Section 1115 Demonstration Waivers and Other Proposals to Change Medicaid Benefits, Financing and Cost-sharing: Ensuring Access and Affordability Must Be Paramount
Joint principles of the following organizations representing front-line physicians:
American Academy of Family Physicians
American Academy of Pediatrics
American College of Obstetricians and Gynecologists
American College of Physicians
American Osteopathic Association
American Psychiatric Association
CHICAGO – Dec. 8, 2017 –On behalf of the more than 560,000 physicians and medical students represented by the combined memberships of the above organizations, we have adopted the following principles for designing, evaluating, reviewing and approving proposals to change Medicaid benefits, financing and cost sharing through Section 1115 demonstration waivers or other legislative or regulatory policies. Our members are the frontline physicians who care for patients in rural, urban, wealthy and low-income communities, and are the foundation of the American health care system.
States have historically utilized waivers of federal Medicaid law to create or test innovative demonstration programs to expand care to new populations, offer new services, and deliver care in new and different settings. Waivers have been both broad, affecting large segments of the Medicaid program, and narrow, focused on specific populations or services.
Recently, states have contemplated Medicaid Section 1115 waivers that would have the effect of restricting or limiting access, conditioning the receipt of care on meeting standards outside of the objectives of the Medicaid program, and/or altering the underlying financing of care itself, shifting financial risk to enrollees.
Given the broad array of current and possible future state waiver proposals, our organizations adopt the following waiver principles, seeking to ensure that state waivers “first, do no harm” to current or future enrollees. Earlier this year, we issued joint recommendations on Priorities for Coverage, Benefits and Consumer Protections Changes. Consistent with those recommendations, we now offer the following principles to guide decisions by state and federal authorities on proposals to change Medicaid benefits, financing and cost sharing. The group of six frontline physician organizations affirms that state waivers must:
1. Maintain and/or strengthen affordability protections: CMS should ensure that waivers and other proposed changes to Medicaid do not create barriers to coverage and care by requiring enrollees to pay significantly higher premiums, deductibles, co-payments and other out-of-pocket costs for Medicaid enrollees compared to current federal and state requirements and/or by establishing time limits on eligibility. Studies show higher premiums and relatively small increases in cost-sharing creates barriers to coverage and access to care, especially for those with the lowest incomes:
2. Maintain/and or strengthen benefits: CMS should ensure that the full range of care, treatment, and services that would otherwise be provided is maintained and/or strengthened. CMS should ensure that waivers and other proposed changes to Medicaid do not reduce coverage of essential benefits, maternity care, substance use disorder treatment, mental health services, immunizations, and for children, services covered under the federal Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, which mandates basic preventive and therapeutic health services that are deemed medically appropriate and necessary for children.
3. Limiting Barriers to Eligibility and Coverage: CMS should ensure that waivers and other proposed changes to Medicaid do not impose punitive requirements that individuals be employed, be actively seeking a job, or be enrolled in a job training or job recruitment program and/or impose mandatory drug testing as a condition of eligibility.
4. Maintaining and/or strengthening access to any qualified provider: CMS should ensure that waivers and other proposed changes to Medicaid do not discriminate against otherwise qualified providers of women’s health services by denying state or federal funding to them.
5. Preserve and enhance existing funding mechanisms:
6. Sustain and strengthen waiver transparency, stakeholder engagement, and evaluation: CMS should ensure states and the federal government include stakeholders in waiver development, follow required comment periods at both the state and federal level, and properly evaluate waiver impact on enrollees, families, and providers.
1 Artiga, S., Ubri, P., & Zur, J. (2017) The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings. The Henry Kaiser Foundation
2 Artiga, Ubri, and Zure. The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings, Kaiser Family Foundation, June 1, 2017. Accessed 7th of September 2017 at
3 Frost JJ et al., Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program, Milbank Quarterly, 92(4):696–749
4 Garfield, R., Rudowitz, R., & Damico, A. (2017) Understanding the Intersection of Medicaid and Work. The Henry J. Kaiser Family Foundation, February 2017. Accessed Dec. 7, 2017 at http://files.kff.org/attachment/Issue-Brief-Understanding-the-Intersection-of-Medicaid-and-Work
5 Hall, Randi. Drug Testing and Public Assistance. Center for Law and Social Policy. Updated October 2016. https://www.clasp.org/sites/default/files/public/resources-and-publications/publication-1/2016.02.04-Drug-Testing-and-Public-Assistance-Brief-FINAL.pdf
6 Lawrence, H. C. and Ness, D. L. (2017). Planned Parenthood provides essential services that improve women’s health. Ann Intern Med.
7 Texas Health and Human Services. HHS Women’s Health Update, May 15, 2017, Slide 13. Available at https://hhs.texas.gov/sites/default/files//documents/about-hhs/leadership/ advisory-committees/whac/zika-may-15-2017/whac-women-health-updatemay-15-2017.pdf. Last retrieved Aug. 15, 2017. (the number of clients accessing health care for FY 2016 equals the unduplicated client counts for women enrolled and clients served in FY 2016 through the Texas Women’s Health Program (54,756 women) and Health Texas Women (15,580 women). The unduplicated client count for both programs and the total number served in FY 2016 was 94,851 women.).
8 Texas Health and Human Services Commission. (2017). Final report of the former Texas Women’s Health Program: Fiscal Year 2015 Savings and Performance.