This article was co-authored by Jennie Riley (Executive Director, Rx Foundation) and Lynne Garner (President and Individual Trustee, Donaghue Foundation); and it originally appeared in Health Affairs’ Blog on April 10, 2019.
Over two months in 2018, the Donaghue Foundation and the Rx Foundation assessed and responded to a request from a group of researchers based at the University of Pennsylvania Center for Health Incentives and Behavioral Economics (CHIBE) and Columbia Law School to fund two population-level surveys that would complement their independent evaluation of the 1115 Medicaid waiver (the one including “community engagement” such as work) in Kentucky.
While the results of the first survey, which seeks to understand the knowledge and beliefs of the general population in Kentucky about the state’s new and controversial Medicaid waiver program, will not be available until later in 2019, the decision to support two surveys that will enhance the results of the state-funded evaluation reinforced several lessons for us as grantmakers.
Lesson No. 1: Relationships Are Important
The Donaghue Foundation had previously worked with Kevin Volpp and the CHIBE team members in several contexts, and we knew the high caliber of their work. So when they came to us with a request for support to expand the scope of their evaluation of Kentucky’s Medicaid waiver policy, we were willing to give it serious consideration even though it was outside of our major grant programs and required an expedited proposal review process.
Volpp’s team (Atheendar Venkataramani and Kristen Underhill) had already been asked by Kentucky to serve as the independent evaluators for the package of reforms they were testing, including a “community engagement” requirement (that is, eighty hours of work, school, or volunteer activity a month); premium payments at all income levels; and tightened requirements for re-enrolling if a beneficiary falls out of the program. However, knowing there was widespread confusion about the program and understanding its potential impact on lower-income people, the researchers sought to measure baseline knowledge of the new policies, as well as opinions about how these requirements affect people’s lives. Knowing that similar Centers for Medicare and Medicaid Services (CMS) waivers are being considered for roll-out in other states, the CHIBE team recognized this as one of the most important policy issues currently affecting vulnerable populations and the urgent need to document and understand the nuances of these policies as they unfold.
Despite slightly different missions in the realm of health care delivery, the Donaghue Foundation and the Rx Foundation had also previously worked together. We currently co-fund a multiyear project under Donaghue’s Greater Value Portfolio and regularly share updates on our respective priorities and opportunities. Our baseline of trust made it easy to ask whether this project would be of interest to both foundations and to work through the different decision processes of the two funders by sharing questions, concerns, and expert input along the way.
Lesson No. 2: Be Nimble For Time-Sensitive Ideas
Anyone who has ever applied for, or been in a position to award, a grant knows that the gears of philanthropy often move slowly and with great deliberation. In this case, the CHIBE team needed to know relatively quickly if there would be funding to support this survey work in Kentucky, because the baseline survey was scheduled to be completed before the Medicaid waiver was implemented. Perhaps because each funder is small and has a minimum of organizational layers, we were able to facilitate a streamlined process of review and discussion, leading to approval of the co-funded survey work in just two months. Despite the abbreviated timeline, both foundations integrated review of specific detailed questions from several outside advisers, as well as internal review of a full proposal.
Ultimately, the two foundations approved a combined total of $273,742 in grant funds to be distributed over two years for two surveys to be completed and analyzed—one before and one after the waiver implementation.
Lesson No. 3: Be Willing To Invest In Work That Might Be a Head-Scratcher For Others
This expanded evaluation of the Kentucky Medicaid waiver is unlike any other project in either foundation’s current portfolio. Plus, some health funders may question whether funding evaluations for “work-requirement” policies unwisely legitimizes these programs.
However, as a research-focused project that has important implications for changes to Medicaid policy across the country, and to health care access for vulnerable populations, it is at the nexus of where our respective foundations’ priorities overlap.
We point to the New England Journal of Medicine article published by the leaders of this evaluation effort for a more detailed explanation of why this feels urgent to us as health funders. They say that while CMS mandates independent evaluation of 1115 waiver demonstrations, “the Government Accountability Office has noted striking methodological deficiencies in prior evaluations.” We agree with the authors that rigorous evaluation of policies lacking a current evidence base is critical for both ethical and practical reasons.
We also chose to commit this funding at a time when the future of the Kentucky Medicaid waiver was uncertain. CMS initially approved the waiver in January 2018, it was then sent back to CMS by a DC federal district court in June 2018, and then CMS reapproved it with few modifications in November 2018. We made this commitment while the legal basis for these changes to Medicaid was still uncertain, in part, because these untested policies are being rolled out in multiple states without evidence about how well people understand them. Even the preimplementation baseline survey would provide useful information. However, Donaghue and Rx structured our agreements with the evaluators so that the funding for the second survey of Kentucky residents was contingent upon the implementation of the 1115 waiver program.
In a letter to Health and Human Services (HHS) Secretary Alex Azar II in November 2018, the Medicaid and CHIP Payment and Access Commission (MACPAC) summarized serious concerns about the implementation of a similar work requirement in Arkansas. While program implementation in Arkansas began on June 1, 2018, as of November 8, 2018, there was still no approved evaluation design in place.
On March 27, 2019, the DC federal district court vacated HHS approval of both Kentucky’s and Arkansas’ Medicaid waivers, thereby preventing the implementation of the Kentucky program and suspending the demonstration in Arkansas so as to halt coverage losses. Yet the tension over work mandates continues, with appeals likely in those states’ cases and a new court case in New Hampshire.
While the legal basis of these untested Medicaid policies continues to be played out in the courts, we see an ongoing need for funders to help close this evidence gap in states with approved 1115 waivers and ensure that we all understand the impact of implementing these new policies on access, health outcomes, and costs.
Conclusion
We recognize that it’s not always possible to make quick funding decisions to support emergent opportunities. In this case, though, Rx and Donaghue were able to build upon their existing relationships and to streamline their decision making to support the development of a new evidence base in an area of changing health policy that may have substantial impact on people’s lives and on Medicaid policy throughout the United States.
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