Barriers to Oral and Other Health Care Are Underway in Several States: What You Need to Know
State Medicaid programs could be expanded through Section 1115 of the Social Security Act. These programs typically provide both health and oral health services to populations with limited income.
However, with ongoing efforts to decrease the number of people who can access affordable health care, multiple states are using or planning to use Section 1115 waivers to add restrictions - not supports - for consumers seeking critical care. These restrictions will result in less access for many low-income adults, children, pregnant women, the elderly and people with disabilities that are currently eligible and receiving services.
We know that inequities and disparities are an underlying cause of poor oral health - whether the barriers in question reflect, for example, lack of access to transportation or having a disability. We should be working on ideas to create more access rather than limit services. Unfortunately, 1115 waiver trends do not help folks who are struggling.
Some of the proposals within 1115 waivers include:
Work requirements: Given the green light earlier this year by the Trump administration’s Centers for Medicaid and Medicare Services, several states are implementing work requirements that threaten health services for working as well as non-working individuals. For example, up to 46% of low-income workers in Kentucky are at risk of losing coverage for a month or more due to a new policy in that state.
Increased reporting requirements: Increased frequency and more complicated paperwork of enrollees make it harder to obtain or maintain Medicaid. Nonetheless, 1115 waivers can make these requirements even more burdensome.
Lockouts: In some cases, enrollees will face permanent disenrollment from coverage due to failing to submit paperwork such as reporting a change in income or employment status.
Time limits: Some states are seeking to implement arbitrary limits on coverage which could further jeopardize people’s financial security (which the policymakers in question state they want to expand) because of limited wellness and primary services. Emergency services are always more expensive.
Additional premiums and copays: The 1115 waivers can also be used to increase fees. This goes against Medicaid’s goal of enhancing and increasing affordability of care by putting unemployed and low-wage workers at further risk of not being able to pay for the services they need.
We should also remember that the other major support for children’s health, Children’s Health Insurance Program (CHIP) funding, is currently threatened due to a Trump administration proposal to Congress. The restrictive 1115 waivers and the threats to CHIP are a threat to health for our society’s most vulnerable populations.
Restricting Medicaid blocks people from financial security. It misleadingly claims to prioritize the state’s finances. But we know that if we really want to save on clinical services, we need to expand access to primary care, and to also improve the community determinants that lead to better health. Doing so would diminish the economic effects (such as the demand for Medicaid) of illness that is often exacerbated by the multiple disinvestments in our communities - including unstable work opportunities and other barriers to economic justice.
As constituents and enrollees, we can push for participatory policymaking which engages communities in the 1115 waiver process from development to implementation. Only then will these waivers be used for their intended purpose: to improve reach and efficiency of Medicaid.
If you are interested in joining other voices that are weighing in on the 1115 waiver process, see this Google Form addressing CMS that is being coordinated by our friends at the Children’s Dental Health Project.