While efforts to pass major federal legislation to repeal and replace the Affordable Care Act (ACA) and restructure and reduce federal Medicaid financing may be on hold temporarily, the focus of the Centers for Medicare and Medicaid Services (CMS) and states is expected to turn to achieving significant Medicaid program changes through Section 1115 demonstration waivers. Going back to the mid-1990s, each new administration has used discretion to approve and promote different types of demonstration waivers. Although few waivers have been approved recently, the Trump Administration has signaled its openness to allowing states to test policies that have never before been approved in Medicaid and is considering waivers that seek to impose work requirements, drug screening and testing, eligibility time limits, enforceable premiums, and other eligibility and enrollment restrictions on existing expansion adults and/or traditional Medicaid populations. The limited waiver activity that has occurred so far in 2017 provides some insights into how the purpose of waivers and their approval process, implementation, and oversight may be evolving. As of September 2017, there were 33 states with 41 approved waivers and 18 states with 21 pending waivers. This issue brief presents three questions to help analyze the evolution of federal waiver policy as new waiver proposals and decisions emerge.
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