Tag Archives: State flexibility

Important Concerns about the State Waiver Process

On Tuesday evening, legislative language emerged regarding a proposal negotiated by conservative and centrist House Republicans. The proposal, which would further amend the Obamacare “repeal-and-replace” legislation, would allow states to waive some (but not all) of the law’s major insurance regulations.

Specifically, states could request a waiver to:

  • Beginning in January 2018, vary rating by age more than Obamacare (current law says that insurers cannot charge older individuals more than three times the premiums paid by younger enrollees);
  • Beginning in January 2020, set their own essential health benefits—the categories of services all insurance sold must cover; and
  • Beginning after the 2018 open enrollment period, permit insurers to vary premiums by health status and/or eliminate the mandatory 30 percent penalty for individuals who do not maintain continuous insurance coverage—provided that the state has established a program of actual or invisible high-risk pools, or some other mechanism through the bill’s Stability Fund to stabilize its insurance markets.

Some conservatives may have philosophical concerns with this approach, on several levels. It perpetuates a federal regulatory regime for health insurance, maintaining Obamacare as the default option. Not only does the bill take the position that “If you like your Obamacare, you can keep it,” it ensures that states will keep Obamacare unless and until they affirmatively do something to opt out of the law—a position that turns federalism on its head.

Over and above those philosophical concerns, two very practical matters lurk.

How Many States Will Actually Apply for Waivers?

While Washington has discussed this waiver concept for nearly a month, exactly zero Republican governors have publicly expressed an interest in applying for a waiver. Granted, details have been scarce to find, and frequently changing. But with Republicans occupying literally two-thirds of the nation’s governorships, the silence from state houses seems deafening.

Two plausible theories could explain the silence. First, in some states, governors need explicit authority from their legislatures to take an action like applying for a waiver. Unless and until their legislatures provide explicit authorization, governors cannot apply for anything, even if they wanted to.

With most legislatures heading out of session, and filing deadlines for the 2018 plan year fast approaching, it seems a stretch to think that many, if any, states will apply for a waiver for next year, even if the bill gets signed into law within a month. And with 36 governors’ races on the line next fall, how many governors will want to implement waivers for the 2019 plan year—thus guaranteeing Obamacare will be an issue in the last week of their campaigns, with open enrollment starting mere days before the November 6 plebiscite?

Moreover, on the political front, the waiver process essentially punts to the states a decision—repeal of the Obamacare regulatory regime—that Congress can, and should, have taken on its own. Why should anyone believe that states will request waivers from the Obamacare regulations, when it was Congress’ own lack of political will that shifted the decision to the states in the first place?

Can a Future Administration Deny Waiver Renewals?

Supporters of the waiver concept have attempted to reassure conservatives that the state waivers would be automatic from Washington, and could not be held up by a future Democrat Administration. And with respect to initial approval of waiver applications, the language released does seem fairly straight-forward: It allows states to self-certify they are applying to achieve at least one of several stated objectives, and deems waivers approved, allowing the Secretary of Health and Human Services (HHS) to deny them only in the case of an incomplete application.

But the language in subsection (4)(A), reproduced in full below, suggests that extending waivers once granted could be far from a sure thing:

No waiver for a State under this subsection may extend over a period of longer than 10 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request. [Emphasis mine.]

The bill text distinguishes between “an application submitted in paragraph (1)”—the initial waiver application—and a “continuation of such waiver.” That distinction, coupled with the permissive language given to the HHS Secretary—who has the power to “den[y] such request in writing,” for reasons not explicitly stated—could give a future Administration all the opening it needs to deny future waiver extensions.

A Better Solution

The above concerns notwithstanding, the waiver debate has put paid to the notion that Congress cannot repeal Obamacare’s major insurance regulations as part of a repeal bill passed through budget reconciliation. In other words, the question is not one of process, and what the Senate parliamentarian will allow, but one of political will—whether Republicans want to repeal Obamacare or not. Rather than punting those decisions off to governors, and keeping the law’s regulatory structure firmly intact in Washington, Congress should finish its job and deliver the repeal it has promised the American people for the past seven years.

Reforming Medicaid, Beginning on Day One

A recent article listing five ways in which Health and Human Services Secretary-designee Tom Price could reform health care surprisingly excluded solutions for our nation’s largest taxpayer-funded health care program—Medicaid. That’s right: While Medicare spends more federal dollars, state and federal taxpayers spend more on Medicaid overall. With federal program spending scheduled to top $400 billion next fiscal year, and Medicaid consuming a large and growing share of state budgets, Dr. Price should waste no time making critically important reforms.

Ultimately, conservatives should work to convert Medicaid into either a block grant or per capita cap, where states would receive fixed payments from the federal government in exchange for additional flexibility to manage their programs as they see fit. While Congress must approve the legislative changes necessary to create a block grant or per capita cap, Dr. Price and Centers for Medicare and Medicaid Services Administrator-designee Seema Verma—who has a great deal of experience managing state Medicaid programs—can take steps, beginning on Day One, to give states more flexibility and freedom to experiment.

The prime place for Price and Verma to start lies in Medicaid’s “1115 waivers,” so named for the section of the Social Security Act (Section 1115) that created them. Under the 1115 process, HHS can waive certain requirements under Medicaid and the State Children’s Health Insurance Program (SCHIP) for “any experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives” of the programs.

Unfortunately, such waiver authority is only as effective as the Administration that chooses to exercise it—or not, as has been the case for much of the last eight years. One section of Obamacare actually increased the bureaucracy associated with 1115 waivers, requiring states to undertake a lengthy process, including a series of hearings, before applying for a waiver (because Obamacare itself was written in such a transparent manner). Subsequent legislative changes have sought to streamline the process for states requesting extensions of waivers already granted.

However, Dr. Price and Ms. Verma can go further in allowing states to reform Medicaid. They can, and should, upon taking office immediately propose a template waiver application for states to utilize. They can also publicly indicate their intent to approve blanket waivers—that is, waiver applications meeting a series of policy parameters will be automatically approved. While Congress should ultimately codify state flexibility into law—so no future Administration can deny states the ability to implement needed reforms—the new Administration can put it into practice while waiting for Congress to act.

As to the types of waivers the Trump Administration should look favorably upon, House Republicans’ “Better Way” proposal and a report issued by Republican governors in 2011 provide two good sources of ideas:

Work Requirements: Despite repeated requests, the Obama Administration has steadfastly refused to allow states to impose a requirement that able-bodied Medicaid beneficiaries either work, look for work, or prepare for work through enrollment in job-training programs. Because voluntary job-referral programs have led to impressive success stories, states should have the ability to impose work requirements for Medicaid recipients.

Cost-Sharing and Benefit Design: Whether through enforceable yet reasonable premiums, modest co-payments, Health Savings Account-like mechanisms, or a combination of all three, states should have greater freedom to utilize consumer-directed health care options for beneficiaries. These innovations would not only turn Medicaid into a product more closely resembling other forms of health insurance, they can also help reduce costs—thus saving taxpayers money.

Premium Assistance and Wellness Incentives: Current regulatory requirements for premium assistance—in which Medicaid pays part of the cost associated with an eligible individual’s employer-based insurance—have proven ineffective and unduly burdensome. States should have more flexibility to use Medicaid dollars to subsidize employer coverage, without providing additional wrap-around benefits. Likewise, states should have the ability to offer incentives for wellness and healthy behaviors in their Medicaid programs, just as successful employers like Safeway have done.

Payment Reforms and Managed Care: With health care moving away from a fee-for-service model, in which doctors and hospitals get paid for each service performed, states should have the ability to innovate. Some may wish to implement bundled payments, which would see Medicaid providing a lump-sum payment for all the costs of a procedure (e.g., a hip replacement and associated post-operative therapy). Others may benefit from a waiver of the current requirement that Medicaid beneficiaries have the choice of at least two managed care plans—a requirement that may not be feasible in heavily rural areas and states.

Program Integrity: With fraud endemic in federal health care programs, states should receive flexibility to track down on scofflaws—for instance, the ability to hire contingency fee-based contractors, and more scrupulously verify beneficiary eligibility and identity. By monitoring suspicious behavior patterns through the use of “big data,” these efforts could save both Washington and the states billions.

Reforming a program that will cost state and federal taxpayers an estimated $607.2 billion this fiscal year will not be easy, and will not happen overnight. But the sprawling program’s vast size and scope also demonstrate why the new Administration should start its work immediately. While Congress can and should fundamentally reform Medicaid, HHS can use blanket 1115 waivers to allow states to experiment as soon as they can. In this way, the “laboratories of democracy” can drive the innovation needed to bring Medicaid into the 21st century, lowering health costs and saving taxpayers money.

The Next Obamacare Battleground: State Insurance Premiums

The New York Times reported last week on the Obama administration, in an effort “to avoid another political uproar over the Affordable Care Act,” urging state insurance commissioners to hold down premium increases for 2016. The Times cited a letter that Kevin Counihan, who oversees the federal insurance exchanges, sent to state commissioners last month asking states “to carefully consider as you make your final rate decisions” several factors the administration said would contribute to more moderate cost increases than those already experienced.

But trends in many states appear likely to force premiums higher. Continued low enrollment after the 2015 open-enrollment season means that some insurers still face a group of enrollees who are older and sicker than their initial projections. One report out this summer by pharmaceutical benefits manager Express Scripts indicated that people who enrolled in exchange plans have higher prescription-drug costs than participants in other health insurance plans, including greater use of costly new treatments for diseases such as Hepatitis C. So some carriers may seek higher premiums to reflect their rising costs.

Premium increases are obviously unpopular, but state regulators must protect insurers–an insolvent insurer cannot provide financial protection to anyone. The Oregonian reported in June: “While some insurers proposed rates similar to or better than this year’s, officials are ordering them to be raised—saying they need to close a sizable gap between what insurers have collected and what they spend on claims.” One insurer that proposed a rate decrease for next year, Kaiser Health Plan of the Northwest, was forced to raise premiums by 8.3%. A carrier that proposed a 9% increase ended up with a 34.8% hike in rates. The commissioner’s office forced these adjustments to ensure that carriers do not pay out more in claims than they generate in premiums.

One could see Mr. Counihan’s letter as the opening stages of a blame game over premiums. Of course, rising health costs, anemic enrollment in plans administered through the insurance exchanges, and unpopular product design are not the fault of state insurance commissioners. And there are risks to trying to dictate outcomes to states, including that state officials might be distracted from their focus on preserving carriers’ solvency if pressed by federal officials more focused on achieving politically desirable outcomes.

This post was originally published at the Wall Street Journal’s Think Tank blog.

What’s Blocking Consensus on Health Care

In the wake of the Supreme Court’s King v. Burwell ruling, some have argued that a more bipartisan approach to health policy may emerge. But fundamental philosophical disagreements between liberals and conservatives suggest that rapprochement will be difficult.

Philosophical disagreements played into in the debate over pre-Obamacare health coverage. Many conservatives argued that people should be allowed to keep their plans (as the president originally promised). Most also want to liberalize the ACA’s definition of “insurance.” That involves widening the age rating bands—older people will pay a little more, so younger people can buy cheaper policies—and eliminating some benefit requirements so that, to use a frequently cited example, single men don’t have to purchase pregnancy coverage and retired couples don’t have to buy plans that cover well-baby visits. In a speech in October 2013, just after the failed HealthCare.gov launch, President Barack Obama talked about how some Americans have “cut-rate plans that don’t offer real financial protection in the event of a serious illness or an accident.” The administration had always wanted to eliminate some plans. Political pressure and the technical meltdowns of many exchanges upon their launch that fall forced the administration to extend the period for which some plans were grandfathered. But this was a temporary concession to political reality; its objective has not changed.

Another example of administration flexibility working toward its preferred ends involves the program that allows states to seek years-long waivers from certain provisions of the ACA. By one argument, the “State Innovation Waiver” would allow states to “alter the ACA’s generous ‘minimum essential benefits’ requirements,” which mandate types of coverage. Some of those requirements involve coverage that many people don’t want or need, and that contribute to insurance premium increases. Language in section 1332 of the ACA says that states using a waiver must cover as many individuals, with at least as comprehensive insurance benefits. In other words, states can alter the “minimum essential benefits”—but only in a way that makes them more generous, not less so. If states want to prioritize resources for certain groups—say, individuals with disabilities—over coverage of able-bodied adults, the “flexibility” in Obamacare would prove elusive.

The administration has also been inflexible about some approaches to state Medicaid expansion. Utah proposed adding job search requirements as part of broadening the program, but the administration refused to go along. Last year, Pennsylvania’s then-governor, Tom Corbett (R), proposed a mandatory work/job-search requirement, but administration opposition led to the proposal becoming a voluntary job referral service.

Ideally, states function as laboratories of democracy, and one state’s experiments can spark broader national trends. But when it comes to health care, the administration and Obamacare are offering little flexibility to states whose leaders have differing philosophical objectives. This suggests that, at least in the near term, bipartisan health experiments will remain an elusive goal.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Barack Obama, Science Denier

In a Think Tank post last week, I wrote that in trying to sell Obamacare’s Medicaid expansion to states, the administration “has made no attempt to argue that expansion represents the most economically efficient use of those dollars—that the funds could not be better used building bridges, returned to citizens,” or other things. A study released this month raises questions about the very utility and efficiency of Medicaid coverage.

The study, from MIT’s Amy Finkelstein, Nathaniel Hendren, and Erzo F.P. Luttmer, used data from an Oregon health insurance experiment—in which some low-income citizens received access to Medicaid and some did not, based on the results of a random lottery—to estimate the utility of Medicaid coverage. They found that beneficiaries valued Medicaid at 20 cents to 40 cents on the dollar; in other words, for every $1,000 the states and federal government spent on health coverage, the average beneficiaries felt like they were receiving goods or services valued at $200 to $400.

In response, Bloomberg View’s Megan McArdle asked whether the poor would prefer cash benefits to Medicaid. It seems like a fanciful question; for one thing, programs providing cash benefits—such as the Earned Income Tax Credit—historically suffer from a large incidence of fraud. But say a state wanted to offer residents such a choice. Would the Obama administration allow it?

The state waiver program included in Obamacare provides flexibility only to the extent that states provide coverage at least as generous to as many people as the health-care law itself. A state cannot target resources only to certain groups—individuals with disabilities, for example—or provide slimmed-down coverage to some beneficiaries. Under that logic, it seems that if a state wanted to provide residents a choice between a smaller cash benefit and Medicaid insurance coverage, the administration would not permit such a measure—even though, according to the MIT study, the average beneficiary would prefer this outcome, and taxpayers would benefit as well.

While the Obama administration talks about its flexibility, that appears to apply only when such flexibility promotes the administration’s objectives. The president said early in his tenure that for too many years “rigid ideology has overruled sound science.” Now, an MIT study shows “sound science” questioning the efficiency and utility of Medicaid coverage for beneficiaries. Will the administration react to this scientific evidence, or will its own ideology prevent the consideration of more innovative, and potentially more effective, policies?

This post was originally published at the Wall Street Journal’s Think Tank blog.

Medicaid Expansion and the Economy

Last week, the White House released a report outlining the economic benefits to states of expanding Medicaid. The report continues a line of argument the Obama administration has used in encouraging states to expand Medicaid under the Affordable Care Act, the president’s health-care law.

The administration faces several obstacles in attempting to sell this argument to reluctant states.

The first is the argument I outlined yesterday—namely, the “poverty trap” exacerbated by several elements of Obamacare. In addition to concluding that the law as a whole will reduce the size of the labor force by the equivalent of approximately 2.3 million full-time workers in 2021, the Congressional Budget Office specifically has found that “expanded Medicaid eligibility under [the law] will, on balance, reduce incentives to work.” For instance, while individuals who exceed the threshold for Medicaid eligibility will likely become eligible for subsidized premiums on insurance exchanges, they would also become subject to thousands of dollars in premium payments and cost-sharing—all because of a potentially small increase in income. CBO has found that these kinds of “cliffs” discourage work.

Second, the Obama administration has rejected requests from states to impose work or job-search requirements in conjunction with the Medicaid expansion. While the administration has claimed to offer flexibility to states when it comes to altering the Medicaid benefit, it has steadfastly refused to consider any mandatory work or job-search requirement. Given the CBO’s analysis, the administration faces a rhetorical challenge in explaining how expansion can benefit the economy yet simultaneously reduce incentives to work—particularly as it declines to give states the ability through work requirements to mitigate against those disincentives.

Additionally, the White House report solely examines the benefits of increased federal funding to states without examining the source of that funding. Most notably, the health law included more than 18 tax increases, which according to the most recent CBO estimates will raise over $1 trillion in revenue—with obvious dampening effects on state economies. 

Perhaps most importantly, various economists, including Harvard’s Katherine Baicker, have dismissed the notion that health care should serve as an economic engine. While the administration claims states that expand Medicaid will grow their economies, it has made no attempt to argue that expansion represents the most economically efficient use of those dollars—that the funds could not be better used building roads, returned to citizens, or even remain in the Treasury to reduce the federal deficit. In that sense, then, the administration might do well to heed one of its own former officials—Ezekiel Emanuel, former official in the Office of Management and Budget: “Health care is about keeping people healthy or fixing them up when they get sick. It is not a jobs program.”

This post was originally published at the Wall Street Journal’s Think Tank blog.

Why States Are Hesitating to Expand Medicaid

Just before the July 4 holiday the White House Council of Economic Advisers released a report titled “Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid.” The Pew Trusts also released a data compilation last week. But that one showed why many states, which had large and growing Medicaid programs even before Obamacare, have not rushed to embrace greater expansion.

Pew examined data from 2000 to 2012 and found large increases in state Medicaid spending even after adjusting for inflation. Nationally, Medicaid spending grew an average of 4% more than inflation every year during this period. All but two state Medicaid programs grew at real (inflation-adjusted) rates greater than 2% annually. In addition, programs in eight states and the District of Columbia grew at rates exceeding 5.9% per year–meaning that spending doubled during the 12-year period, even after accounting for inflation.

Some might argue that robust economic growth, which leads to an expanding revenue base, could allow states to absorb sustained increases in Medicaid spending greater than the level of inflation. But the Commerce Department’s Bureau of Economic Analysis found that inflation-adjusted gross domestic product grew 23.1% from 2000 through 2012. Meanwhile, Medicaid spending grew nearly three times as fast in inflation-adjusted terms: an average of 63% nationally. Only one state, New Hampshire, increased its Medicaid spending at a rate slower than the national economy grew from 2000 through 2012.

So during the decade before Obamacare took effect, states had dramatically increased their Medicaid expenditures—spending well above inflation and exceeding the economic growth their revenue forecasts are based on. Greater Medicaid expenditures have an opportunity cost: Many states have had to divert funds from education or other priorities to cover increased spending on health. Little wonder that many states have decided not to expand Medicaid further. In some respects, it may be smarter to ask why so many decided to embrace expansion.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Clinton Tries to Sell Obamacare–But That Dog Won’t Hunt

Earlier today, former President Clinton spoke about Obamacare in Little Rock, reprising his role as “explainer-in-chief” to tell the American people how well Obamacare is working now, and will work when the exchanges launch in just 26 days.

But as Bill Clinton himself might say, that dog won’t hunt. Contrary to his claims, the law is not reducing costs, is causing people to lose their health coverage, and does not provide states with flexibility to implement the measure:

  • President Clinton claimed that the law would make health coverage more affordable. But the law hasn’t met then-Senator Obama’s 2008 campaign promise to reduce premiums by $2,500 per family—not by a country mile. Instead, premiums have gone up for the average employer plan—and the mandates included in Obamacare will raise costs and premiums beginning next year for many families.
  • President Clinton claimed that people who currently have coverage largely wouldn’t be affected by the law. But many Americans are losing coverage—because their plan doesn’t meet new government-imposed standards, or because their insurance company is dropping out of state markets. Many other Americans are being affected by the higher costs of Obamacare, as recent disclosures by firms like UPS and Delta indicate. And multiple unions agree that the law will “destroy the very health and well-being of our members along with millions of other hard-working Americans.”
  • President Clinton claimed that states would have more flexibility to implement the law. But even liberals have admitted that the supposed “flexibility” works only one way—states are allowed only to increase regulations and government involvement, not decrease them.
  • President Clinton claimed that if states don’t expand Medicaid, their tax dollars would go to other states to fund Obamacare’s coverage expansions. That’s just not accurate. If states don’t expand Medicaid, those tax dollars would stay in the federal Treasury—and what’s more, their state budgets would be better for it, because Obamacare will cost state budgets a bundle.

As to Clinton’s claim that those who oppose the law should try to fix it rather than repealing it, President Obama has committed to repeal the sequester—a provision the President himself signed into law. If President Obama believes the sequester is so harmful that it should be repealed—and the Administration is threatening to shut down the federal government if the sequester is not repealed—then why should conservatives abandon their belief that Obamacare is so harmful that it should be repealed?

The answer is simple. Liberals didn’t abandon their belief in a government-centric scheme for health care after President Clinton’s failed effort in the 1990s. Likewise, conservatives should not now abandon their belief—based on all the implementation failures to date—that Obamacare won’t deliver for the American people. It is so unworkable that it should be defunded and repealed.

This post was originally published at the Daily Signal.

Do’s and Don’ts of Improving State Medicaid Programs

A PDF of this document is available here.

Across the country, state legislatures are considering whether and how to implement Obamacare’s Medicaid expansion.  Ten simple reasons illustrate why states should reject Obamacare’s government-centric expansion and instead develop their own innovative solutions:

 Obamacare’s Medicaid expansion harms states

  •  Medicaid is “Not a Jobs Program:”  Former Obama administration official Zeke Emanuel wrote in a New York Times op-ed that hospitals and other health providers should not view health programs as a never-ending government jobs program.  Research suggests tax increases needed to fund Medicaid expansion will destroy jobs, not create them.
  • Medicaid “Not Real Insurance:”  Medicaid’s problems with poor beneficiary access to physicians have been well documented.  One Michigan beneficiary said it best: “You feel so helpless thinking, something’s wrong with this child and I can’t even get her into a doctor….When we had real insurance, we would call and come in at the drop of a hat.”
  • Not True Flexibility:  Guidance recently issued by the Obama administration shows continued unwillingness to contemplate flexibility in Medicaid.  Washington continues to place limits on even modest cost-sharing for recipients to incentivize healthy behaviors.
  • “Bait and Switch” from Washington, Part I Given the significant Medicaid spending cuts President Obama himself previously proposed to rein in massive federal deficits, the high federal Medicaid matching rates included in Obamacare are unlikely to remain.
  • “Bait and Switch” from Washington, Part II:  States with premium assistance demonstrations now must ask permission from Washington to extend them beyond 2016.  HHS has shown little flexibility for states, and it could show even less after millions more Americans are enrolled in taxpayer-funded benefits.

True Reform: What states should do instead

  • Customized Beneficiary Services:  Providing beneficiaries with a choice of coverage options can provide plans an incentive to tailor their benefit packages to best meet individual needs.  Similar incentives promoting competition in the Medicare Part D drug benefit helped keep program cost more than 40% below estimates.
  • Coordinated and Preventive Care:  Reform programs in states as varied as Indiana, Rhode Island, and Florida focus on individualized, coordinated services to beneficiaries – an improvement on the top-down, uncoordinated care model of old.  In many cases, preventive care interventions for Medicaid recipients suffering from chronic conditions can ultimately save money.
  • Personal responsibility:  Cost-sharing can be an appropriate incentive to encourage recipients to take ownership of their health and discourage costly practices, such as ER visits for routine care.  More than two-thirds of participants in the Hoosier State’s Healthy Indiana Plan consider their cost-sharing levels appropriate, proving that families of modest means are willing and able to provide some financial contribution to their cost of care.
  • Home and Community-Based Services:  Providing long-term care in home settings, rather than in more costly nursing homes can improve quality and save taxpayers money.
  • No New Federal Funds:  Most importantly, innovative programs in Rhode Island, Indiana, Florida, and elsewhere neither seek nor require the massive new spending levels contemplated by an Obamacare expansion.

Medicaid’s ‘Titanic’ Problems

Various press outlets have reported on Texas Governor Rick Perry’s statement earlier this week that expanding Medicaid “is not unlike adding a thousand people to the Titanic.”  However, fewer news reports have focused on this closely related story:

Only 31 percent of Texas doctors said they were accepting new patients who rely on Medicaid, the health insurance program for the poor and disabled, in the survey provided to The Associated Press on Sunday.  In 2010, the last time the survey was taken, 42 percent of doctors accepted new Medicaid patients.  In 2000, that number was 67 percent.

States are looking for ways to modify their Medicaid programs, but yesterday HHS once again indicated it would deny them that flexibility.  The questions are obvious:  Does anyone think a program where fewer than one in three doctors will see new patients needs anything but major reform?  And why is this Administration still blocking states’ attempts to reform their Medicaid programs and instead trying to defend an indefensible status quo?