Lauren Moran, MPP

May 17, 2021

Across the nation, health care stakeholders are intensifying their focus on addressing inequities in care delivery and reducing racial and ethnic disparities in health care access and outcomes. Medicaid is the primary source of health care coverage for over 77 million Americans, with Black and Latino communities making up approximately 46 percent of enrollees. As such, Medicaid programs are a significant player in reducing health disparities and advancing health equity.

Medicaid medical directors have a unique leadership opportunity to address equity through their oversight of services covered by Medicaid and their connections with providers delivering those services. From their vantage point, medical directors have insight into provider and patient experiences, as well as the barriers that can hinder access and treatment. CHCS recently spoke with internist and pediatrician Nathan Chomilo, MD, Medical Director of Minnesota Medicaid and MinnesotaCare to get his perspectives on priority opportunities for addressing health equity for people served by the state’s Medicaid program.

Q: Many of today’s state policy discussions are centered around advancing health equity through key Medicaid levers. Where do you see the most opportunity for impact?

In Minnesota we are also looking at what our data tells us about racial equity and our quality metrics, recognizing that the same intervention will not work for all enrollees.

A: There’s opportunity in just about every decision and discussion that we have as Medicaid policymakers, but I see four main areas to work on racial and health equity. The first is eligibility and enrollment. This past year has been a natural experiment where folks aren’t being disenrolled due to funding stipulations connected to the federal relief packages. We have an opportunity to see how that impacts overall access to care and hopefully come up with some answers about what’s best when it comes to renewal periods.

A second lever is access to care. Being enrolled doesn’t guarantee someone gets the care they need. So how can we ensure they have access to culturally acceptable care from providers that reflect their community? How do we ensure they not only have access to mental/behavioral health, dental and specialty care but to other providers who have evidence of reducing disparities in outcomes like community health workers and doulas? Then there is ensuring literal access through benefits like nonemergency medical transportation and telehealth. Whether it is a fee-for-service, managed care, ACO or other structures, we have the ability to view these policies and benefits through an equity lens.

Another lever is looking at the quality-of-care enrollees are receiving. Pediatric colleagues in Seattle are exploring quality metrics for their hospital and identifying which metrics they’re behind on compared to other hospitals, and then specifically examining the racial demographic breakdown of those lagging metrics. They are finding that when they focus on closing racial gaps, the overall quality metric goes up. In Minnesota we are also looking at what our data tells us about racial equity and our quality metrics, recognizing that the same intervention will not work for all enrollees. We’re specifically trying to identify gaps, build our processes to address them, and look for better, community-informed metrics.

The last one is early opportunities. Many disparities and gaps we see throughout the lifespan start early: prenatally through the first three years of life. We can home in on how services, prenatal models, and opportunities to connect young families and expecting persons to other supports through Medicaid are optimized to give children and young families more equitable opportunity for health and to reach their full potential from the very start.

Q: Can you share an example of how Minnesota’s Medicaid program is advancing health equity in the short- and long-term? What are some of the challenges associated with these goals?

A: Minnesota has a pilot program called Integrated Care for High-risk Pregnancies. This program launched about five years ago to address birth disparities. In Minnesota white birthing persons and infants have much better outcomes than Black and Indigenous birthing persons and infants. We built a program that really tried to engage communities from the start to build a collaborative care model that addresses disparities on multiple levels. There is a community advisory board that helps make decisions with the Medicaid team about how grant funds are stewarded and how success is defined and framed. This program is a partnership between state government agencies, medical institutions, and communities. It has successfully demonstrated that we can share power and stewardship over Medicaid resources. This requires an ongoing commitment that this won’t be a single pilot project that then disappears.

We’re now looking to scale the pilot effort to increase the accessibility of the program for Black and Indigenous birthing persons through a proposal in our Governor’s budget and proposed use of American Rescue Plan funding. The hope is to build the program up to address specific outcomes, identify what’s key for addressing disparities resulting from structural racism, and repair the violation of trust.

Listen: Bridging the Gap Between Medicaid Policymakers and Research

Dr. Chomilo discusses the importance of aligning Medicaid policymakers and research to better understand the experiences and realities of Medicaid enrollees in neighborhoods they serve.

Q: As Medical Director, why is it important to promote health equity for Minnesota’s Medicaid enrollees?

If we don’t address the structural issues on how our enrollees are able to access care, chief among them structural racism, then we’re not doing our full jobs as stewards of this program or, in my mind, as a medical director charged with improving the health of our population.

A: I see it as a crucial part of the job because so many of the inequities disproportionately impact those we are charged with serving within our Medicaid program. One way I’ve framed that is in how we talk about the impact of investments and cuts to our programs across communities. For example, an analysis of 2018 data done last year by the State Health Access Data Assistance Center showed that approximately 64 percent of Black children and 54 percent of American Indian and Native American children in Minnesota depend on Medicaid or CHIP for their health care coverage versus 17 percent of white children. Changes, investments in, and cuts to these programs will therefore disproportionately impact different communities. When we’re talking about health equity, it’s critical to think about how our programs impact communities along these lines of disparity that developed over hundreds of years. If we don’t address the structural issues on how our enrollees are able to access care, chief among them structural racism, then we’re not doing our full jobs as stewards of this program or, in my mind, as a medical director charged with improving the health of our population.

Q: How does your role enable you to help Minnesota achieve its health equity goals?

A: I’m a half-time Medicaid medical director and half-time physician in a practice that sees at least 50 percent Medicaid patients. This helps me translate the impact of policy decisions on enrollees and gives context for policy intent versus what might be the actual result. Understanding our unique health care systems in Minnesota helps me to know how a proposed policy would actually get implemented across different systems.

I’m also able to speak from my lived experience and am active in the community, including with academic researchers on health equity and community advocates. I’m able to bring these perspectives and weave them into recommendations for community engagement and policy development. My role creates an opportunity to push for ideas that not only sound good or have academic merit but are also informed by those who will be directly impacted and affected by them.

Q: Minnesota uses managed care as the primary Medicaid delivery system. What opportunities do you see to promote health equity with and through your managed care organizations?

It is clear that addressing not just health equity but racial equity must be among the priorities of those we entrust to care for our enrollees.

A: The real goal is to be quite clear that addressing structural racism, promoting anti-racism, and capturing and measuring health equity are part of the expectations for any managed care plan who’s serving our enrollees. Our focus on addressing health equity and structural racism must show up in how we pay and award contracts.

If the financial incentives for managed care organizations are not aligned with our efforts around health equity and institutional racism, then we’re going to continue to see gaps persist. I’m proud of the work we’ve done to start embedding that throughout our most recent RFP process. From questions about how MCOs are taking steps to become an antiracist organization, to how are they using value-based purchasing or other incentives to improve racial equity in quality of care, to more directly asking what they are doing to reduce implicit, explicit, and institutional bias experienced by Black and Indigenous people during pregnancy, it is clear that addressing not just health equity but racial equity must be among the priorities of those we entrust to care for our enrollees.

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Don Ross
2 months ago

Thank you, Dr. Chomilo, for sharing your approach and thinking in Minnesota. Every state is learning from the data and insight they obtain from pilots and initiatives. Since we are all trying different things, it is extremely useful that CHCS and other organizations keep the communication, sharing, and comparing going among us. What you shared about initiatives that improved aggregate quality performance having left some sub-populations behind resonated with me and my colleagues who have worked in Oregon, Washington, and Hawai’i Medicaid policymaking. The rising tide does not necessarily “float all boats,” so we always need to have both population-segmented… Read more »