RWJF Comments on Proposed Regulations Regarding Healthcare Access

Summary of RWJF comment:

• Historically, Medicaid eligibility practices in many states have reflected often racist concepts of “deservingness.” Though the Affordable Care Act (ACA) reduced many long-standing eligibility restrictions and administrative burdens in the Medicaid program and made advances toward a more coordinated system of health coverage, states have not uniformly made it easier for individuals to enroll in and retain coverage, ensuring that significant racial inequities in coverage enrollment and retention persist. 
• Enrollment churn—the temporary loss of coverage in which enrollees disenroll and then re-enroll within a short period of time—affects millions of people in the United States, with 10% of Medicaid and CHIP enrollees in 2018 experiencing a gap in coverage over the course of a year. Even short coverage disruptions are associated with lapses in physician care and medication adherence; increased administrative costs for providers, Medicaid managed care organizations, and states; and, in some cases, higher healthcare costs when delayed care results in more expensive healthcare needs.
• Research shows that administrative burdens, such as requiring people to return forms rather than relying on electronic data and verification, reduce the number of people who enroll in and retain health coverage. The impact of administrative burden has been evident in states that implemented Medicaid work requirements, where new employment verification requirements resulted in significant Medicaid coverage losses despite the fact that the vast majority of individuals either met the work requirements or should have been exempt from them.  

Summary of RWJF comments:

• The application of nondiscrimination protections to health programs and activities is of paramount importance to ensuring that everyone has a fair and just opportunity to be as healthy as possible. The large and pervasive disparities and inequities in health and healthcare by race and ethnicity, national origin, age, sex, disability, and income in the United States are driven by many factors, including systemic racism, the physical and psychological stresses of discrimination, differences in economic opportunity, and discrimination within the healthcare system itself. This discrimination occurs within healthcare settings, healthcare financing and coverage, and patient-clinician encounters, and has resulted in delayed care, reduced use of necessary care, lower-value care, undertreatment, and reduced use of preventive care. It also drives a greater likelihood of unaffordable out-of-pocket costs, medical debt, and financial insecurity. Ultimately, populations that experience discrimination in the healthcare system face poorer outcomes and preventable mortality.
• Clear and rigorous regulations will provide key guidance to healthcare systems, health insurance issuers, healthcare professionals, and other stakeholders who will be responsible for complying with these requirements. They will also help ensure that HHS can exercise the full scope of its authority to investigate complaints, take enforcement action, and remedy discrimination against those protected by Section 1557.

Summary of RWJF comment:

• Health is more than an absence of disease. It is a state of physical, mental, and emotional wellbeing. It reflects what takes place in our communities, where we live and work, where our children learn and play, and where we gather to worship. That is why RWJF focuses on identifying, illuminating, and addressing the barriers to health caused by structural racism and other forms of discrimination, including sexism, ableism, and prejudice based on sexual orientation.
• RWJF strongly supports HHS’ efforts to modernize its implementing regulations for Section 504 of the Rehabilitation Act of 1973 to strengthen prohibitions against discrimination on the basis of disability in healthcare and human services programs. An update to the regulations is long overdue; the 2023 Proposed Rule would be the first update since the regulations were originally promulgated in 1977.

Summary of RWJF comment:

• Access to safe and high-quality reproductive medical care, including abortion, is an essential element of comprehensive healthcare and health equity. Trust between patients and providers is a critical component to ensuring meaningful access, particularly in the current moment where access to abortion and other reproductive healthcare services is under attack. 
• Current attempts to restrict access include efforts to criminalize abortion and its providers, which threatens the ability of medical professionals to protect the health of their patients and erodes individuals’ rights and autonomy to make decisions about their own health.

Summary of RWJF comment: 

• Our comments present research that underscores the importance of access to health coverage for DACA recipients and other lawfully present immigrant populations addressed in the Proposed Rule; identifies areas where CMS could strengthen the Proposed Rule; and identifies additional actions CMS could take to expand access to health coverage for immigrant populations. 
• DACA recipients’ current exclusion from Marketplace and Medicaid creates significant barriers to accessing healthcare and widens health disparities.
• Research demonstrates that DACA recipients are significantly contributing to their families and communities. 
• Other lawfully present immigrants addressed in the Proposed Rule need timely access to healthcare.