements compel states to maintain Medicaid eligibility standards and services at 2008 levels.
For example, when the Kansas Legislature last year tried to save the state money by raising the premiums paid by those enrolled in HealthWave, which in Kansas provides health coverage to children in Medicaid- and CHIP-eligible families, HHS said that wasn't possible due to the maintenance-of-effort requirements in the reform law.
The Patient Protection and Affordable Care Act, which Republicans call Obamacare, was signed into law a year ago this month and the controversy and partisanship that surrounded its passage through Congress has not subsided.
Brownback is among the new GOP governors who were elected campaigning against it. During the campaign he pledged to uphold the law, but also to, "fight it every step of the way."
The letter was one of at least three public missives that Brownback has sent Sebelius or President Obama about Medicaid or health reform since he took office in January.
One of the major goals of his administration is to cut between $200 million and $400 million from state Medicaid spending beginning in fiscal 2013, which begins July 1, 2012. As his letter made clear, it is unlikely that can be done without Medicaid rule waivers granted by the federal government.
"Unyielding budget constraints"
Kansas has among the most restrictive Medicaid eligibility standards in the nation and because of that - unlike Arizona or other states that are eliminating Medicaid services for thousands of their residents - it has little or no leeway to cut people off without violating the federal maintenance-of-effort requirements.
"Given the unyielding budget constraints we face, we have no choice but to make significant changes in Kansas’ Medicaid program," Brownback wrote Sebelius. "Yet an over-reaching federal MOE will lock Kansas into an out-of-date, oversized, and unaffordable program. Most concerning to me is that the huge increases render the MOE standard unachievable, threatening the loss of the Medicaid program for vulnerable Kansans who are already in the program."
It wasn't immediately clear Thursday whether Sebelius has legal authority to grant Brownback's request to waive the maintenance-of-effort requirements since they are written into the reform law.
"HHS is reviewing what authority the secretary has - if any – to waive the maintenance of effort under the current law," said Melissa Nitti, an agency spokesperson.
Sherriene Jones-Sontag, Brownback's chief spokesperson, said "We are asking the secretary to work with Kansas to identify an achievable interpretation of the MOE requirement using authority granted to her in section 1115 of the Social Security Act."
Not a formal request
In any event, Nitti said, Brownback's letter did not qualify as a formal waiver request. Waiver requests are routinely filed by states with HHS and there is a proscribed method for filing them.
According to the reform law, the maintenance‐of‐effort requirements apply to adults until the major components of health reform go into effect on Jan. 1, 2014, and to children until Sept. 30, 2019.
Until those dates, states also are barred from imposing new paperwork or other barriers that would make it harder for people to enroll in Medicaid or CHIP.
The intent of the requirements was to assure that people do not lose coverage before health reform is implemented, according to an analysis of the law's MOE provisions prepared by the Georgetown University Health Policy Institute.
"In the absence of such provisions, some states might have scaled back Medicaid or CHIP coverage in response to current fiscal problems or in anticipation of health reform, even as changes are being made to move the country forward in providing families with affordable coverage options," the analysis stated.
In addition to waiving the MOE requirements, the Brownback letter asked Sebelius to give Kansas its federal Medicaid dollars in the form of a block grant.
Other GOP governors also are asking for that at least publicly, notably Govs. Haley Barbour of Mississippi and Rick Scott of Florida.
That message first came loud and clear during the National Governor's Association meeting last month in Washington, D.C.
But Nitti said no state as of yet has formally requested a block-grant waiver, including Kansas.
Block grants would allow the governors to spend federal Medicaid money largely as they see fit. But they also would cap the federal aid, which means state's would need to cover costs that exceeded the block grant or make cuts. Currently, the federal government covers a fixed percentage of Kansas Medicaid costs regardless how much they go up.
Also on Thursday, two HHS officials held a press conference to announce a new set of proposed regulations that they said would allow states more flexibility to implement the health reform law. Currently, the law allows states beginning in 2017 to use their own approaches to meeting the law's goal of affordable, widespread health coverage.
The proposed rules, in keeping with a proposal now before Congress and endorsed by President Obama, would let states push that up to 2014 by applying for "innovation" waivers.
States would be eligible for the waivers, according to Steve Larsen of HHS, if they demonstrate they can meet these broad goals of the Affordable Care Act:
"States have good ideas," Larsen said. "We welcome suggestions for improving this process from all stakeholders."