Lauren Moran, MPP and Mark Larson

January 11, 2021

Over its 55-year history, Medicaid has evolved substantially and is a critical component of the U.S. health care system, now providing health coverage to more than 74 million Americans. In the last year, Medicaid has been essential to the COVID-19 response efforts and is core to strategies for advancing health equity.

In 2020-21, CHCS is celebrating two significant milestones — its 25-year anniversary and one decade of the Medicaid Leadership Institute. For the last quarter century, CHCS has worked with Medicaid stakeholders in every state to develop and implement strategies to improve the quality and efficiency of health care delivery, particularly for people with the most complex medical, behavioral health, and social needs. Since 2009, 59 Medicaid directors in 40 states, the District of Columbia, and the U.S. Virgin Islands have participated in the Medicaid Leadership Institute to hone their leadership skills and maximize opportunities to improve Medicaid services. Looking back at the last 25 years, we recently spoke with Medicaid Leadership Institute alumni — including current and former Medicaid directors — about what’s on the horizon for Medicaid’s next decade.

Q: In recent decades, Medicaid programs have led significant initiatives to advance innovations in payment and care delivery models. What do you envision the future holding for these efforts?

The changes happened quickly to address COVID, but many have long-term benefits for Medicaid beneficiaries. We must evaluate these changes and continue to refine and innovate in the years to come.

A: Gary Smith (Medicaid Director, U.S. Virgin Islands): The USVI is experiencing an aging population as many younger islanders have moved to the mainland for economic opportunities since the 2017 hurricanes. The twin storms have also increased lingering issues with stress and mental health for those residents who remain. A community-based approach to both long term services and supports (LTSS) and behavioral health will be the most cost-effective solution. In response, we are building a home- and community-based system of LTSS for our aged, blind, and disabled population. We are committed to a community-based approach to rebuild and restructure the long -term care delivery system, which will provide greater opportunities for social and economic mobility, as well as better health outcomes for people served by Medicaid.

Dave Richard (Medicaid Director, North Carolina): As state budget pressures mount, Medicaid programs will continue to require changes that improve quality while controlling cost. In North Carolina, like other Medicaid programs across the country, we rapidly changed our policy to modernize telehealth, updated policies around long-term care, and focused payments to encourage better practices related to COVID. The changes happened quickly to address COVID, but many have long-term benefits for Medicaid beneficiaries. We must evaluate these changes and continue to refine and innovate in the years to come.

Becky Pasternik-Ikard (Former Medicaid Director, Oklahoma): I expect enhancements in care delivery to continue, especially incorporating care management, particularly at the local level. It’s proven to control costs and maintain or improve chronic conditions. I also anticipate the continued prioritization of telehealth as an alternative to in-person visits and the movement away from institutional to community- or home-based settings to continue.

Q: The pressure on Medicaid to both control costs and increase quality are longstanding. How do we measure the success of these efforts?

A: D. Richard: States must incorporate real evaluation standards within our programs that truly measure outcomes for our beneficiaries. This will require us to improve our partnerships with academic institutions for the independent evaluation of program impact and effectiveness. Too often we evaluate on the short term when we need to evaluate the long term. We must make the case to legislative bodies to avoid annual reactive approaches for Medicaid programs.

B. Pasternik-Ikard: Success can be measured by: (1) gains in access to care and timeliness of care; (2) gains in primary and preventive care services; (3) improvement in certain prioritized national and state identified health outcomes, especially for targeted conditions and populations; (4) improvements in provider and member/family experience; and (5) stability in both the primary care and specialty networks.

Q: How can Medicaid leaders communicate the value of Medicaid?

Talk about Medicaid in terms of its impact on real people’s lives, not as a payment or delivery system. Tell a diversity of stories. Demonstrate in relatable terms the breadth of the program’s reach, from temporary help for pregnant women, children, or adults in the workforce to long-term supports for the elderly and disabled.

A: D. Richard: To understand how to best communicate the value of Medicaid, we need to spend time with our beneficiaries and providers to see the impact on the ground. Too often we speak in a Medicaid language that emphasizes budgets, medical terms, and bureaucratic language that does not translate to the general public. We must begin to talk about how our programs impact communities in ways that are understandable to the public. Rather than leading with the size of our budgets, we should lead with the human impact of the program. We need to talk about what Medicaid means to a family with a child with a disability, the impact of preventive care for a child, and the importance of prenatal care for a mother.

Jen Steele (Former Medicaid Director, Louisiana): Talk about Medicaid in terms of its impact on real people’s lives, not as a payment or delivery system. Tell a diversity of stories. Demonstrate in relatable terms the breadth of the program’s reach, from temporary help for pregnant women, children, or adults in the workforce to long-term supports for the elderly and disabled. Paint a picture that is as inclusive as possible, making it a program for “us” and not “them.”

G. Smith: While Medicaid enrollment has increased in the last decade, studies indicate that potentially an additional 20,000 islanders may be eligible for the program. Outreach through trusted community forums, like churches and nonprofit organizations, may be the best strategy to communicate the importance of establishing and maintaining Medicaid eligibility. To the extent that we can succeed in this effort, we can relieve a tremendous burden on the locally financed public health delivery system that provides many services without the benefit of a federal Medicaid match.

Q: Reducing disparities and advancing health equity is a central focus for many health policy stakeholders. What opportunities does Medicaid have to impact health equity?

A: D. Richard: Our programs directly impact the communities that have the most health disparities, and we have significant tools to address health disparities in both fee-for-service and managed care. We need to focus on how social determinants impact health disparities. In particular, we should focus on what the Medicaid program can do in conjunction with other governmental and private sector initiatives. Too often we silo our efforts and do not seek coordination with other partners, including other governmental agencies. Our efforts also need to target regions of our states by coordinating with local officials. It is critical that we invest in long-term success and not just short-term process outcomes.

We have also learned through COVID-19 that long-standing health inequities that we knew existed were even more harmful than we realized. This requires us to view all our policies and payment structures through an equity lens as we move forward.

Q: COVID-19 has shaken the foundation of the U.S. health care system in many ways. What are key lessons for Medicaid from the last year’s experiences?

Medicaid has the leadership capacity and should always be included in any state-level strategic planning for solutions.

A: B. PasternikIkard: Medicaid has the leadership capacity and should always be included in any state-level strategic planning for solutions. State Medicaid agencies have learned what additional Centers for Medicare & Medicaid Services’ authorities are available during this time. We also learned Medicaid’s capacity for speed, flexibility, adaptability, and the depth of abilities within our agency staff to offer innovative solutions.

J. Steele: I think the biggest lesson for Medicaid from 2020 is the necessity of being nimble and adaptable. Medicaid is a complex program that historically has been slow to change. The COVID-19 public health emergency demands unprecedented flexibility and a brisk pace — and states and the federal government have risen to the occasion. The trick now is reshaping our institutions to work this way over the long term as such demands may well be our “new normal.”

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