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Analysis

Dems Slam Medicaid Overhaul in FY 2020 HHS Budget Proposal

By MedPage Today  
   March 14, 2019

Democrats rip the Trump administration for 'taking a hatchet to every part of the healthcare system,' undermining the ACA, slashing spending for Medicare, and pushing work requirements on Medicaid.

This article was first published on Wednesday, March 13 in MedPage Today.

By Shannon Firth, Washington Correspondent, MedPage Today

WASHINGTON -- Health and Human Services Secretary Alex Azar fielded sharp criticism from Democrats over the Trump administration's fiscal year 2020 budget proposal during a House Energy & Commerce Health Subcommittee hearing this week.

"The Trump administration has taken a hatchet to every part of the healthcare system, undermining the Affordable Care Act, proposing a fundamental restructure of Medicaid, and slashing Medicare," Chairwoman Anna Eshoo (D-Calif.) said in her opening remarks at Tuesday's hearing. "This budget proposes to continue that sabotage."

Rep. Frank Pallone (D-N.J.), chairman of the full committee, said the "sham" of a budget proposal, along with efforts to restrict contraception access and squeeze Medicaid funding, amounted to a "devastating record for an agency whose mission is to advance the health and well-being of all Americans."

Republicans for the most part praised the secretary's work, though a few raised questions over the administration's efforts on containing drug prices.

Lead Republican for the subcommittee, Rep. Michael Burgess, MD (R-Texas), called Azar the "most transparent and accessible" HHS secretary he's ever known. Burgess went on to commend the agency's work in expanding programs aimed at preventing or treating opioid abuse, or for helping those in recovery, and also highlighted proposals to curb childhood cancer and eliminate HIV.

The Trump administration's $4.7 trillion budget includes $1.29 trillion for HHS. "Program level" allocations include $6.1 billion for the FDA, $12 billion for the CDC, $34.4 billion for the National Institutes of Health, and $6.3 billion for the Centers for Medicare and Medicaid Services. Each of these, with the exception of the FDA, is less than what was pledged for fiscal year 2019.

Overhauling Medicaid

One of the most radical provisions in the proposal centers around mandating work requirements for Medicaid recipients.

Rep. Joe Kennedy (D-Mass.) noted that in less than a year, nearly 20,000 Americans lost healthcare coverage in Arkansas -- the first state to implement work requirements. At the same time, the state's unemployment rate has increased.

Azar said the agency did not have data yet on why people had dropped off the program. It's possible some Medicaid recipients found work and received coverage from their employer, he said. "We just don't know."

At this, Kennedy pounced: "So your agency's budget proposes implementing mandatory work requirements for Medicaid beneficiaries, not knowing what the impact will be?" he said. "You want to extend that to every single state. What's the logic in that?"

Azar underscored that only "able-bodied adults" receiving "free healthcare" on the backs of taxpayers would be required to work or take part in community-engagement activities, including job-training.

"Can you point me to one study that says work requirements make people healthier?" Kennedy asked.

Rep. G.K. Butterfield (D-N.C.) also zeroed in on changes to the Medicaid program in the budget proposal, including a transformation to a per-capita cap block grant and cuts of $1.4 trillion.

He noted that one in five Americans rely on the program. "Just wait for the firestorm that this will create," Butterfield said.

Transparency at HHS

Pallone questioned Azar about his inaction in sharing documents related to the agency's involvement in the Texas v. The United States case, which aims to repeal the ACA on grounds that it's unconstitutional. (A federal judge ruled in December that the law was unconstitutional, but soon afterwards, agreed to stay all proceedings while the case is appealed, according to Health Affairs.)

Pallone said he hadn't received a single document from the secretary in 9 months.

Azar said he aims to send him as much material as he can "as soon as possible," but he added that laws related to executive privilege also need to be reviewed.

A second round of questioning involved another oversight issue, that of family separations at the border, after Azar declined an invitation to be a witness for a House hearing in February (the agency sent a career public health staffer formerly at the Office of Refugee Resettlement instead).

Another Perspective

Rep. Greg Walden (R-Ore.), ranking member for the full committee, lauded the 2020 budget proposal as a plan that promotes "fiscal responsibility" and maintained protections for pre-existing conditions.

He noted that it "strengthened" the Medicare program by extending its solvency for 8 more years, tackled overpayment to post-acute care providers, and targeting the drug companies.

Democrats, meanwhile, argued that by promoting short-term limited duration plans, the proposal does not protect those with pre-existing conditions. The proposal also resurrects the Graham-Cassidy ACA repeal bill first offered in 2017, and cuts $460 billion from Medicare, Eshoo noted.

Amid his praise, Walden did express some concern over HHS making changes that would affect "protected classes."

He said patients are not happy about new step therapy requirements that force them to re-try drugs they know will not work for them, before they can access more effective options.

Azar said he was aware of such concerns and would take such feedback "very seriously."

Rep. Gus Bilirakis (R-Fla.) also questioned the secretary about access to prescription drugs through Medicare.

He asked whether the government could negotiate better deals for the Medicare program than the plans do.

Azar responded that the only way to negotiate better deals would be if the government restricted the formulary and told seniors which drugs they could and couldn't get. "You may have Humira; you may not have Enbrel," he said as an example.

Given the pushback that's already been seen around step therapy, Azar suggested that such a tactic might not be very popular.

“Can you point me to one study that says work requirements make people healthier?”


KEY TAKEAWAYS

One of the most radical provisions in the Trump budget centers around mandating work requirements for Medicaid recipients.

Republicans lauded the 2020 budget proposal as a plan that promotes 'fiscal responsibility' and maintained protections for pre-existing conditions.

Democrats argued that by promoting short-term limited duration plans, the proposal does not protect those with pre-existing conditions.


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