Lauren Moran, MPP

December 5, 2019

Medicaid, which serves nearly one in four Americans, has a significant impact on the health and well-being of low-income populations across the nation. The program is in a unique position to stimulate innovations in health policy and practice that enhance care, better manage costs, promote health equity, and improve health outcomes for its beneficiaries, particularly those with complex health and social needs. Regardless of recurring shifts in the policy and funding landscape, Medicaid directors and their senior staff are charged with improving the health of millions of residents in their states.

One trusted source of information that Medicaid leaders often turn to is the Medicaid and CHIP Payment and Access Commission (MACPAC). Since 2010, this non-partisan legislative branch agency has provided policy and data analysis and recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and states on issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). The U.S. Comptroller General appoints MACPAC’s 17 commissioners, who bring broad expertise and a wide range of perspectives from across the nation. Anne Schwartz, executive director of MACPAC, recently spoke with the Center for Health Care Strategies about current trends in Medicaid policy, what those trends might mean for Medicaid leaders, and MACPAC’s role in informing Medicaid innovation.

Q: Can you briefly describe MACPAC’s mission and some of the trends it is following?

A: MACPAC was set up to provide policy and data analysis and recommendations. Our primary client is Congress, but we frequently make recommendations to the Secretary of Health and Human Services. We really see ourselves as a nonpartisan resource for Congress that makes recommendations grounded in data and evidence, and as a general resource to the health policy community, which includes the states and various stakeholders.

The trends that we’re following are a constantly changing set of issues. Right now, some of the big themes include: addressing issues around high-cost specialty drugs and how to manage those costs; promoting integrated care for beneficiaries who are dually eligible; and better understanding what’s going on in value-based payments, particularly in managed care. We are also initiating a new line of work around maternal health and mortality.

Q: How does MACPAC balance federal versus state priorities when making recommendations?

When considering solutions to whatever issue we may be discussing, we always consider the potential effects at the federal and state level. We also think about how potential solutions may influence plans, providers, and beneficiaries.

A: We get input from a variety of sources when we set our agenda. We focus on where Congress needs assistance and try to respond to their short-term needs and anticipate where they will need help in the future. We also keep track of what’s going on in the administrative side of the federal government and understanding pressing issues. Our commissioners also have a variety of interests that is reflected in our work plan. When considering solutions to whatever issue we may be discussing, we always consider the potential effects at the federal and state level. We also think about how potential solutions may influence plans, providers, and beneficiaries.

Q: Many Medicaid programs are focused on partnering with other health and human services agencies to foster cross-sector alignment to improve outcomes for members. What do you see as the greatest opportunities in this area? The greatest challenges or obstacles?

A: This is an issue that comes up in a variety of different contexts. We are acutely aware of the capacity constraints facing states and we look for ways states can partner to improve their capacity. There are a number of states and territories partnering with each other on Medicaid Management Information System (MMIS), such as West Virginia and the U.S. Virgin Islands. Another example is the New England states that have a long-standing tradition of partnering through the New England States Consortium Systems Organization (NESCSO).

We know that procurement rules can be a barrier to creating formal partnerships, and states have limited bandwidth. Unless there is a sense of real and measurable gain out of the collaboration, it can be difficult to commit. We’ve discussed whether an increased federal match for those kinds of activities would be of interest to states. But, more money on the administrative side is potentially a political problem if a Medicaid program is trying to demonstrate that it’s running a lean program. Other states may not want to keep track of another quarter of a percent match. This is an area where we do not have good solutions yet even though we have a strong understanding of the issue.

Q: The Medicaid policy landscape is always evolving. What do you see on the horizon for Medicaid at the federal level? At the state level?

A: Medicaid expansion is the tail that’s been wagging the Medicaid dog since 2010, particularly in the press — it is now an evergreen issue. We’ve seen more states wanting to take the expansion but under various conditions. Issues around expansion will continue, as well as what forms expansion could take. There is also this looming question that we’re waiting for guidance on from CMS around block grants. Tennessee was the first one out of the gate with its proposal. What is CMS going to say about what they’re willing to entertain for waivers for block grants and what potential issues could arise from those proposals?

Q: How is the role of data changing in the overall operations of Medicaid?

A: The question of value in Medicaid automatically invokes data because if you’re talking about value, you’re talking about outcomes measured by what is spent upfront. You need to have data not only to set proper payments, but also to construct initiatives to address quality, figure out how to calibrate payments to achieve outcomes, and then measure performance.

Q: How is the diversity of perspectives across Commission members an asset to thinking about Medicaid policy?

There are different perspectives that need to be represented on the commission, so it is absolutely a feature of our work. What is at MACPAC’s table is a microcosm of the interests that are at every Medicaid policy decision table, whether the state or federal level.

A: The diversity among the Commission members is part of our statutory authority. There are different perspectives that need to be represented on the commission, so it is absolutely a feature of our work. What is at MACPAC’s table is a microcosm of the interests that are at every Medicaid policy decision table, whether the state or federal level. In some ways, the Commission was set up to help Congress sort through what the differences might be among the various stakeholders on any policy issue. It is very interesting to watch the members educate each other and help each other understand their various perspectives. That sort of collegiality leads to commissioners really valuing each other.

Q: Why is strong program leadership so critical to the success of Medicaid programs? What advice would you give to a new Medicaid leader?

My advice to new Medicaid leaders is the advice I would give to anyone in a new leadership position: start off being a good listener and don’t try to do everything.

A: Medicaid programs don’t run on their own. Expectations about performance, direction, and vision don’t happen unless someone is there to drive it. We see exciting things coming out of Medicaid programs where there are seasoned and inquisitive leaders who are really trying to move their programs.  My advice to new Medicaid leaders is the advice I would give to anyone in a new leadership position: start off being a good listener and don’t try to do everything.

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