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President’s Message
By Joseph Nnodim, MD
To Fray a Safety Net
In the spring, State Senator Mike
Shirkey et al. introduced a bill
(SB-897) that will direct the
Department of Health and Human
Services to apply for a Section 1115
Waiver under the Social Security Act
to enable it impose work requirements
(> 80 hours/month) on able-bodied
Medicaid recipients as a condition for
continued coverage. The stated lofty
albeit specious purpose of the legislation
was to prepare these adults for “a life of
self-suf ciency and independence from
government interference”. Rather
conveniently, an exception was made for counties with unemployment rates greater than 8.5%, e.g. Cheboygan [20.9%] and Chippewa [10.5%] counties represented by State Senator Wayne Schmidt (R-Traverse City), one of the bill’s co-sponsors. A similar but less magisterial bill (HB-5701) also emanated from the House, authored by State Representative Jim Runestad et al.
The bill was passed by the Senate on a 26-11 vote, with all Democrats and one Republican voting against. Our reaction was swift and spirited. We addressed a letter to the Governor, making a case for him not to sign a piece of legislation that seeks to undermine the laudable achievements in recent years (e.g. Healthy Michigan of 2013) that have expand health care coverage. A University of Michigan survey (Tipirneni R. et al. JAMA Intern Med. 2018; 178(4): 564-7) found that over 50% of Medicaid recipients in the state were either working or in school. Further, the Senate’s own Fiscal Agency drew attention to the bill’s  nancial irresponsibility, estimating that the program it proposes will cost $20 - 30 million annually to administer. Sadly, on June 22, 2018, SB-897 was signed into law as Public Act 208 of 2018.
At least 10 other states are engaged in an undertaking similar to the process that played out in ours. They all drew inspiration from the address given to state Medicaid Directors in November 2017 by Administrator Seema Verma of the Centers for Medicare and Medicaid Services (CMS) in which she made a commitment to “turn the page” in the Medicaid program and allow
states more freedom to experiment. In January 2018, CMS announced that it would support states seeking ostensibly to help working-age, able-bodied Medicaid bene ciaries improve their “well-being and achieve self-suf ciency” through community engagement.
In January 2018, Kentucky became the  rst state to apply for and receive a waiver from the CMS to pursue the so-called community engagement for Medicaid enrollees. In 2014, the then- governor, Steve Beshear, had expanded Medicaid (Kentucky HEALTH) under the
Affordable Care Act, like Governor Rick Snyder had impressively done the year before herein Michigan. As a result, Kentucky’s uninsured rate fell from 14.3% in 2013 to 5.1% in 2016. Now, up to half a million persons were going to be subjected to the new work requirements which were supposed to go into effect on July 01 and an estimated 95,000 were expected lose Medicaid coverage. There, as here, the policy was clearly wrong-headed and, not surprisingly, a case was brought against the Department of Health and Human Services (DHHS) in the US District Court for the District of Columbia by plaintiffs led by the Kentucky Equal Justice Center, Southern Poverty Law Center, and National Health Law Program. The judge vacated the approval of Kentucky’s waiver by the Secretary of DHHS on the grounds that it was “arbitrary and capricious” and sent it back to CMS for further review. There is hope that the venerable safety-net program, signed into law on July 30, 1965 by President Lyndon B. Johnson, may yet weather the current onslaught and remain in the service of need rather than ideology.
The last word has not been spoken on this vexed subject by any means. New developments can be expected to occur both here in Michigan and in other states in the months and years ahead. For our part, faithful to our mission of advocacy on behalf of our patients, we will remain vigilant and never hesitate to convey our sentiments to the powers that be, as and when necessary.
4 Washtenaw County Medical Society BULLETIN JULY / AUGUST / SEPTEMBER 2018


































































































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