On March 3, 2016, the U.S. Department of Health and Human Services (HHS) gave formal approval to Michigan Governor Rick Snyder’s proposal to expand Medicaid eligibility and coverage for low- and moderate-income children and pregnant women affected by Flint’s lead crisis through a §1115 demonstration. (The proposal was reviewed in an earlier blog post.)
Under the terms of the approval, Medicaid will be extended to an additional 15,000 lead-exposed children and pregnant women served by the Flint water system. Once eligibility is established, children will remain eligible until they reach age 21. This expanded eligibility standard effectively doubles the state’s normal Medicaid eligibility rules for Flint’s pregnant women and children, raising it from twice to four times the federal poverty level. (Families with incomes above this level can purchase Medicaid coverage.) Both existing and newly eligible beneficiaries will be entitled to receive all Medicaid benefits, including comprehensive pregnancy care, and early and periodic screening, diagnosis, and treatment (EPSDT) services to promote healthy child development. Additionally, the state will provide targeted case management to approximately 30,000 pregnant women and children affected by the crisis, to ensure access to necessary health, educational, and social services.
Notably, the administration did not approve the state’s proposal to use federal Medicaid funds for lead abatement. Instead, Centers for Medicare and Medicaid Services Administrator Andrew M. Slavitt suggested that his agency would work on an alternative solution that would allow the state to use part of the state’s annual Children’s Health Insurance Program (CHIP) allocation for this purpose. While the Clinton administration established a clear and far-reaching precedent for using Medicaid, the nation’s largest health insurance program, to address underlying environmental lead exposure risks in Rhode Island, the Obama administration chose instead to repurpose the Michigan’s relatively modest CHIP grant for this purpose.
Even with the separation of lead abatement activities into a distinct financing stream, the Flint §1115 demonstration once again underscores Medicaid’s irreplaceable role in the U.S. health care system as well as the importance of the demonstration powers granted the HHS Secretary in times of community crisis. No insurance system other than Medicaid can be modified quickly to absorb the victims of a public health catastrophe, and its benefits for children are unmatched.
Of course, approval of the demonstration is only the first step.
Finally, while attention now is necessarily and appropriately on the provision of immediate care for Flint’s families, evaluation is a cornerstone of federal demonstration law. I am hopeful Flint’s tragedy will yield lessons on how best to invest health care resources as part of a response to a public health disaster. The core of the evaluation, of course, must focus on the state’s success in using Medicaid financing to detect and treat lead exposure in children. But also important is an examination of Medicaid’s unique coverage parameters for children, as well as the state’s experience in using Medicaid managed care as a key partner during a public health crisis response.