Their answer: Yes. By streamlining and standardizing the waiver process, the Centers for Medicare and Medicaid Services (CMS) would allow states to pursue more innovative strategies that improve care and lower costs, argued six former governors (three Democrats, three Republicans) who make up the Governors' Council. Council members include former Govs. Phil Bredesen (Tennessee), Jim Douglas (Vermont), Brad Henry (Oklahoma), Linda Lingle (Hawaii), Mike Rounds (South Dakota) and Ted Strickland (Ohio).
For now, the application and review process is “an 800-pound gorilla,” said Douglas at a briefing with reporters.
States can apply for three kinds of waivers that exempt them from certain provisions of the Social Security Act, which allow them to: enroll Medicaid patients in managed-care programs (Section 1915b); move long-term care patients into community settings (Section 1915c); and pursue broad reform initiatives (Section 1115). They can also file for state plan amendments (SPA) that make minor changes to their Medicaid programs.
The Governors’ Council made six recommendations that they say would bring more transparency to the waiver process and reduce the administrative burden for states. Generally, they called for setting clear parameters and developing templates that would ensure states know what to include in their applications in order to gain approval. They urged a more timely process; reviews are supposed to take 90 days, but CMS often extends the period with further questions. One Tennessee waiver took a year to be approved, Bredesen said.
The governors also recommended establishing a mechanism that would allow waivers that have proven successful to become permanent or semi-permanent. For example, Bredesen said his state’s TennCare is built on various waivers. But every five years, Tennessee must reapply, despite the fact that the program couldn’t function without the waivers. Vermont saved more than $260 million over five years with its Global Committment to Health initiative, Douglas said, but still faced uncertainty when reapplying for a waiver.
With the Medicaid expansion under the Affordable Care Act (ACA) looming, the council stressed the necessity of adapting such changes. “These are going to be triply important,” Bredesen said. “This antiquated, serial process… needs to be streamlined.” The governors also contend that a more normalized process would simplify efforts to transfer successful waiver programs across state lines.
Jason Grumet, president of the Bipartisan Policy Center, acknowledged that the recommendations were primarily designed to “start a dialogue” about improving the process. But the feeling on the council was that the issue was ripe for discussion.
“We should all value efficiency,” Strickland said. “I think there is a feeling that the process is not as efficient as it could or should be.”
The council’s full report can be found below.
