Beyond the Fraud Algorithm
Last week, we covered the responses of disability advocates to the Centers for Medicare and Medicaid Services (CMS) call for information on waste, fraud, and abuse in healthcare programs like Medicaid. Despite these federal claims of waste, the data is just not there to justify cuts to essential services. Even now, underfunding of Medicaid HCBS has left over 600,000 individuals on waiting lists nationwide, meaning we have yet to fulfill the need for community care for a large number of disabled people and elders nationwide. Over 26.7 million people are uninsured in America, with 14 million more predicted to become uninsured by 2034 (according to the Congressional Budget Office). Home care is a critical part of our healthcare infrastructure, and more funding is still needed to ensure this service is provided fully, as part of a functioning healthcare system.
The Kaiser Family Foundation estimates there are about 5.1 million home care recipients nationwide. Meanwhile, CMS inaccurately claimed that 5 million people were using the program in New York alone (an exaggeration over ten times the 450,000 in-state individuals who do use these services). This claim was used as part of a broader argument against wasteful spending.
Claims of fraud are being used to cut federal Medicaid funds already. The Georgetown Center for Children and Families (CCF) discusses how the withholding of Medicaid funds in Minnesota is part of a larger trend of federal payment deferrals following claims of fraud.
Medicaid continues to be the primary payer for HCBS, and exaggerated claims from federal officials are not just sloppy, but a dangerous strategy to undermine support for essential care, falsely equating an already underfunded service with programmatic financial inefficiency. This is a dangerous precedent for an agency that is boasting the use of artificial intelligence to identify alleged cases of Medicare and Medicaid fraud.
If funding for Medicaid is slashed, it will contribute to the growing population of the “chronically ill uninsured” that Drew Altman addresses in a recent KFF blog. When healthcare is underfunded, disabled individuals will be hardest hit. Medicaid HCBS is the pathway for ending institutionalization of people with disabilities, and ultimately costs less per person than institutional care. Through HCBS (home care), communities are able to meet the vision of the Americans with Disabilities Act (ADA), which requires communities to proactively support community integration and living. Health Affairs outlines the bipartisan history of implementation programs that have supported the expansion of HCBS.
Advising on Medicaid Work Requirements
Wherever you are based, the Medicaid unwinding from 2023 offers some critical lessons for implementing work requirements in 2026 and 2027. Here are some highlights from a recent KFF article to support your outreach and guidance to people enrolling in and maintaining their coverage:
- During unwinding, many states expanded the number of touchpoints before renewal and engaged in multi-modal communication strategies. These included broad efforts (e.g., traditional communication campaigns, paid advertising, press conferences, and toolkits for partner organizations), direct outreach to enrollees (e.g., mailers and text messaging), and targeted outreach to certain populations such as people with limited English proficiency. States also used new strategies to update contact information, such as using the National Change of Address database and accepting updated contact information from managed care organizations (MCOs), with reductions in returned mail. Groups reported that finding the correct balance of frequency of outreach and ensuring clear messaging is key to not overwhelm or confuse enrollees.
- During the Medicaid unwinding, most states worked with a wide range of groups to reach Medicaid enrollees, including managed care organizations (MCOs), providers (such as community health centers, other primary care providers, and pharmacies), community-based organizations, navigator/assister organizations, and faith-based groups to amplify state outreach efforts. State officials and groups working directly with affected enrollees found local marketing and word of mouth to be effective methods for reaching enrollees. Many states also held regular meetings to provide updates and review data with others involved in unwinding. Feedback loops with community partners helped identify early problems; conversely, limited state engagement and communication contributed to frustration and more reports of problems.
As you support people with enrollment and knowing how to navigate work requirements, think through the local resources and partners you can rely on to share this information with Medicaid enrollees.
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