Verma’s support for nontraditional approaches to Medicaid coverage dominated the hearing. 

Feb. 16—Repeatedly pressed on Republican plans to repeal and replace the healthcare reform law’s Medicaid expansion, President Donald Trump's nominee to lead the Centers for Medicare & Medicaid Services (CMS) emphasized access over coverage.

The focus on Medicaid during the Senate Finance Committee’s confirmation hearing Thursday for Seema Verma came as Republican legislators are considering proposals to shift the program from an open entitlement to a block grant with per capita caps, according to policy advisers involved in the process.

“I am endorsing the program being changed to make it work better for the citizens that rely on it,” Verma said. “What I support is the program working better, and whether that is a block grant or per capita cap there are many ways we can get there.”

Critics of such changes worry they could reduce federal funding and force states to reduce benefits or enrollment. The Affordable Care Act’s (ACA’s) Medicaid eligibility expansion was adopted by 31 states and has been credited with adding 16.4 million enrollees—including millions who were previously eligible—since the expansion started in October 2013, according to a recent report from CMS. 

“If we were to go to a program that would be innovative but we don’t have the resources, then vulnerable people are going to get hurt,” Sen. Ben Cardin (D-Md.) said.

But Verma questioned the appropriateness of a focus on enrollment totals.

“Coverage doesn’t necessarily translate to access to care,” Verma said.

She noted that one out of three physicians do not accept Medicaid patients and that many enrollees face lengthy waits to access care—especially from specialists.

Verma highlighted results from the Healthy Indiana Program (HIP) 2.0, which she helped design, including its ability to reduce emergency department visits, improve medication adherence, and increase primary care visits among those who opted to contribute to health savings accounts (HSAs). And those HSA users were the sickest enrollees in the Medicaid program, she said.

“Just because they don’t have income doesn’t mean they are not capable—that they don’t want to have choices,” Verma said.

That initiative drew some bipartisan praise and criticism. Sen. Joe Donnelly (D-Ind.) described HIP 2.0 as a “common-sense Hoosier approach,” while Sen. Ron Wyden (D-Ore.) worried that 2,500 beneficiaries were reportedly “bumped from coverage” because they did not make required contributions.

Verma cautioned that she doesn’t think the exact approach of HIP 2.0 will work in other states.

“I will usher in a new era of state flexibility to improve outcomes,” Verma said.

But that flexibility is expected to be accompanied by greater accountability on the part of states—similar to the accountability that states demand from the growing number of Medicaid managed care insurers they use.

Verma is expected to use her authority under the ACA to approve waivers for more state Medicaid experiments

The waiver process is “very intractable; states have to do reams of paperwork to get approval from the federal government,” Verma said.

Verma said she will continue to utilize the Center for Consumer Information and Insurance Oversight (CCIIO), which was created by the ACA to oversee the rules of the ACA marketplaces. Republicans have urged its elimination on the basis that it acts as a national insurance commissioner, and usurps the roles of state insurance commissioners.

“My assessment of the role of CCIIO will depend on how Congress decides what to do with the [ACA],” Verma said.

Diverging from the Obama administration’s use of CMMI may involve moving away from mandatory models, which CMS has emphasized over the last year.

“We need to make sure we are not forcing, not mandating, individuals to participate in an experiment or some type of trial that there is not consent around,” Verma said. “Before the evaluation goes full scale, it should be done on a small population, or small frame.”

Before any pilots are expanded, Verma said, results should be shared with stakeholders and members of Congress.

“And there should be discussion of that before that becomes government policy,” Verma said.

Medicare Issues

Democrats blasted Republican proposals to eventually introduce a voucher approach to Medicare.

“I don’t support that,” Verma said, referring to a voucher program.

One major departure from the Obama administration may be Verma’s willingness to incentivize Medicare enrollees to improve care outcomes.

“When we think about outcomes and holding providers accountable for outcomes, a lot of that also depends on patients,” Verma said. “How can we engage patients to be part of that equation so that they have the same investment, they have some investment, to work with their providers toward achieving outcomes?”

Verma declined to endorse negotiating prices with drug manufacturers under the Part D program.

As part of  CMS’s antifraud efforts, Verma committed to working with the Justice Department to identify drug makers that misclassify their drugs as generics. She also plans to review CMS’s drug classification processes to ensure brand-name drugs are not again misclassified as generics—as happened with Mylan’s EpiPen treatment.

Provider Impacts

The ongoing backlog in hospital appeals of denied Medicare claims drew concerns from Verma.

“It’s a balance we have to strike in being aggressive with fraud and abuse and focusing our penalty efforts on the bad players without penalizing providers that are trying to do the right thing,” Verma said.

Verma said she was deeply concerned about the administrative burden placed on physicians and hospitals—especially small providers and those in rural areas. One of her stated goals was ensuring that CMS rules and regulations don’t hamper physicians’ efforts to serve beneficiaries.

“We have to be very careful with our rural providers to be sure we are not putting additional burdens on them,” Verma said.

Getting smaller and rural providers to take on financial risks “will be a formidable challenge,” Verma said.

“There’s also holding providers accountable for outcomes, and it’s another thing altogether to have them accepting risk,” Verma said.

She supports the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as “an important step forward” but wanted better engagement with stakeholders “on the front end and all of the way through the process.” Regulations implementing MACRA are expected to continue being generated for years.

ACA Marketplaces

Verma said she was not familiar with the details of the marketplace stabilization proposed rule issued by the Trump administration this week, so she could not comment on it. But she said changes are needed to ensure better options and access to care through plans sold in the marketplaces.

The Uber driver who took her to  the hearing said he had ACA marketplace coverage but could not afford to use it because it had a $6,000 deductible.

“That’s a great story where coverage doesn’t necessarily translate to access,” Verma said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare


Publication Date: Thursday, February 16, 2017