Legal, Policy, Social Determinants

Expanding health equity through Covid-driven state Medicaid legislation

Covid has pushed state health agencies to use Medicaid in ways that would never have been imagined before. With one in five Americans saying they are unable to afford healthcare, how are state governments using this historic moment to expand equitable access to care?


Protection people health and insurance concept. Hand shield protect wooden human on table

Now that the Supreme Court declined to hear red-state arguments defending Medicaid work requirements originally slated for March 29, state health departments can once again focus on increasing health equity by expanding Medicaid’s scope in non-traditional ways.

Even before Biden took office, the Covid pandemic forced states to use Medicaid in many ways that would never have been imagined before. With one in five Americans saying they are unable to afford healthcare, what state legislation can we expect to expand equitable access to care?

Key solutions to improve health equity being addressed at the state level include Medicaid expansion; the extension of postpartum Medicaid access from 60 days to a year; establishment of a statewide quality strategy as required by CMS, expansion of telehealth, allowing family to be paid as caregivers for their loved ones, value-based contracting and the addressing of social determinants of health through Medicaid programs.

“These concepts aren’t foreign, we just have to worry about the woodwork,” said Michael Cook, partner and co-leader of the Health Practice Group at Liles Parker in a phone interview. “How do we get the maximum bang for our buck? Targeting and coordinating is the hard part; using the resources we have, knowing we don’t have unlimited resources and that we will be counted on to show we used them wisely.”

Widening access to Medicaid
Since the Covid emergency was declared, states have seen dramatic increases in their Medicaid rolls, and even more dramatic increases in the number of people that need insurance but cannot afford to buy it on the private market. One tool states have to support low-income families struggling to cover healthcare is the “Medicaid Expansion” provision of the Affordable Care Act.

Twelve Republican-led states sought CMS waivers to the expansion, but under the American Rescue Plan Act, Biden has sweetened the deal. In addition to an existing 90% of federal matching funds offered under the ACA for the expansion population, states also receive a 5 percentage point increase in their regular federal matching rate for 24 months after expanding Medicaid access.

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Joe Biden’s administration will have to fight the Texas Attorney General’s challenge to provisions in the American Rescue Plan Act that make it more expensive for states not to expand Medicaid access to include people with household incomes nominally above the 100% poverty line threshold, but states that have accepted the deal have found it invaluable during Covid.

“We’ve seen a tremendous need for the program,” said Karen Kimsey, services director for the Virginia Department of Medical Assistance, in a March presentation to the American Bar Association.

Kimsey told listeners that since the State of Emergency was declared, Virginia’s Medicaid program has gained over 300,000 new members, of which roughly half were covered through the Medicaid expansion. Virginia’s governor and legislature signed Medicaid expansion into law in May 2018 and put the program into effect in 2019. As a result, its uninsured rate dropped a full percentage point.

“This drop in the number of uninsured people in Virginia is the direct result of the decision to expand Medicaid and reject rigid work requirement proposals,” said Ashley C. Kenneth, senior vice president for Policy and Legislative Affairs at The Commonwealth Institute.

Expanding postpartum access
Biden’s American Rescue Plan Act also offers states the opportunity to stretch postpartum access to Medicaid from 60 days to a full year.

Washington State has taken the initiative to make this extension permanent, passing a law last month that requires the state’s Health Care Authority (HCA) to provide one year of postpartum coverage through Apple Health to all residents whose income falls at or below 193% of the federal poverty level.

The U.S. has a bad record in maternal care with one of the world’s highest maternal mortality rates among developed countries, according to data from the Organization for Economic Cooperation and Development (OECD). Twenty mothers died for every 100,000 live births in 2019, more than double the rate just two decades ago. Over half of these women — 52 percent — died in the year after delivery.

Sponsor of the Washington bill Emily Randall expressed the law’s urgency, saying: “We know that there are disproportionate health outcomes for particularly moms of color. We also know that two months is hardly enough time to get yourself cared for after giving birth to a new baby and trying to get all of its many visits done. And we also know because of the extension of the FMAP increase under the federal policy, we have been extending coverage and ensuring that new birth parents are covered for longer. And what I don’t want to do at the end of the emergency is to create a huge cliff and all of a sudden kick everyone off.”

Opening the doors to immigrants
Virginia acknowledged the profound barriers to care faced by immigrants last month by rescinding what’s known as the “40-quarter rule,” which required immigrants to have worked 10 years in the United States to be eligible for Medicaid coverage. This move immediately opened up coverage to an additional 4,000 Virginians and the office expects to have data on how many additional Virginians will be eligible per year and an accurate budget impact, shortly.

“This historic policy change is long overdue,” Kimsey said. “I am so grateful we were able to break down this unjust barrier and offer these individuals access to doctor visits, prescriptions, hospital care and all of the health care services they need to be safe and thrive in these uncertain times.”

Addressing Social Determinants of Health
States are also finding creative ways to cover people’s social welfare needs that impact health through their Medicaid programs.

North Carolina’s Health and Human Services Secretary Mandy Cohen recently told the story of the “a-ha” moment where she realized that social determinants of health, such as access to food, housing, education and employment, are an intrinsic part of medicine.

As a third-year resident, she had spent weeks trying to diagnose why a woman in her 20s was losing weight and her hair. Only after a technician gently nudged her that she should ask whether the young woman had been eating, did she think to ask.

“What a huge failure, on my part, as a doctor,” she told listeners at a recent AMA conference. “Oh my God,” Cohen said she thought, “she hasn’t eaten for six to eight weeks while I’ve run all these dumb blood tests.”

This moment led her to begin asking all patients about social determinants, and creating protocols for health systems to do so while Chief Operating Officer and Chief of Staff for Centers for Medicare and Medicaid Services (CMS) between 2015-2017. Now, her state is the first to invest in a full-service, wrap-around health and human services program called NCCare360, powered by Unite Us, a technology service that enables health and human services providers to send and receive electronic referrals, communicate in real-time, share client information, and track outcomes.

The system also taps in community-based organizations, social service agencies, health systems, independent providers and community members, creating a statewide coordinated care network.

Finally, it uses technology from Expound Decision Systems to analyze the success of interventions addressing social determinants of health.

Cohen was on the short-list of contenders to head CMS, a role recently given to Manatt, Phelps & Phillips, LLP partner and longtime Biden ally Chiquita Brooks-LaSure, who is also deeply committed to health equity.

Value-Based Contracting
Georgia’s state health agency has started down the path toward incorporating value-based purchasing into its Medicaid-funded care. It has piloted this approach through its Georgia Families 360 program for children in foster care, receiving adoption assistance, or involved in the juvenile justice system.

“How this program works is we withhold 5% of the contractor’s capitation payment until they meet certain metrics and targets,” Lynnette Rhodes, Medical Assistance Plans Division, said in a March presentation to the ABA. “And then at the end of the fiscal year we do an evaluation, and depending upon where they landed, we will either refund back all of that 5% or whatever portion it was that they’ve met.”

Rhodes reported the program has been a success, thus far, with Amerigroup Community Care meeting 95% of the targets since 2014.

“There has been a delay in terms of implementing that program in the regular managed care population and that has to do with funding and appropriations,” Rhodes said, “but we are hoping to do so in the very near future.”

Paying and Protecting Caregivers
Since the beginning of the Covid pandemic, Georgia has joined New York in offering Consumer-Directed Personal Assistance and Respite Care, which allows people with disabilities and seniors receiving Medicaid to pay family members for their care.

The American Rescue Plan also ups the amount states can receive in federal matching funds for Medicaid home and community-based services (HCBS) by 10 percent through March 30, 2022, given implementation or expansion of these programs. HCBS help seniors and people with disabilities live independently in the community by assisting with daily self-care and household activities.

Though the bill does not yet outline specific activities, examples of initiatives that states might fund include: supporting direct care workers, family caregivers, and HCBS providers adversely affected by the pandemic; offering services to address the pandemic’s impact on seniors and people with disabilities; and increasing the number of people receiving HCBS, according to Kaiser Family Foundation.

A number of states have also begun extending paid sick time for people suffering from Covid symptoms and their caregivers. Many of these Americans received protections under the Families First Coronavirus Response Act (FFCRA) until it expired in December.

States that gained access to paid sick time under the FFCRA experienced about 400 fewer cases of COVID-19 per day, according to research from Cornell University and the Swiss Economic Institute.

A National Partnership for Children and Families report showed that eight in ten voters in the 2020 election support a permanent paid family and medical leave program for workers and caregivers.

Overall, state health agencies have remained creative and committed to addressing disparities at the state level, Cook said.

“Red state, blue state Medicaid directors, they all have the same goal,” Cook said in a phone interview, “they might get there different ways but these folks are absolute professionals, whatever their governors’ positions might be.”

Photo: marchmeena29, Getty Images