Trump Administration’s First Work-based Medicaid Waiver May Produce Little New Evidence

A new waiver policy intended to promote work by Medicaid recipients drew substantial criticism when it was announced by the Trump administration earlier this week. But will it generate any valuable new evidence of what works?

It is too early to know for sure, but the first approved plan submitted by the state of Kentucky does not seem especially promising.


The Kentucky Plan

The Kentucky proposal, called Kentucky Health, would impose work requirements on adults aged 19-64, with exemptions for certain groups such as pregnant women and the disabled. Failure to fulfill the proposed work requirements would result in a loss of coverage. The proposal also features rising premiums, as well as a substance use disorder program open to all Medicaid beneficiaries (Kentucky has been very significantly affected by the growing opioids crisis).

CMS approved the plan on January 12, authorizing it for five years through September 2023. The demonstration project is expected to start in July, according to state officials, if it is not halted by a lawsuit before then.  If fully implemented, it is expected to reduce the number of people  enrolled in the state Medicaid program by about 100,000, according to state estimates, saving an estimated $2.4 billion over five years, most of it in federal funds.

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Posted in Children and Families, Health

House Committees Explore Possible Welfare Changes

Despite a weekend retreat between President Trump and GOP congressional leaders that seemingly put partisan welfare changes on the backburner, several House leaders are looking at ways to push forward anyway.

According to Reuters:

House Agriculture Committee Chairman Mike Conaway, a Texas Republican, said the 2018 farm bill will including tighter work requirements for the Supplemental Nutrition Assistance Program (SNAP), better known as food stamps. He gave no details.

House tax committee Chairman Kevin Brady, also a Texas Republican, said his panel is exploring ways to get workers who are “trapped in the welfare system … off the sidelines.”

Representative Bradley Byrne, an Alabama Republican, said safety net programs are under review by a bipartisan group he co-chairs called the Opportunity Action Caucus. He said he hoped the group this month would propose ways for “able-bodied people who are presently on one or more of our welfare programs, to go out and get the skills and training they need to get a job.”

The Reuters article also cites yesterday’s decision by the Trump administration to approve work-focused waivers in the Medicaid program as evidence that Republicans are pushing forward on the issue. It also cites positive polling:

[P]olling in mid-2017 by the Kaiser Family Foundation found 70 percent of respondents favored work requirements for Medicaid for non-disabled adults. At the same time, 74 percent said they had a favorable view of Medicaid as it is now.

In Wisconsin, House Speaker Paul Ryan said he does not see his chamber taking on more ambitious entitlement changes. He emphasized the need for a “bipartisan consensus.”

The Reuters article does not cite any similar activity in the Senate, where Senate Majority Leader Mitch McConnell has been less enthusiastic than Ryan about entitlement changes.

Nevertheless, if the House does something bipartisan, it may provide the basis for inclusion of some of the provisions in a broader deal later in the year. This is a relatively common occurrence in Congress, particularly if the changes do not prompt major push-back from the narrowly-divided Senate.

Posted in Children and Families

Trump Administration Terminates SAMHSA Evidence Clearinghouse Amid Questions About Its Objectivity

A Trump administration decision to terminate the contract of one of the federal government’s top evidence clearinghouses, the National Registry of Evidence-based Programs and Practices (NREPP), has raised questions about its ongoing commitment to evidence.  But the decision may have actually reflected the opposite — a stronger commitment to evidence amid concerns about the clearinghouse’s credibility and that of the medical research industry as a whole.

The clearinghouse, operated by the Substance Abuse and Mental Health Services Administration (SAMHSA), reviews studies of evidence-based mental health and substance use programs, including those related to opioids, an administration priority.

The contractor overseeing the clearinghouse received word of its termination from SAMHSA over the Christmas holidays. However, the decision may have been made much earlier in the year, according to a story yesterday in the Washington Post:

Agency officials froze the existing website in September, and no new postings have been added, according to mental health advocacy groups. As a result, about 90 new programs that have been reviewed and rated for their scientific merits since September are not available to the public, they said.

SAMHSA has been largely silent on the matter, saying only that the duties of the clearinghouse will now be shifted to a new Policy Lab that was created by federal law and that was launched earlier this month. [Edit: SAMHSA has issued a statement. See below.]

In describing the Lab’s duties, Elinore McCance-Katz, the agency’s new administrator, told Congress last year that:

[T]he primary focus of the Policy Lab is to “periodically review programs and activities” relating to the diagnosis, prevention, treatment and recovery from mental illness and substance use disorders. The lab will also identify programs or activities “that are duplicative and are not evidence-based, effective or efficient,” she said.

The Policy Lab will also play a role in awarding grants to state and local governments, educational institutions and nonprofits to develop evidence-based interventions, she said.

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Posted in Health

Trump Administration’s Plan B for Evidence-based Welfare Reform? Medicaid Waivers

Just days after a weekend retreat at Camp David, where President Trump and the Republican congressional leadership agreed to set aside House Speaker Paul Ryan’s ideas for welfare reform, a Plan B appears to be emerging.

The goal?  Encourage more states to adopt work requirements, a longtime Republican objective.  The principal strategy?  Medicaid waivers, a tool intended to build the evidence base of what works.

Medicaid is the largest source of welfare-related spending for the nation’s poor, dwarfing similar federal programs like TANF. Total Medicaid spending exceeds $500 billion per year. It provides health insurance to more than one in five Americans.

In a letter sent today to state Medicaid directors, CMS said that states could pursue work requirements for Medicaid recipients using Section 1115 waiver authority.  Such waivers are intended to support experiments, pilots, and demonstration projects of various kinds under Medicaid and CHIP.  They must be budget-neutral and include evaluations.

Such waivers are intended to build out the evidence base. It is unclear what evidence-based strategies the states might use to promote work by Medicaid recipients.

At least 34 states are currently using the waivers for various other purposes, including expanding coverage and modifying provider payments. They are usually focused on controlling health care costs while improving access and quality. Several states have used them to implement their Medicaid expansions under the Affordable Care Act.

The Obama administration consistently rejected state requests to use them for work requirements, according to the Washington Post. That policy has now been reversed by the Trump administration.

In its letter to state Medicaid directors, the administration said it would also support state efforts to align SNAP or TANF work-related requirements with the Medicaid  program.

The change could have an immediate impact. According to the New York Times, at least 10 states have expressed interest in using them for work requirements: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin.

CMS could approve the first waiver for Kentucky as soon as Friday.

“This is going to go to court the minute the first approval comes out,” Matt Salo, executive director of the National Association of Medicaid Directors, told the Post.

Earlier this week, President Trump had indicated during a press event at Camp David that he wanted to work on a bipartisan basis with Democrats on welfare reform. The new policy seems contrary to those sentiments, but it may also increase pressure on both sides to take up the issue this year.

Previous bipartisan welfare reform efforts had included significant evidence-based provisions, including consideration of a possible welfare-focused evidence clearinghouse.


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Posted in Children and Families, Health

Is a Bipartisan Evidence-based Welfare Bill Still Possible This Year?

Early news reports from a weekend retreat at Camp David between President Trump, Sen. Mitch McConnell, and House Speaker Paul Ryan suggest that a Ryan-backed plan to revamp the nation’s welfare laws along partisan lines is now dead.

Little noticed in the reports, however, was the fact that Trump left the door open to working with Democrats on a more bipartisan plan — something that is not completely inconceivable, despite the poisonous partisanship that has marked Washington of late.

Ryan had headed to the weekend retreat hoping to win over the president and McConnell. The president was initially supportive, but McConnell opposed the plan as undoable in the Senate, where Republicans hold a narrow 51-vote majority, and Trump eventually sided with McConnell.

According to Politico:

The increasingly dire political environment for the GOP is one of the reasons senior Republicans have leaned on Ryan to scale back his entitlement reform ambitions. A majority of Ryan’s more conservative conference are eager to cut spending and would surely embrace his ideas. But doing so could put the two dozen House Republicans in Hillary Clinton-carried districts in an even more tenuous position.

Two Republican sources said Ryan has narrowed his entitlement push to welfare programs only, like food stamps and housing for the poor. He’ll likely push for work requirements for adults who do not have disabilities and frame this issue as one that helps — not hurts — the poor by breaking the “cycle of poverty” and helping the unemployed get jobs. Republicans would likely be able to target such programs through powerful budget reconciliation procedures that prevent the use of the filibuster in the Senate.

While Trump and White House officials have signaled a desire to take up the matter, it’s unclear if they will be able to convince a more cautious McConnell to get on board.

After this weekend’s meeting in Camp David, the answer was apparently no, at least not as Ryan had framed it. But Trump suggested that he was still open to a bipartisan plan during a Saturday press event.

“It’s a subject that’s very dear to our heart,” Trump said. “We’ll try and do something in a bipartisan way, otherwise we’ll be holding it for a bit later.”

“But we’ll be looking to do that very much in a bipartisan way,” he added.

Trump’s Saturday statements reflected McConnell’s views, which he expressed last month:

“I’ve been here a while, and the only time we’ve been able to do that is on a bipartisan basis,” McConnell told reporters about welfare reform before leaving Washington for the Christmas recess. “It was Ronald Reagan and Tip O’Neill, who raised the age of Social Security and that was before I got here, so it’s been a while.”

“The sensitivity of entitlements is such that you almost have to have a bipartisan agreement in order to achieve a result,” he added.

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Posted in Children and Families

GAO Finds Federal Use of Evaluation Appears Unchanged Since 2013

A GAO report released in late September has found that that fewer than half (40 percent) of surveyed federal managers say that an evaluation had been completed within the past 5 years of any program, operation, or project they were involved in. The figure is statistically unchanged from 2013, the last time GAO surveyed federal managers on the topic.

The apparently unchanged use of evaluation comes despite years of promotion under the Obama administration, public scorecards released by outside groups like Results for America, and actions by Congress, such as the creation of the Commission on Evidence-based Policymaking. According to the report:

For several years, OMB has encouraged agencies to use program evaluations and other forms of evidence to learn what works and what does not, and how to improve results. Yet, agencies appear not to have expanded their capacity to conduct or use evaluation in decision making since 2013.

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Posted in Evidence

Evidence Commission Recommendations Generate Pushback in House Hearing

A hearing today by the House Committee on Oversight and Reform appeared to generate more questions than support for the recommendations of the Commission on Evidence-Based Policymaking.

The hearing’s four witnesses, all of whom served on the commission (including the chair and co-chair, Katharine Abraham and Ron Haskins), used their time to explain its 22 recommendations. However, the central purpose and value of those recommendations — to help build a national evidence base on federal programs and interventions to determine which work and which do not — did not seem to be clear to most of the members of the House committee.

Several Democrats used the occasion to criticize the Trump administration for policies that they felt were insufficiently evidence-based, including those on global warming and teen pregnancy prevention.  Republicans seemed skeptical that a new office — the proposed National Secure Data Service — was needed at the Commerce Department, expressing a traditional Republican small-government point of view.

The central bipartisan point, that evidence could enable federal agencies to achieve better outcomes at lower cost, seemed lost on most of the members of Congress who were present.

Fortunately, backing from the commission’s main supporters in Congress — House Speaker Paul Ryan and Sen. Patty Murray — is still likely to be strong enough to ensure that some form of “downpayment” legislation moves in the weeks ahead.

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Posted in Evidence

What Does the Federal Evidence Infrastructure Look Like?

What is needed at the federal level to expand the use of evidence?  Where are we?  What else do we need to do? Earlier this month, the Forum for Youth Investment released a very good report that answers these questions.

The report, Managing for Success: Strengthening the Federal Infrastructure for Evidence-based Policymaking, does an excellent job describing the existing infrastructure. It breaks this information out across five types of evidence (data, statistics, evaluation, performance metrics, and social and behavioral sciences) and six infrastructure components (White House, interagency, and agency offices plus policies, guidebooks, and assistance to state and local governments).

Compiling all of this information in one place — mostly in the appendices — was a useful endeavor all by itself. The paper also includes multiple recommendations for improvement — recommendations that take on added relevance because they appear to be rooted (at least in part) in interviews, recommendations, and feedback from federal officials.

The paper was released at the same time as the final report of the Commission on Evidence-Based Policymaking, although the Forum’s paper seems broader than the Commission’s work, which focused primarily on making data more accessible to researchers.

What were some of the Forum paper’s more notable recommendations? One suggested that evidence is too often viewed in terms of what works and what does not, with associated implications for program budgets. Instead, the paper recommends greater use of budget-neutral strategies.

According to the paper:

Perhaps more problematically, such use creates a backlash against evidence itself. There are cases in which Congress has responded to a negative evaluation of a popular program by passing legislation prohibiting any future evaluations of it. As one federal official noted, “we have a history in which negative results on an evaluation can mean that the money goes away. But the problem you are trying to solve has not gone away. The ‘fear factor’ is real for programs—if anyone fears that the information will be used to kill their program, the learning won’t happen.” …

Fortunately, there are two approaches to using evidence that are revenue neutral and therefore have the potential to be scalable.

The first is shifting funding from programs that evidence suggests do not work to programs that evidence suggests do work, for the same population and issue area …

The second approach is to use evidence to spend the exact same amount of money on the exact same program but to encourage or require changes to the program that will make it more efficient and effective.

This approach, which the paper suggests should be used by both OMB and Congress in budget development, seems to mirror what the Obama administration did with evidence. That approach was criticized by some on the right, however, for not cutting back programs that are not effective. So far, the Trump administration seems to be taking a harder line.

The other recommendations range from technical to familiar (for example, the paper echoes previous recommendations to create chief evaluation officers in federal agencies and set aside 1% of program funds for evaluations). Nevertheless, the paper serves as a good companion piece to the Evidence Commission’s work.

Posted in Evidence

Evidence Commission’s Proposed Data Service May Be Built in Stages

Additional details are beginning to emerge about next steps following the release last week of the final report of the Commission on Evidence-Based Policymaking.

A hearing by the House Committee on Oversight and Reform, originally scheduled for September 12, has been postponed, possibly until September 27. The hearing was reportedly delayed because of hurricanes and resulting flight cancellations that prevented members of Congress from returning to Washington.

Despite the delay, the House is still expected to push forward a bill to implement some of the commission’s recommendations. At this time, it appears that this “downpayment” legislation will be attached to the Open Government Data Act (HR 1770, S 760), which commands bipartisan support in both chambers.

However, it also appears that the commission’s central recommendation — the creation of a National Secure Data Service to act as a liaison to pre-approved researchers who want access to federal data — will need to wait until a second bill moves in Congress later this year or next. Until that time, the Center for Administrative Records Research & Applications at the Census Bureau may be doing some of the initial work preparing for the new service.

During a call sponsored by Results for America earlier today, Katharine Abraham, the chair of the commission, affirmed the central importance of the proposed Data Service. Abraham and Ron Haskins, the co-chair, are meeting with stakeholders to support the commission’s recommendations.

Their work is being supported by the Bipartisan Policy Center.  Results for America and others are also drumming up support on Capitol Hill.

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Posted in Evidence