Attending to Medicaid

Party Game Central, Crack the Whip, at <http://www.partygamecentral.com/pgcstandard/gametmpstd.asp?gn=CRACK+THE+WHIP> (last visited June 23, 2004).

“Sharp turns and quick double-backs” is a fair description of the past 20 years of health policy.

See especially, Schneider A. , The Medicaid Resource Book, Kaiser Commission on Medicaid and the Uninsured Website [hereinafter, “The Yellow Book”] available at <http://www.kff.org/medicaid/2236-index.cfm> (last visited July 1, 2004).

Congressional Budget Office, Baseline for Medicaid and the State Children's Health Insurance Program and Medicare, March 2004. Total spending for Medicaid is computed off the baseline (which reports federal spending only) by assuming that federal spending represents fifty-seven percent of total Medicaid spending.

Levit K. , “Health Spending Rebound Continues in 2002,” Health Affairs 23, no. 1 (2004): 347–159.

Key Facts: Health Coverage for Low-Income Children (May 2002), Kaiser Commission on Medicaid and the Uninsured Website, at <http://www.kff.org/uninsured/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14044> (last visited July 1, 2004).

Crowley J. and Elias R. , Medicaid's Role for People with Disabilities (August 2003), Kaiser Commission on Medicaid and the Uninsured Website, at <http://www.kff.org/medicaid/4027.cfm> (last visited July 1, 2004); Meyer J. and Zeller P. , Profiles of Disability: Employment and Health Coverage (September 1999), Kaiser Commission on Medicaid and the Uninsured Website, at <http://www.kff.org/medicaid/2151-index.cfm> (last visited July 1, 2004).

Issue Paper: Dual Eligibles: Medicaid's Role in Filling Medicare's Gaps (March 2004), Kaiser Commission on Medicaid and the Uninsured Website, at <http://www.kff.org/medicaid/7058.cfm> (last visited July 1, 2004).

Health Insurance is a Family Matter (September 2002), Institute of Medicine of the National Academies, at <http://www.iom.edu/report.asp?id=4356> (last visited July 1, 2004).

Stone J. and Yacker H. , Prescription Drug Coverage for Medicare Beneficiaries (Washington, D.C.: Congressional Research Service, 2002).

Long Term Care: Aging Baby Boom Generation Will Increase Demand and Burden on Federal and State Budgets, 108th Cong., Senate Special Committee on Aging, March 21, 2002 (statement of David Walker, Comptroller General of the United States), at <http://www.gao.gov/new.items/d02544t.pdf> (last visited July 1, 2004).

America's Health Care Safety Net: Intact but Endangered, Institute of Medicine Website, at [hereinafter America's Safety Net] <http://www.iom.edu/Object.File/Master/4/118/0.pdf> (last visited June 23, 2004).

Cordero K. , “Medicaid Cuts Endanger Health Care for All Children,” Children's Hospitals Today (Spring 2003), National Association of Children's Hospitals and Related Institutions (NACHRI) & National Association of Children's Hospitals (N.A.C.H.) Website, at <http://www.childrenshospitals.net/Content/ContentGroups/Publications/Childrens_Hospitals_Today/Articles/200311/Medicaid_Cuts_Endanger_Health_Care_for_All_Children.htm> (last visited July 1, 2004); see also, Kelly C. , “Introduction to Medicaid Mission Impossible?” Children's Hospitals Today (Spring 2002), at National Association of Children's Hospitals and Related Institutions (NACHRI) & National Association of Children's Hospitals (N.A.C.H.) Website, at <http://www.childrenshospitals.net/Content/ContentGroups/Publications/Childrens_Hospitals_Today/Articles/200211/Introduction_to_Medicaid_Mission_Impossible_htm> (last visited July 1, 2004).

America's Safety Net, supra note 13.

See, e.g., Martinez R. and Closter E. , Public Health Departments Adapt to Medicaid Managed Care, Issue Brief 16 (November 1998), Center for Studying Health System Change Website, available at <http://www.hschange.com/CONTENT/65/?topic=topic01#care> (last visited July 1, 2004).

See Weil A. , “There's Something About Medicaid,” Health Affairs 22, no. 1 (2003): 13–30.

See Mills R.J. and Bhandari S. , Health Insurance Coverage in the United States: 2002 (Washington, D.C.: U.S. Census Bureau, 2003); Medicaid Matters: Hearing from Families, produced by Kaiser Commission on Medicaid and the Uninsured, 9 min. (2003), at <http://www.kff.org/medicaid/mm-index.cfm> (last visited July 1, 2004).

Bauer T. and Fuld J. , “Remove Barriers and Eligible New Yorkers Will Enroll: Lessons From DRM,” New York Forum for Child Health: Forum Update #7 (New York: The New York Academy of Medicine, 2002).

There is no single provision in federal law that concisely sets forth the entitlement to coverage. Judicial interpretations of the federal Medicaid law have generally grounded the entitlement in section 1902(a) (8), Title XIX of the Social Security Act, 42 USC.1396(a)(8).

Health Insurance Coverage in the United States: 2002, supra note 18.

By contrast, smaller public coverage programs (for example, separate, non-Medicaid, SCHIP programs) and other public programs that help pay for medical services (such as the Ryan White program, the Maternal and Child Health block grant program, and various pharmacy benefit programs) do not extend a legal entitlement to coverage. Smith B. and Rosenbaum S. , State SCHIP Design and the Right to Coverage, Center for Health Services Research (Washington, D.C.: George Washington University, 2001). As a result, the number of people provided services under these programs can be capped, waiting lists can be formed, and enrollment can be closed for budget or other reasons.

Dale S. and Verdier J. , “Issue Brief: Elimination of Medicare's Waiting Period for Seriously Disabled Adults,” Commonwealth Fund 660 (2003), available at <http://www.cmwf.org/programs/medfutur/dale_waitingperiod_ib_660.pdf> (last visited July 1, 2004).

Holahan J. , Variations Among States in Health Insurance Coverage and Medical Expenditures: How Much is Too Much (June 2002), Urban Institute, at <http://www.urban.org/url.cfm?ID=310520> (last visited July 1, 2004) [Low-income is defined as having income below 200 percent of the federal poverty line].

Authors' analysis of MSIS 2001 data submitted by states to the Centers for Medicare and Medicaid Services. Data do not include Washington or Hawaii, neither of which have submitted data to CMS as of April 19, 2004.

Social Security Amendments of 1965, Pub. L. 89–97, 79 Stat. 286 (July 30, 1965) (codified as amended in scattered sections of 42 U.S.C.)

Deficit Reduction Act of 1984, Pub. L. 98–369, 98 Stat. 494 (July 18, 1984) (codified as amended in scattered sections of 42 U.S.C.)

Omnibus Budget Reconciliation Act of 1986, Pub. L. 99–509, 100 Stat. 1874 (Oct. 21, 1986), 42 U.S.C. § 1396a (2004) [hereinafter OBRA 1986).

Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, 102 Stat. 683 (July 1, 1988), 42 U.S.C. § 1396a (2004) [hereinafter MCCA 1988].

OBRA 1986, supra note 28, 42 U.S.C. § 1396a, 1396d.

MCCA 1988, supra note 29, 42 U.S.C. § 1396d(p).

Omnibus Budget Reconciliation Act of 1989, Pub. L. 101–239, 103 Stat. 2106 (Dec. 19, 1989), 42 U.S.C. § 1395 et. seq. (2004) [hereinafter OBRA 1989].

Omnibus Budget Reconciliation Act of 1990, Pub. L. 101–508, 104 Stat. 1388 (Nov. 5, 1990), 42 U.S.C. § 1396a (2004).

Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. 104–193, 110 Stat. 2105, Aug. 22, 1996), 42 U.S.C. § 602 (2004).

Balanced Budget Act of 1997, Pub. L. 105–33, 111 Stat. 251 (Aug. 5, 1997), 42 U.S.C. § 1397aa (2004) [hereinafter BBA 1997].

Ticket to Work and Work Incentives Improvement Act of 1999, Pub. L. 106–170, 113 Stat. 1860, (Dec. 17, 1999), 42 U.S.C. § 1396o.

S. Rep. No. 265, 107th Cong., (2002), at <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_cong_reports&docid=f:sr265.107.pdf> (last visited July 1, 2004).

Omnibus Budget Reconciliation Act of 1981, Pub. L. 97–35, 92 Stat. 357 (Aug. 13, 1981), 42 U.S.C. § 1396uu (2004).

OBRA 1989, supra note 32, at 42 U.S.C. § 1396a (2004).

Omnibus Budget Reconciliation Act of 1993, Pub. L. 103–66, 107 Stat. 312, (Aug. 10, 1993), 42 U.S.C. § 1396a(a)(10)(A)(ii) (2004) [hereinafter OBRA 1993].

Id., at 42 U.S.C. § 1396v.

Breast and Cervical Cancer Treatment and Prevention Act of 2000, Pub. L. 106–354, 113 Stat. 1381 (Oct. 24, 2000), 42 U.S.C. § 1396r-1b.

For example, federal program data show that there were 13 million beneficiaries in 1968; program data for 2001 show enrollment above 47 million. The Congressional Budget Office projects that enrollment will reach 52.4 million in 2004. Health Care Financing Administration (HCFA) data for 1968 provided by the Kaiser Commission on Medicaid and the Uninsured; 2001 data from Georgetown University Health Policy Institute's analysis of the 2001 Medicaid Statistical Information System (MSIS) data; 2004 data from Congressional Budget Office's March 2004 Medicaid Baseline.

Crowley and Elias , supra note 8.

See, e.g. Key Facts: Children's Health — Why Health Insurance Matters (May 2002), Kaiser Commission on Medicaid and the Uninsured Website, at <http://www.kff.org/uninsured/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14132> (last visited July 1, 2004); see generally, Consequences of Uninsurance, Institute of Medicine Website, at <http://www.iom.edu/project.asp?id=4660> (last visited June 23, 2004).

This is based on the “regular” matching rates in effect in fiscal year 2004. Enhanced rates, which ended as of June 30, 2004, lowered state contributions to twenty to forty-seven percent. The federal matching rate varies by state, with poorer states having a lower state spending requirement. See, Federal Medical Assistance Percentages, United States Department of Health and Human Service Website, at <http://aspe.os.dhhs.gov/health/fmap.htm> (last visited June 23, 2004).

National Association of State Budget Officers (NASBO), 2002 State Expenditure Report (Washington, D.C.: NASBO, 2003).

Cohen-Ross D. and Cox L. , “Making It Simple: Medicaid for Children and CHIP Income Eligibility Guidelines and Enrollment Procedures,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2000); General Accounting Office (GAO), Medicare Savings Programs: Results of Social Security Administration's 2002 Outreach to Low-Income Beneficiaries, GAO-04-363, March 26, 2004; Perry M. Kannel S. Valdez R. and Chang C. , “Medicaid and Children: Overcoming Barriers to Enrollment,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2000); GAO, Medicaid and SCHIP: Comparisons of Outreach, Enrollment Practices, and Benefits, GAO/HEHS-00-86, April 2000; Smith V. Ellis E. and Chang C. , “Eliminating the Medicaid Asset Test for Families: A Review of State Experiences,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2001); GAO, Medicaid: Demographics of Nonenrolled Children Suggest State Outreach Strategies, GAO/HEHS-98-93, March 1998; Cunningham P. , “Targeting Communities With High Rates of Uninsured Children,” Health Affairs Web Exclusive (July 25, 2001), at <http://content.healthaffairs.org/cgi/content/full/hlthaff.w1.20v1/DC1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Targeting+Communities&andorexactfulltext=and&searchid=1088433853632_786&stored_search=&FIRSTINDEX=0&resource-type=1&journalcode=healthaff> (last visited July 1, 2004); Kenney G. Haley J. and Dubay L. , “How Familiar Are Low-Income Parents with Medicaid and SCHIP?” New Federalism Series B. No.B-34 (Washington, D.C.: Urban Institute, 2001); Summer L. Parrot S. and Mann C. , Millions of Uninsured and Underinsured Children are Eligible for Medicaid (Washington, D.C.: Center on Budget and Policy Priorities, 1997).

Dunkelberg A. , “Simplified Eligibility for Children's Medicaid in Texas: A Status Report at Nine Months,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003); Mann C. , “Reaching Uninsured Children Through Medicaid: If You Build it Right, They Will Come,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2002).

Smith V. , “States Respond to Fiscal Pressure: A 50-State Update of State Medicaid Spending Growth and Cost Containment Actions,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2004); National Conference of State Legislators (NCSL), State Medicaid Actions: A Two-Year Review of State Actions as a Result of the States' Fiscal Crisis (Washington, D.C.: NCSL 2003); Ku L. and Nimalendran S. , Losing Out: States are Cutting 1.2 to 1.6 Million Low-Income People from Medicaid, SCHIP and Other State Health Insurance Programs, (Washington, D.C.: Center on Budget and Policy Priorities, 2003).

Hadley J. and Holahan J. , “Is Health Care Spending Higher Under Medicaid or Private Insurance?” Inquiry 40, no. 4 (2003/2004): 323–342.

See Challenges Facing the Medicaid Program in the 21st Century: Hearing Before the Subcommittee on Health of the House Committee on Energy and Commerce, 108th Cong., October 8, 2003 (statement by Diane Rowland, Executive Director of the Kaiser Commission on Medicaid and the Uninsured).

GAO, Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect Children's Access to Care, GAO-01-883, September 2001; The problem has been particularly severe with respect to dental services, prompting the agency that oversees the Medicaid at the federal level (the Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration) to issue a directive to states to take steps to examine whether low provider rates might be affecting children's ability to obtain Medicaid-financed dental services; see Letter from T. Westmoreland, Director, to State Medicaid Directors (January 18, 2001), at <http://www.cms.hhs.gov/states/letters/smd118a1.pdf> (last visited July 1, 2004).

As discussed above, originally, Medicaid eligibility was linked to welfare eligibility and childless adults did not fit under either of the two major welfare programs — the Aid to Families with Dependent Children program and the Aid to Aged, Blind and Disabled program (the precursor to the federal Supplemental Security Income, or SSI, program). Under the law, states can cover adults who are pregnant, living with a child, elderly or disabled.

This imbalance is mirrored at the Federal level in the consideration of legislation to require States to offer home- and community-based care. The Medicaid Community-based Attendant Services and Support Act (Mi-CASSA) has been introduced and re-introduced in the Congress for many years, but its consideration has been haunted by cost-estimates that are predicated on an assumption that more people would use such care than use institutional services. See Glazier R. , “The Re-invention of Personal Assistance Services,” Disability Studies Quarterly 21, no. 2 (2001), available at <http://63.240.118.142/_articles_html/2001/Spring/dsq_2001_Spring_12.html> (last visited July 1, 2004).

Based on data analyzed by Holahan J. and Bruen B. , “Policy Brief, Medicaid Mandatory and Optional Eligibility and Benefits,” The Urban Institute and the Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2001).

For example, in 1997, federal law was amended to provide states more authority to set rates for institutional providers (nursing homes and hospitals) and to require Medicaid beneficiaries, under certain conditions, to enroll in managed care. In that same year, states were allowed new options to presumptively enroll children in Medicaid and to keep children enrolled for up to twelve months regardless of changes in financial circumstances; See Yellowbook , supra note 3.

Since August 2002, the Bush Administration has released three major waiver initiatives: the Health Insurance Flexibility and Accountability (HIFA) initiative, see, Centers for Medicaid and Medicare Services Website, at <http://www.cms.hhs.gov/hifa/> (last visited June 24, 2004); Pharmacy Plus, at <http://www.cms.hhs.gov/medicaid/1115/pharmacyplus.asp> (last visited June 24, 2004); and Independent Plus, at <http://www.cms.hhs.gov/independenceplus/> (last visited June 24, 2004). Each encourages states to submit section 1115 demonstration waiver requests that meet the guidelines set forth in these initiatives. The Administration has consistently cited waivers as a key policy tool to provide states greater programmatic flexibility; See, U.S. Department of Health and Human Services, News Releases, Statement By Tommy G. Thompson, Secretary of Health And Human Services Regarding “Insuring America's Health” Report (January 14, 2004), at <http://www.hhs.gov/news/press/2004pres/20040114.html> and HHS Secretary Urges Congress To Approve Uninsured Package (September 30, 2003), at <http://www.hhs.gov/news/press/2003pres/20030930b.html> (last visited July 1, 2004).

Rousseau D. and Schneider A. , “Current Issues in Medicaid Financing- An Overview of IGTs, UPLs, and DSH,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2004); GAO, Medicaid: Improved Federal Oversight of State Financing Schemes is Needed, GAO-04-228, February 2004; Coughlin T. , “States' Use of Medicaid UPL and DSH Financing Mechanisms,” Health Affairs 23, no. 2 (2004): XX–XX; GAO, Major Management Challenges and Program Risks: Department of Health and Human Services, GAO-03-101, January, 2003; GAO, Medicaid: States Use Illusory Approaches to Shift Program Costs to Federal Government, GAO/HEHS-94-133, August 1, 1994.

See Medicaid: Intergovernmental Transfers Have Facilitated State Financing Schemes: Testimony before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives , 108th Cong. Committee on Energy and Commerce, March 18, 2004 (statement by Kathryn G. Allen, Director, Healthcare, General Accounting Office): 10; GAO, Medicaid: Improved Federal Oversight of State Financing Schemes Is Needed, GAO-04-228, February 13, 2004; GAO, Medicaid: HCFA Reversed Its Position and Approved Additional State Financing Schemes, GAO-02-147, October 30, 2001.

Smith V. , supra note 51; NCSL, supra note 51; Ku and Nimalendran , supra note 51.

Gill S. Guyer J. Mann C. , “Section 1115 Medicaid and SCHIP Waivers: Policy Implications of Recent Activities,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2000); For state-specific waiver fact sheets, see <http://www.kff.org/medicaid/waivers-index.cfm> (last visited June 24, 2004).

See discussion of waivers and waiver initiatives, supra note 59.

Budget of the United States Government, Fiscal Year 2005: Department of Health and Human Services, Office of Management and Budget (OMB) Website, Executive Office of the President Website, at <http://www.whitehouse.gov/omb/budget/fy2005/hhs.html> (last visited June 24, 2004).

See Inter-governmental Transfers: Violations of the Federal-State Medicaid Partnership or Legitimate State Budget Tool? Hearing Before the Subcommittee on Health of the House Committee on Energy and Commerce,” 108th Cong., April 1, 2004 (statement by Dennis Smith, Director, CMS, Center for Medicaid and State Operations).

Title IV, Jobs and Growth Tax Relief Reconciliation Act of 2003. Pub. L. 108–27.

Smith V. , supra note 51.

Boyd T. and Wachino V. , “Is the State Fiscal Crisis Over? A 2004 State Budget Update,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2004).

For example, Oregon, has adopted a series of very deep reductions in coverage; it eliminated the portion of its program that covered people impoverished by their medical expenses and instituted new premium policies for poor adults that have caused about half of those adults to drop out of the program, See Oregon Health Research & Evaluation Collaborative Website, at <http://www.ohpr.state.or.us/OHREC%20welcome2.htm> (last visited June 24, 2004). Several states, including Florida and California, are considering major waiver initiatives that could affect the entitlement, benefits, cost-sharing and financing for everyone covered under their Medicaid programs. Ulferts A. “Bush Strives to Rein in Medicaid,” St. Petersburg Times, February 22, 2004; Ulferts A. , “Medicaid Records Hard to Come By,” St. Petersburg Times, March 31, 2004; For California, see Medi-Cal Redesign Website, at <http://www.medi-calredesign.org/overview.aspx> (last visited June 24, 2004).

All of the presidential candidates who had a broad-based health care reform proposal included a substantial role for Medicaid (or a program with similar elements), with some anticipating a considerably expanded role as compared to today, see, “Side-by-Side Summary of Presidential Candidates' Proposals for Expanding Health Insurance Coverage,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003); Collins S.R. Davis K. , and Lambrew J. , “Health Care Reform Returns to the National Agenda: The 2004 Presidential Candidates' Proposals,” Commonwealth Fund 671 (2004): 7–10.

Collins S.R. , On the Edge: Low-Wage Workers and Their Health Insurance Coverage, Commonwealth Fund 626 (2003); This study found that fifty-three percent of workers making less than ten dollars an hour were eligible for their employer's health plan, as compared to eighty-seven percent of workers making more than fifteen dollars an hour.

Tax credits have been advanced as one possible way to help low-income people afford private coverage, and refundable tax credits have been proposed as a way to extend this subsidy to the millions of Americans whose incomes are too low to owe income tax (or to owe an amount of tax that would exceed the potential subsidy amount). A number of structural issues would have to be resolved for a refundable tax credit system to work well as a way to finance health insurance for low-income people; see Blumberg L. , Health Insurance Tax Credits: Potential for Expanding Coverage (Washington, D.C.: The Urban Institute, 2001). To date, the refundable tax credit created under the recent Trade Act has had limited take up, in part due these structural problems; as of the end of 2003, only about 3.6 percent of the workers who were potentially eligible had enrolled in the advance credit. Dorn S. and Kutyla T. , “Issue Brief: Health Coverage Tax Credits Under the Trade Act of 2002,” Commonwealth Fund 721 (2004): 3; see also, Pear R. , “Sluggish Start for Offer of Tax Credit for Insurance,” New York Times, January 25, 2004.

Hadley J. and Holahan J. , supra note 52.

Congressional Budget Office (CBO), March 2004 Medicaid Baseline (Washington, D.C., United States Government Printing Office, 2004); Center for Medicare and Medicaid Services (CMS), National Health Care Expenditures Projections: 2003–2013 (Washington, D.C.: CMS, 2004).

“If God did not exist, it would be necessary to invent him,” Epitre a l'Auter du Livre des Trois Imposteurs, November 10, 1770, quoted in Bartlett J. , Bartlett's Familiar Quotations 15th ed. (Boston: Little, Brown, 1980): 344.

Some new tools could help states contain Medicaid costs without compromising the quality of care; for example, disclosure to state Medicaid agencies of drug pricing that would allow states to improve their ability to set drug prices. Some changes would need to occur within the Medicaid program while other measures go beyond Medicaid and would help Medicaid as well as other payers contain costs.

Ku L. , The Medicaid-Medicare Link: State Medicaid Programs Are Shouldering a Greater Share of the Costs of Care for Seniors and People with Disabilities, (Washington, D.C.: Center on Budget and Policy Priorities, 2003).

Bruen B. and Holahan J. , “Shifting the Cost of Dual Eligibles: Implications for States and the Federal Government,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003).

Federal minimum income eligibility standards for parents vary by state; for parents with no earned income, they range from thirteen percent of the federal poverty line in Alabama to sixty-seven percent of the federal poverty line in Connecticut (based on the 2004 Federal poverty line). Authors' calculations based on data on July 1996 eligibility levels from U.S. House of Representatives, Committee on Ways and Means, 104th Cong., Background Material And Data On Programs Within The Jurisdiction Of The Committee On Ways And Means (Green Book), Table 8–12: 437.

“Churning” refers to loss of coverage, often due to administrative requirements, followed by re-enrollment in the program. This not only disrupts coverage and care, but also results in added costs. Fairbrother G. Park H.L. and Haidery A. , Policies and Practices That Lead to Short Tenures in Medicaid Managed Care, Draft, (Princeton, NJ: Center for Health Care Strategies, 2003); Short P.F. Graefe D.R. , and Schoen C. , “Churn, Churn, Churn: How Instability of Health Insurance Shapes America's Uninsured Problem,” Commonwealth Fund 688 (2003): 9–10.

States should, of course, be permitted to adopt procedures that assure program integrity. States have generally found that streamlined processes do not interfere with states' ability to take a variety of measures (including data matches, using information from other state programs, and random audits) to assure that people who are enrolled are eligible for the program. Cohen-Ross D. and Cox L. , “Preserving Recent Progress in Health Coverage for Children and Families: New Tensions Emerge,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003).

Research has repeatedly shown that premiums and cost sharing, if set too high, will deter low-income people from enrolling in coverage and accessing necessary care; See, Hudman J. and O'Malley M. , “Health Insurance Premiums and Cost-Sharing: Findings from the Research on Low-Income Populations,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003); Ku L. , Charging the Poor More for Health Care: Cost-Sharing in Medicaid, (Washington, D.C.: Center on Budget and Policy Priorities, 2003); Tamblyn R. , “Adverse Events Associated with Prescription Drug Cost-Sharing among Poor and Elderly Persons,” Journal of the American Medical Association 285, no. 4 (2001): 421–429; HRSA State Planning Grant Consultant Team, Income Adequacy and Affordability of Health Insurance in Washington State (University of Washington Health Policy Analysis Program, Rutgers University Center for State Health Policy, RAND, William M. Mercer, Inc., The Foundation for Health Care Quality, 2002). The recent experience in Oregon where more than half of the poor adults who were subject to premiums dropped out of the program shows that even relatively modest premiums (in this case, premiums ranged from six dollars to twenty a month) can be too high for poor people; McConnell J. and Wallace N. , Impact of Premium Changes in the Oregon Health Plan (February 2004), Oregon Health Research & Evaluation Collaborative, at <http://www.ohpr.state.or.us/OHREC%20welcome2_files/Reports%20and%20Briefs/Impacts%20of%20Premiums%20-%20FINAL.pdf> (last visited July 1, 2004).

For the list of HHS waiver initiatives, see supra note 59. For a description of the new Health Insurance Flexibility and Accountability waiver initiative and some of the implications of the new waivers, see Mann C. , “The New Medicaid and SCHIP Waiver Initiatives,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2002); Mann C. Artiga S. and Guyer J. , “Assessing the Role of Waivers in Providing New Coverage,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003); Artiga S. Guyer J. and Mann C. , supra note 63; and other waiver reports and fact sheets prepared by and for the Kaiser Commission on Medicaid and the Uninsured, at <http://www.kff.org/medicaid/waivers.cfm> (last visited June 24, 2004).

Guyer J. , “The Financing of Pharmacy Plus Waivers: Implications for Seniors on Medicaid of Global Funding Caps,” Kaiser Commission on Medicaid and the Uninsured (Washington, D.C.: Kaiser Family Foundation, 2003).

Recently the far-reaching nature of waiver activity has attracted critical attention from the Congress as well. See, Letter from Senators Charles Grassley and Max Baucus to CMS Director Mark McClellan, June 16, 2004.