I recently heard Maine Department of Health and Human Services Commissioner Mary Mayhew speak. Her department administers many of our state’s biggest benefit programs, including Mainecare (or Medicaid), Supplemental Nutrition Assistance (SNAP, formerly food stamps), Temporary Assistance to Needy Families (TANF, formerly Aid to Families with Dependent Children), and General Assistance.
Mainecare is the biggest of the benefit programs. It is jointly funded by the state and federal governments and administered by the state to provide medical care to people with low income and limited resources. The state decides who qualifies.
SNAP is a joint federal-state program that provides low-income, low-resource households with money to buy the basic foods necessary for good health.
TANF is a joint program that provides temporary assistance to families while their parents work toward self-sufficiency.
General Assistance is a state program that provides temporary help to people who lack the means to buy basic necessities.
Mayhew recalled the situation at DHHS when she took over. In 2011, the agency employed 3,400 people to administer $3.4 billion, about half the state government’s total expenditures. Maine ranked third in the nation for the percentage of its population enrolled in Medicaid, second for the percentage of households on SNAP benefits, third for the percentage of households on TANF, and second in the nation for welfare expenditures as a percentage of overall state expenditures.
DHHS was spending about $2.5 billion dollars on Mainecare to care for about 360,000 enrollees. About $1.8 billion of that came from the federal government. Those numbers were the peak of a decade spent expanding the Medicaid program in Maine. In 2002, DHHS spent $1.4 billion to cover about 200,000 Mainers. Between 2002 and 2010, enrollment increased about 78 percent, while Maine’s population increased only 7 percent. Mainecare went from covering about 15 percent of Maine’s population to covering about 27 percent.
Enrollment accelerated because Maine expanded Mainecare by broadening the criteria for eligibility. It was not free. The more people enrolled, the greater Maine’s state share of the program’s cost. Maine experienced regular budget shortfalls. It got by through not paying hospitals for care they provided to Mainecare beneficiaries, and by shortchanging other providers in terms of reimbursement rates.
TANF is supposed to be temporary, and recipients are supposed to work if they are able to. But Maine had not been meeting the work requirement and had been operating under a waiver that eliminated time limit on benefits. The SNAP program is supposed to have a minimal work requirement, but Maine had been waiving that, too.
Meanwhile, the DHHS had been lurching from financial crisis to financial crisis. It did not rigorously enforce eligibility requirements. It measured success by the number of people it enrolled in welfare programs. It formulated its annual budgets by taking the previous year’s expenditures and increasing them by a factor to account for inflation.
Under Mayhew, the department instituted evidence-based management. It started analyzing its data and measuring the performance of its programs. It forecasts the demand for benefits and services. It projects its spending needs. It investigates suspicious activity and refers fraud for prosecution. As a result, its spending is under control. It doesn’t have a shortfall. It can plan, and not just react.
The department repaid the debt to hospitals. It changed the application process from one whose goal was to qualify every applicant for as many benefits as possible, to one whose goal is to get applicants the benefits they need and qualify for.
It refocused Mainecare on the state’s most needy: the elderly and disabled. It encouraged regular users of expensive emergency room care to use more efficient preventative and primary care. It let the waiver on the work requirement for SNAP benefits expire. It imposed a five-year cap on TANF benefits and partnered with the Department of Labor to create a pathway to work for TANF recipients. It put photographs on EBT cards and blocked their use at casinos, liquor stores and strip clubs.
As a result, Mainecare, SNAP and TANF caseloads and spending have declined and Maine is no longer an outlier among the states.
These changes have not come without opposition. Democrats have repeatedly tried to expand Mainecare. Mayhew noted states that did so, like Colorado, Illinois and Kentucky, have experienced significant overruns in their shares of the cost.
In summary, the commissioner said that her department had been unsustainably growing its benefit programs, spending more money than it had, and crowding out other worthwhile programs. It created a culture of dependency where people were trapped in poverty for generations.
The department is now stabilized and in control of its programs. It is instilling a work ethic and self-esteem in its beneficiaries.
That’s the part of the DHHS story that Mayhew’s opponents would like to ignore.