Initially, after the Supreme Court made the Affordable Care Act (ACA) Medicaid expansions optional to the states, only about half chose to take advantage of the opportunity. But given the opportunity to improve the health of state populations, and to take advantage of generous increases in federal matching funds, many more have since followed suit. By December of 2018, the total number of expanding states had risen to 37. Through Medicaid's waiver process, the states have also enjoyed increased flexibility in how they can manage the program, which some have used to promote what are collectively referred to as "personal responsibility" policies, such as increased cost-sharing, work requirements, and incentives to encourage healthy behavior. Medicaid and other safety-net programs have a long history with similar initiatives. Work requirements were an essential ingredient of welfare reform in the 1990s, and pre-ACA waivers under Section 1115 of the Medicaid statute allowed experiments with small premiums and other cost sharing features that were otherwise prohibited under the original legislation in 1965. Until recently, however, work requirements were not permitted in Medicaid, and cost-sharing provisions were tightly limited. But since 2017, with interest in expansion persisting in many initially opt-out states and a conservative Republican administration in the White House, waiver restrictions have been substantially relaxed by the Centers for Medicare and Medicaid Services (CMS). On September 7, 2018, AcademyHealth convened a conference of about 30 policy analysts and public officials to review and discuss research related to the new Section 1115 expansion waivers and to identify the most pressing research needs going forward. What follows is a synthesis of the presentations and discussions at the meeting, along with relevant background from the gray and peer-reviewed literature. The discussion was off the record, so this brief will review the comments largely in paraphrase, and without attribution. A blog post describing the meeting discussion is also available at https://www.academyhealth.org/blog/2018-09/ experts-examine-evidence-medicaid-and-personal-responsibilityrequirements.
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