CQC to Govs: Consider Patients Before Applying Bad Insurance Practices to Medicaid

Dear Governor:

As you recently gathered in Rhode Island for the summer meeting of the National Governors Association, most of the country’s political attention was focused on the debate in Washington, D.C. over the fate of the Affordable Care Act. Less noticed, but also critically important, is the fact that each of you holds in your hands today the ability to radically reshape Medicaid for your state’s most vulnerable citizens regardless of the outcome of that debate.

This power is significant considering the 69 million Medicaid enrollees living across your states.

We are health care advocates who have come together to speak up for patients and health care consumers. We view it as our purpose to ensure that patients are the first and most important stakeholder in any health care policy decision, whether that decision is made by a legislator, health insurance commissioner, insurance company CEO, president, or governor. And that is why we’re writing to you.

Recently, you received a letter from Tom Price, Secretary of the U.S. Department of Health and Human Services, and Seema Verma, Administrator of the Centers for Medicare and Medicaid Services. In that letter, the authors encouraged you to seek to “align Medicaid and Private Insurance Policies for Non-Disabled Adults.” While aligning state Medicaid policies with those of private insurance carriers is a policy goal that has merit, it also demands careful consideration.

Patients and policymakers alike can agree that Medicaid can look to private insurance for efficiencies in the system and ways of promoting well-coordinated care. We applaud those efforts, but caution that some efficiencies have come at the expense of patients. This year alone, we’ve seen too many private insurers take steps that may save them money, but leave patients with unreasonable – and in some cases, dangerous – burdens. For example:

• Emergency coverage: Just this month, one insurer implemented a policy in which they can decide after the fact that they will not cover a patient’s visit to an emergency department, even when such emergency coverage is in the consumer’s policy. As of July 1 of this year, consumers in four states – Georgia, Missouri, New York, and Kentucky – were placed in the untenable position of having to assess whether their condition would later be determined sufficiently dangerous to warrant emergency coverage. Doctors should be assessing emergency situations, not patients.

• High Deductibles: Studies show that low-income individuals and families with high-deductible plans often delay or forgo necessary doctor visits and emergency care because they just can’t afford it. Vulnerable Medicaid beneficiaries should not be effectively locked out of using their health care coverage because of excessive out-of-pocket costs.

• Denials of life-saving care: Cases of insurance companies taking on the role of doctor and denying patients life-saving medicines that have been ordered by physicians is also becoming all too common. The Wall Street Journal recently detailed several cases in which patients were forced to go through countless hours of paperwork and appeals just to get vital cholesterol medication approved by their insurance carriers. As one cardiologist put it, “At the end of the day, you would like to do what is best for the patient. But you really don’t have the time to play the insurance games.”

Medicaid may have things it can learn and adopt from the insurance industry, but practices like these aren’t among them.

Your constituents are counting on you to defend their needs and we know that you – our nation’s governors – are committed to ensuring they have quality health care. As such, we implore you to keep Medicaid beneficiaries top of mind as you consider requesting waivers from federal Medicaid standards. We also strongly encourage you to adopt the following principles for assessing the scope and breadth of any waiver request:

• High-quality, comprehensive health care should be available and affordable to all Americans;

• Insurance design should be improved to better meet the needs of consumers; and

• The health care delivery system should be modernized to put the patient at the center.

With these as your priorities in designing your waivers, we believe Medicaid beneficiaries in your state will get the better-quality care we all know they deserve.

Consumers for Quality Care Board of Directors
Donna Christensen, M.D.
Jim Manley
Scott Mulhauser
Jason Resendez