MACPAC’s Recommendations Hit the Mark on Immediate Ways to Improve Medicaid

  ·  Health Policy Hub   ·   Rachel Rosales

During its January meeting, the non-partisan Medicaid and CHIP Payment and Access Commission (MACPAC) made several recommendations to Congress that could pave the way for additional improvements to Medicaid with a more receptive administration and new Congress. MACPAC’s recent recommendations address three policy areas: extending postpartum coverage, instating an automatic countercyclical Medicaid financing adjustment during economic downturns, and estate recovery policies related to long-term services and supports (LTSS). We at Community Catalyst applaud MACPAC’s recommendations and call on Congress to make these recommendations a reality.

What are the details behind each of MACPAC’s recommendations?

  • Extending Postpartum Coverage. MACPAC recommends that Congress extend the Medicaid postpartum coverage period from 60 days postpartum to one year postpartum. The recommendations also call for the provision of full Medicaid benefits for this population in exchange for a 100% federal matching rate.

The United States is the “only industrialized nation with a maternal mortality rate that is on the rise.” With Medicaid covering 43 percent of all births in the US, these policy recommendations have the potential to make a large impact on maternal mortality rates. Studies show that “nearly 60 percent of pregnant [people] experienced a month-to-month change in insurance type during the nine months of pregnancy, and half were uninsured at some point in the six months following birth.” The churn in coverage contributes to this alarming statistic — one-third of pregnancy-related deaths occur during the first year after the end of a pregnancy. Notably, the higher rates of uninsurance among people of color compared to white people correlate with disproportionately higher rates of maternal mortality among birthing people of color. With the year following the end of a pregnancy proving to be a critical and concerning period, a 12-month postpartum coverage period could dramatically and equitably improve maternal mortality rates as it means that postpartum people would have access to Medicaid coverage and services for their postpartum health issues across the entirety of that period.  

MACPAC’s recommendation also highlights the importance of full-scope Medicaid benefits for pregnant and postpartum people. Under current federal law, states are required to provide Medicaid coverage for pregnancy-related services for incomes up to 133% of the federal poverty level (FPL), but there is “no formal federal definition of what services states must cover for pregnant people beyond inpatient and outpatient hospital care.” The patchwork of pregnancy-related coverage means that states providing less comprehensive coverage could be endangering the lives of new and expectant mothers if they can’t access services such as “prenatal care, labor and delivery, family planning services and supplies, and any other medically necessary services.” Full-scope Medicaid benefits allow for people to address medical and behavioral health conditions that could curb maternal deaths in the perinatal and postpartum periods.

  • Automatic Countercyclical Financing Adjustment During Economic Downturns. MACPAC recommends that Congress adopt a statutory mechanism that instates an automatic Medicaid countercyclical financing model. The “countercyclical financing model would automatically and temporarily increase the federal medical assistance percentage (FMAP) for Medicaid spending…[and] establish an eligibility maintenance of effort (MOE) requirement for the period covered by an automatic countercyclical financing adjustment.”

During economic downturns, Medicaid enrollment increases while state economies weaken, leaving states with little capacity to handle the outflow of state funds. MACPAC’s recommendation would get states more timely and targeted federal funds commensurate with the level of need due to the downturn. The formula to calculate these federal funds would rely on the following economic data: (1) increases in state unemployment and (2) reductions in total wages and salaries. As a result, state Medicaid programs could be spared and protected during economic crises when states often turn to cuts to Medicaid, while the MOE protections would preserve Medicaid benefits and provider rates, ultimately prioritizing beneficiaries and their access to health care.

  • Estate Recovery Policies Related to LTSS Medicaid Coverage. MACPAC recommends that Congress “make estate recovery optional..., allow states with managed LTSS to pursue recovery based on the cost of services where it is less than the capitation payment paid to a managed care plan, and direct the Secretary of HHS to establish minimum hardship waiver standards, including a minimum estate value threshold for estate recovery.”

Estate recovery applies to individuals 55 or older and requires states to “seek recovery of payments from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services.” Estate recovery has led to two unfortunate realities— (1) people avoid enrolling into Medicaid and forgo needed care out of fear of losing their home or (2) beneficiaries may not fully understand the fine print of Medicaid applications and, therefore, do not share relevant information with their heirs. While there are hardship waivers, awareness of such waivers is low and the ability to prove hardship usually requires the assistance of a lawyer.

Among the problems estate recovery policies present, it perpetuates intergenerational poverty and raises equity concerns. “Home ownership is one of the greatest catalysts of class mobility in America” and the estate recovery policy essentially reverses progress made by a generation and pushes families into further cycles of poverty. MACPAC’s recommendation of making estate recovery optional and creating a standardized process for obtaining hardship waivers allows for elderly adults to more equitably retain and pass on their assets without sacrificing needed LTSS care. 

Congress Must Act to Make These Recommendations a Reality

MACPAC’s recommendations demonstrate a comprehensive understanding of three different policy areas that currently pose problems for Medicaid programs and beneficiaries. We at Community Catalyst believe that these recommendations could greatly improve the lives of Medicaid beneficiaries and should be adopted as quickly as possible.