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.
- A major effort will be needed to rapidly identify and enroll thousands of children and pregnant women, using techniques that have proven so effective under the Affordable Care Act, including online enrollment and enrollment assistance through Flint’s public and private health, educational, and social organizations. The eligibility factors are somewhat complex, since the conditions of eligibility relate not only to residence and income but also to evidence of exposure.
- Coverage is unusually comprehensive, with a ban on cost-sharing for any pregnant woman or child who effectively is a designated Flint beneficiary. Because the state will continue to rely on its managed care system for treatment, extensive work may be required to ensure that managed care organizations serving the city have the capacity to enroll 15,000 additional beneficiaries. Managed care organizations also will need primary care and specialty provider networks that can work closely with case managers and ensure prompt access to diagnostic and treatment services to detect the presence of lead as early as possible and to begin to ameliorate its physical, mental, and developmental effects.
- Since abatement services will be funded through separate financing, coordination will be essential in order to ensure that the targeted case management program, which appears to operate in addition to managed care, can readily arrange for abatement resources for the women and children of Flint who are receiving expanded Medicaid services.
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.