WASHINGTON – Big changes could be in store for the Medicaid program under the potential leadership of Seema Verma as administrator of the Centers for Medicare & Medicaid Services.

In nominating Ms. Verma, President Trump called her a leading expert on Medicaid and Medicare who will help “transform our health care system for the benefit of all Americans.”

A relative unknown, Ms. Verma is a health policy consultant who has spent 20 years quietly designing policy projects involving Medicaid, including the crafting of Indiana’s Medicaid expansion under the Affordable Care Act in which she worked closely with Vice President Pence.

How the savvy consultant could alter the Medicaid program during her potential CMS tenure has been the source of much speculation. President Trump and Rep. Tom Price (R-Ga.), Health & Human Services secretary–designee, have called for the restructuring of Medicaid, including the possibility of block grants that would set limits on total annual spending regardless of enrollment or caps that would limit average spending per enrollee.

Ms. Verma’s role in the revamp will largely depend on what Congress allows, said Mark Polston, a Washington, D.C.–based health law attorney and former associate general counsel for litigation in the HHS Office of General Counsel, CMS division, under President George W. Bush.

“We don’t know what cards she has in her hands – let alone what’s in the deck for her to deal from,” Mr. Polston said at a meeting sponsored by the American Bar Association. “That’s really going to be set by Congress.”

Jonathan Blum speaks at a recent American Bar Association conference.

But experts do foresee the CMS providing more state flexibility to design individualized Medicaid programs, said Jonathan D. Blum, executive vice president of medical affairs for CareFirst BlueCross BlueShield in Baltimore and former principal deputy administrator of the CMS under President Obama.

“From a CMS perspective, the Medicaid program is in large part run by the states,” Mr. Blum said at the ABA meeting. “What the new nominee says to me is that there is going to be a very high priority placed upon working with states, working with governors to modify Medicaid programs and to shape them to meet different state priorities.”

Look no further than the Healthy Indiana Plan 2.0 to get an idea of what such plans could look like, said Leslie V. Norwalk, a Washington, D.C.–based health law attorney and a former acting CMS administrator under President George W. Bush. The Indiana plan requires patients to pay a small amount to receive health coverage and includes a lockout period if payments are missed. Ms. Verma could work with governors to develop similar model waivers, Ms. Norwalk said.

Leslie Norwalk speaks at a recent American Bar Association conference.

“Model waivers in this instance might include a lot more personal responsibility, more premiums, more copayments [and requirements that] you have to work if you’re able bodied, to qualify for Medicaid,” Ms. Norwalk said at the ABA meeting. “You might have fewer mandated benefits. You might have less [Early and Periodic Screening, Diagnosis, and Treatment] dollars for certain age cohorts. CMS can do a lot to make it easier for states to change up how their programs work.”

Mr. Blum said he believes a top priority for Ms. Verma will be limiting the disruption that could come if the ACA is repealed and finding ways to cover those who lose coverage.

“What the next team really needs to really realize [is] that those who sign up for coverage – with the exchanges or through the new state expansions – are sicker on average, have lower income on average, and they’re going to have to think very carefully about the transitions going on,” Mr. Blum said at the meeting. “How you think about the transitions, how you think about continuity of care, how you think about disruptions – those will be very real and very tangible for the next team.”

Thomas Scully, a health law attorney and former CMS administrator under President George W. Bush, speaks at a recent American Bar Association meeting.

Although she’s done a lot of work on Medicaid, Ms. Verma has very little experience with Medicare and little or none in working with Capitol Hill, experts pointed out. She will need to build a team that fills the holes of that inexperience, said Thomas A. Scully, a Washington, D.C.-based health law attorney and former CMS administrator under President George W. Bush.

“If she’s smart, she’ll find a deputy who’s very strong on Medicare. She’ll probably also try to find a former Hill staffer who can help her on the Hill,” Mr. Scully said. “The best news for her is that they picked her really early, so she’s got a head start.”

Hiring a deputy with a strong insurance background will also be key, Ms. Norwalk said in an interview. Even if the exchanges are repealed, other CMS programs, such as Medicare Part D and Medicare Advantage rely heavily on insurers, she said.

Ms. Norwalk noted that Ms. Verma may be surprised to find that much of the CMS agenda is controlled by the requirements of Medicare’s regulatory cycle. “[It] will take up a lot of her time, perhaps more than she might anticipate,” she said. “But in addition, you’ll have governors coming in wanting to do waivers. ... The third component will be how much time she spends on Capitol Hill working on whether repeal is done or not, and certainly the replace function and how that works will be a critical component of what she does. [If she’s confirmed,] she’ll be a very busy lady.”

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What’s in store for CMS under Seema Verma?