Despite repeat campaign promises from then presidential candidate Donald Trump that he had no interest in altering Medicaid and other entitlements, it was evident from the start of his administration that there would be big plans in the works for the low-income insurance program. This was evident, most notably, in his appointment of health policy consultant Seema Verma—architect of the uniquely conservative Medicaid expansion waiver in Indiana—to run the Centers for Medicare and Medicaid Services (CMS). Now, one year into the Trump presidency, after Congress's attempts to cut and restructure Medicaid through legislation have proved unsuccessful, the administration has begun in earnest to pursue a regulatory pathway to state-by-state Medicaid reform grounded in Verma's approach to Section 1115 Medicaid waiver design.
As outlined in Health Affairs previously, CMS issued a variety of guidance to states in 2017 indicating how it planned to reduce administrative burden; expand flexibility in the design and implementation of 1115 waivers; and allow for the testing of new policies that align Medicaid with commercial insurance design and encourage greater self-sufficiency and cost-sharing for beneficiaries. The agency also substantially revised the guidelines posted at Medicaid.gov, describing the criteria by which it evaluates whether a proposal aligns with the core objectives of Medicaid.
