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Good Ideas Must Be Evaluated

Two years ago today I was sworn in as CMS Administrator. One of my first actions when I began this journey was to send a letter to the nation’s governors in which I committed to ushering in a new era for the federal and state Medicaid partnership, granting states more freedom to design innovative local solutions. We have followed through on that promise by supporting efforts like waiving decades-old restrictions on addiction treatment services, allowing states to link working age beneficiaries to new opportunities through work and community engagement programs, and rolling back overly prescriptive federal regulations and policies.

We also made a commitment to balancing this state flexibility alongside strong accountability for program outcomes and financial integrity. Those three pillars – flexibility, accountability, and integrity – have guided our work these last two years to transform the Medicaid program, and today we are taking another step forward by releasing new tools and guidance to strengthen monitoring and evaluation of state reform demonstrations.

I recognize that not everyone supports our efforts to prioritize local control. I’ve heard the derisive comments from those in the health policy stratosphere that prefer centralized government command and control of health care in America. It’s not surprising that many of these same people are now working double time to pull us into the big government abyss of Medicare for All.

They decry the very notion of linking eligibility for programs like Medicaid with expectations of work and community engagement, despite these being long-standing bedrock values of our society. They dismiss any possibility that setting and supporting these expectations may actually help families break cycles of generational poverty and improve their health and financial independence more than just handing out a Medicaid card. And they argue vociferously that we overstepped our authority by allowing states to test these theories.

Instead, I argue that prior administrations have undermined the clear intent of Medicaid to operate as a partnership between the state and federal government. States were repeatedly rebuffed at every turn when presenting CMS with new solutions – I know, it happened it me. Congress created Section 1115 of the Social Security Act for a reason, and it explicitly grants the Secretary authority to waive provisions of federal law to approve experimental, pilot, or demonstration projects that further our collective understanding of how best to administer this complex program.

The Medicaid program was designed to serve our most vulnerable populations like children and people with disabilities, so it’s logical that the nature of demonstration projects would change given the unprecedented expansion of Medical eligibility to childless, working-age adults that occurred under Obamacare. Effectively serving the needs of this population will require new and different strategies, and 1115 demonstrations provide a critical vehicle for these efforts—particularly given the statutory requirement for these projects to be effectively evaluated. Through these efforts, we can collect and build an important body of evidence that will support continuous program improvement and new generations of good ideas.

That’s why CMS is releasing a set of new resources to support state monitoring and evaluation efforts. These include templates for states to build effective implementation plans and report critical quarterly and annual monitoring data to CMS. It also includes guidance on how to construct rigorous evaluations for these demonstrations. These were developed with input from subject matter experts, including state program administrators and members of the Medicaid research community. With their support, we have developed key hypotheses, evaluation questions, measures, and approaches that states and their independent evaluator can draw from to develop an evaluation design that CMS can approve, and that can be used to produce a comprehensive evaluation at the end of the five year demonstration.

For example, our guidance on community engagement demonstrations give states specific direction on how to test whether these program lead to increased or sustained employment outcomes by comparing beneficiaries subject to the requirements to those who are not on measures of employment and net income. It provides examples of data sources, research methods, and analytic approaches that can be used to effectively evaluate this question. This level of guidance also cascades across other issues related to health outcomes and socio-economic status.

We support states having the ability to pursue different approaches to meet similar goals or administer common policies. Arkansas is implementing community engagement differently than New Hampshire, which has a different approach than Indiana. But through effective evaluation of these demonstrations, we will gain a stronger understanding of which policies are most effective, and identify opportunities to make improvements. And having clear and consistent monitoring standards will provide early access to data to quickly understand the impacts that a given demonstration is having, allowing the state to make course corrections if necessary.

We don’t have a monopoly on good ideas in Washington. And it isn’t our job to pre-judge the outcomes of different concepts. We must support innovation, rather than act as a barrier to reform. Too many Americans are trapped in poverty, and they deserve our continued focus as we work to find new means to improve their lives and their health. And while we do this, we have a responsibility and have made a commitment to evaluate, monitor, and share the results of state reform efforts with the public so that they can contribute to a larger body of knowledge.  The release of these new resources support that responsibility, and promote our shared accountability to taxpayers and beneficiaries, who deserve a program that delivers results.

For more information, refer to our press release: CMS Strengthens Monitoring and Evaluation Expectations for Medicaid 1115 Demonstrations 

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