Before coming to work at the Agency, I had very little knowledge of Medicaid. I knew it existed, I knew vaguely what it did, but I had very little conception of its innerworkings. In the last five months, however, I have learned more than I ever thought I would know about this particular government entitlement. Specifically, I have delved deeply into the incredibly complex process that goes into keeping this behemoth running, from the policy side.
Say, for instance, that a state or federal governmental body enacts some kind of statutory change (for instance, the recent Health Care Reform bill). Such an act would require the following responses on the part of our Agency. First, new statutory laws mean that the Agency has to revise its administrative laws. Hence, a lengthy rulemaking process follows even the most trivial of legislative acts. Second, Medicaid is jointly operating by state and federal governments; the contract that outlines this joint operation is known as the State Plan. Thus, any legislative act that requires rule changes will probably also require amendments to the State Plan, which requires going through the Centers for Medicare and Medicaid Services (CMS). Finally, some Medicaid programs are not part of Title XIX (of the Social Security Act), but are "waiver" programs that permit the State to provide services that fall outside what is outlined in the SSA. Thus, many legislative changes require changes to our waiver documents, which also require interaction with CMS.
Thus, it's kind of funny to me to see democratic senators and representatives celebrating the victory of HCR as if that is the end of the story. It's a big victory, to be sure, but there is a long road of rulemaking, state plan amending, and waiver amending ahead before any of those new laws are reflected in the day-to-day policy of states like Texas. It's a machine so complex that I sometimes can't even believe it.
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