Here are five changes we would make to Medicaid tomorrow

April 8, 2024
Original illustration by Justine Allenette Ross

Medicaid is ripe for innovation. While there are countless start-ups and community-based organizations working to improve the lives of people on Medicaid, enacting transformational change is hard. And, given the constraints of the federal government and the siloed state-by-state nature of Medicaid, sometimes getting buy-in for innovative solutions or new programs is an uphill battle. 

But we wondered: what are some common sense solutions that could help change health outcomes for people on Medicaid overnight? So we called up a handful of bright minds across the Medicaid ecosystem and asked them exactly that. The premise to these conversations was simple and straightforward, given the opportunity, what is one thing you would do to transform Medicaid? Here, you’ll find their innovative solutions they’d like to see implemented immediately.

Define Medicaid eligibility at the federal level

Ali Khan, Chief Medical Officer Value-Based Care Strategy at Oak Street Health 

If I could wave a magic wand I would set Medicaid eligibility at the federal level. Here’s why. In the current system we set eligibility at the state level—and as a result we end up propagating disparities and leaving folks out in the cold, based on the state they live in. Setting the eligibility level across the country would be incredibly powerful in delivering care to the people who need it.

I’ll give you an example. At Oak Street we serve about 225,000 around the country. And 42% of those folk are dually eligible for Medicare and Medicaid. We serve 21 states, yet we have a bunch of patients who, if they all lived in Illinois, would be dually eligible—but they live in a state that has no Medicaid Expansion. So they are not able to access care, income supports, they are not able to access a bunch of other supportive programming—and they struggle. They have to make hard choices between paying for food or paying for medicines or an electric bill. And that breeds and propagates systemic mistrust that they have in healthcare systems. 

Defining Medicaid eligibility at the federal level in a very real sense is defining the challenge we face across the country in equal terms. 

Align the payment model better

Jason Cunningham, Chief Executive Officer at West County Health Centers, a Federally Qualified Health Center (FQHC)

Aligning the payment model with what is needed to provide care for the most high cost, high needs, and very vulnerable patients. Right now, the way it works for most Federally Qualified Health Centers (FQHC) that provide care for Medicaid patients is you need to have a certain number of patients and a certain number of visits each month to pay for your nurses, your front office, your community health workers, call center, and everything that makes a clinic run. But that’s not actually how it works. 

More often than not the care people actually need is being done by a community health worker or a social worker. But we can’t bill Medicaid that way. The business model doesn’t work for the provider and as a result the patients don’t get the care they need. So what we need to do is to make the payment model less of a volume business and more of a per-member per-month basis.

Which is what has happened with Medicaid here in California as part of California Advancing and Innovating Medi-Cal’s (CalAIM) Enhanced Care Management and Community Supports program. We get a $350 per member, per month from CalAIM for patients that meet a high-risk criteria. For us, it’s been an absolute game changer. We now have five community health workers going out to homes to understand what our patients need—from housing and legal issues to work and health.

We’ve aligned the funding with what we need to provide care. It allows our team of community health care workers and social workers to help address drivers of health and allows me as a physician to address more acute and longterm health needs. It’s been transformational for us and I’d like to see this type of payment model at the federal level.

Create an annual social wellness check

Molly Coye, senior advisor at AVIA and Redesign Health, and healthcare industry veteran

I would have the federal government pull all the levers they can to have states make it a condition of participation that a Medicaid beneficiary should have a social wellness check, similar to the annual Medicare Wellness Visit. Not a physical or a standard check-up, but a wellness check that covers everything from housing and social isolation to mental health and financial instability. A Social Determinants of Health (SDOH) screening, basically. And this should be defined as something that is preferably not administered by a physician. But by a licensed social worker, clinical social worker, or new category of worker in social services support.

This is not just a 15-minute check-up either. It would last at least a half hour and help Medicaid beneficiaries to discover—with their assigned social worker—the impact of these SDOH on their lives. It would become a part of their medical record, and more importantly, CMS and states could compile this information and begin to allocate resources and accountability for addressing them—and track the results of efforts to combat these problems. Ultimately, I would hope that FQHCs and other community services organizations could be funded to coordinate access to these programs as well.

We know how SDOH drive both short and long term health outcomes. This would be a way to educate Medicaid beneficiaries, get people the social supports they need, and better understand at the state and federal level what else needs to be done to improve outcomes.

Create a social benefits package

RJ Briscione, principal at Health Management Associates

I’d like to see the federal government create a social benefits package that would help address the downstream effects of SDOH. In the industry, we call this health-related social needs (HSRN) and research has found that interventions or programs that work to address social risk and social needs—from housing to food—have the real potential to improve outcomes and reduce spending. 

But here’s the thing: it has to be flexible. It can’t be strictly one-size-fits-all. It has to be needs-based. That means helping people with everything from short-term housing and nutritional education to medically-tailored meals and transportation. It has to be a benefit that is based on the actual needs of the individual. We need to help solve problems and give people solutions to improve these drivers of health. Building a comprehensive, flexible, and needs-based HSRN benefits package would go a long way towards improving the health outcomes of people on Medicaid.

Federal continuous eligibility for children

Alice Chen, Chief Health Officer at Centene Corporation

I want universal Medicaid expansion. The way I think about Medicaid is coverage. And the point of coverage is ostensibly to improve population health. Foundationally, the day that we have universal Medicaid expansion across all the states will be a day that we can say we actually have a floor below which people shouldn't be able to fall under. 

But I think that eventually the tide will shift and that’s going to happen. I don’t want to use my one wish on that! 

If I could make one change to Medicaid overnight it would be continuous eligibility to keep children enrolled from birth until the age of six. During the pandemic, Congress implemented the Families First Coronavirus Response Act which required state Medicaid programs to keep people continuously enrolled through the end of the pandemic. I want to see that made permanent. 

If patients are constantly churning in and out of being insured, they don’t really have the platform to do proper preventative care that improves their long term health. Continuous eligibility is a way of keeping a population of people—in this case, kids zero to six—covered so that they have stable access, develop stable relationships with their primary care providers, and can get that primary and preventive care they need through childhood. When people are dropping in and out of coverage, the only thing you can do is the catastrophic piece of health care through urgent care visits. And with children, that early phase in life is so important for future development that it’s a no-brainer to ensure they have continuity of coverage.

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