Nine out of 10 adults in the U.S. struggle with health literacy, the skills necessary to understand and use health information to make important care decisions. Limited health literacy contributes to worsened health outcomes, greater costs, and even higher mortality. Limited health literacy is also  prevalent among populations that have been marginalized, potentially exacerbating existing health and health care disparities across factors like race and ethnicity, age, socioeconomic status, and insurance type.

Limited health literacy disproportionately impacts Medicaid members. Sixty percent of people with Medicaid coverage are either at “below basic” or “basic” health literacy levels compared to only 24 percent of those with employer-sponsored coverage. State Medicaid agencies, which serve large, diverse populations, are uniquely positioned to deploy innovative health literacy strategies and advance health equity at scale.

Health Literacy in Action: State Examples

A number of state Medicaid agencies and plans are actively seeking to improve health literacy practices for greater access, use, and outcomes for their members. What does health literacy look like in practice at the state level? We’ve gathered a few recent examples:

Michigan

In Michigan’s Department of Health and Humans Services (MDHHS), health literacy intersects with workforce efforts and benefits expansion. As part of its overall health equity portfolio, MDHHS conducted a systematic review of health equity interventions and found that health literacy efforts were the most common intervention, and particularly effective when paired with “culturally tailored components.” In 2016, MDHHS contractually required its plans to create a community health worker (CHW) program to deliver health literacy services and other culturally relevant health educational initiatives to plan members. Through a staffing ratio requirement (one CHW FTE per 5,000 members in a plan’s service area), the state incentivized plans to partner with community-based organizations (CBOs) by counting CHWs employed by CBOs as 1.25 FTE. CHWs and health literacy education were also deployed as part of a successful multi-sector plan to improve maternal and infant health outcomes and mitigate racial health disparities, with special attention to low birth weight rates in the state’s managed care population.

Beginning in 2024, the state expanded its coverage of CHWs across the board, the result of a 2023 state plan amendment. Among the expanded CHW program’s goals are “improved health literacy and navigation,” with special attention to addressing health-related social needs. Services covered include training in health literacy skills like health systems navigation, chronic disease management, and health education and promotion.

Michigan also put health literacy into practice by rethinking important written communications for members. In 2018, MDHHS partnered with design firm Civilla to overhaul its state benefits application forms, including its health care application, with person-centered design and health literacy principles at the forefront. The project shortened an aging, complicated public benefits application by 80 percent, greatly improving the experience for both applicants and the MDHHS staff processing the applications.

Oregon

In Oregon, health literacy practices are being integrated into new care and delivery models. In early 2021, Oregon Health Authority instituted a new incentive measure for the state’s 16 coordinated care organizations (CCOs) around “meaningful language access to culturally responsive health care services.” The goal of the metric is to increase and improve health care access for members with limited English proficiency or who are deaf or hard of hearing through providing qualified interpreter services and improving patient-provider health communication. The state also created qualification and training criteria for interpreters that allows multilingual providers and other staff must complete in order to bill for interpretation services.

CCOs and their providers are required to document the need and usage of these services through member and visit level data and an annual self-assessment. The metric measures the percentage of visits for which appropriate language access and culturally responsive care were provided. In the first year of the metric, all but one of the state’s CCOs met the benchmark, contributing to incentive payments of more than $300 million.

California

California is overseeing a statewide focus on health literacy, guided by the national Culturally and Linguistically Appropriate Services standards, including among its 58 counties, which provide county-level behavioral health services. Since 2010, California’s Department of Health Care Services, responsible for administering the state’s Medicaid program, Medi-Cal, has mandated that counties submit an annual report on the state’s Cultural Competence Plan Requirement. The reports evaluate each county’s ability to offer culturally and linguistically appropriate mental and behavioral health care and contain data on the prevalence of behavioral and mental health conditions. They also detail the status of disparities across factors like race and ethnicity, primary language, and income/poverty status, and plans to address those disparities through health literacy tactics such as language capacity and translation services, workforce cultural competence, and organizational training.

Looking Ahead

These are just a few of the ways states are taking action to improve health literacy practices for Medicaid populations. States can prioritize health literacy in chronic disease management and prevention efforts, member education on access and coverage, and by creatively linking payment incentives to health literacy and equity goals. Focusing on health literacy can be a powerful tool for improving health equity, and state Medicaid agencies will continue to find important new ways to embed health literacy principles in their ongoing health equity efforts.