As the COVID-19 pandemic ravaged health systems across the nation, states focused both on serving millions of new Medicaid enrollees and on applying cost controls.
“Making the Most of Medicaid,” a session at the recent NCSL Legislative Summit, examined how two states were attempting to do just that.
In Oregon, which expanded Medicaid under the Affordable Care Act and saw its numbers of uninsured plummet, the state Health Authority is in the process of renewing its 1115 demonstration waiver with the Centers for Medicare & Medicaid Services.
“The focus is about driving health equity,” said Dana Hittle, Oregon’s interim Medicaid director. She described social determinants of health—the conditions in the places where people live, learn, work and play that affect a range of health and quality-of-life risks and outcomes—as vital factors in eliminating health inequities. “We are really focused on what’s best at the community level,” she said. “We have 16 managed care entities. They are regionally based, which allows them to develop partnerships with community-based organizations such as local food banks. They serve about 90% of Oregonians on Medicaid.”
Oregon is asking to maintain coverage of children up to age 6 without having to do annual redeterminations of eligibility, and that redeterminations for children over 6 be done every two years.
The state has designed a social determinant benefits package for individuals going through transitions from criminal justice, juvenile justice and other institutions.
“Those packages focus on stabilizing those individuals prior to exiting whatever institution they’re in so they have developed relationships with clinical providers,” Hittle said. “Rather than leaving custody with a seven-day supply of medication, we’re proposing to get in there 90 days prior to release so they can continue that care that’s really important to avoid recidivism.”
Oregon’s program also focuses on stabilizing housing in terms of rental support and is engaged with the state’s nine federally recognized tribes to align services with their members.
Sen. Elizabeth Steiner Hayward (D), the Senate’s deputy majority leader, co-chair of the Budget Committee and a family physician, noted that her state’s home visiting program, which was created in 2019 and is the nation’s first such statewide service, is universally offered to any family with a new baby.
The program allows families to have a trained family health practitioner come into their home and help address resources. “It might be faith-based, might be an NGO or some specific government program, all community-driven,” Hayward said. “It is up and running slowly because there was a pandemic and that kind of got in the way.”
Tennessee is “a great proving ground for various aspects of health care,” Sen. Bo Watson (R) told the session.
“If you want to look at the categories of health that are terrible, they’re all in Tennessee: the stroke belt, cardiovascular issues, blood pressure, diabetes, obesity, they’re all located in Tennessee.”
Watson said Tennessee was the first state to use managed care strategy to address its health care issues in the Medicaid program.
“We’re fiscally conservative, didn’t expand Medicaid and there have been no discussions about expanding in last couple of sessions,” he said. “We have an aggressive program of saving costs. One of our provisions is we get to share in those savings. The state is incentivized to create cost-effective programs, and we are able to reinvest that in programs we’re developing.”
Jessica Hill, chief of staff of TennCare, Tennessee’s Medicaid agency, said the state has “a unique 10-year agreement that included flexibilities with our state Medicaid program and opportunities to be rewarded with efficient operation through additional federal funding that can be invested in TennCare.”
Watson, who chairs the Finance Committee, encouraged lawmakers to “stretch your Medicaid program, stretch your director, make them think creatively and innovatively.” He described the program as a federal-state partnership in which the federal government often tries to drive the narrative.
“I think both Oregon and Tennessee have been somewhat aggressive in our approach to negotiations with federal government,” he said.
“Most of you are probably spending 20%-30% of your budget on Medicaid. You want to make sure your constituents are getting what is appropriate, but you also want to make sure it’s being delivered in an effective and efficient way. You have to have a system to challenge your health care marketplace to drive the innovation that drives efficiencies.”
Mark Wolf is a senior editor at NCSL.