Improving Health and Controlling Costs in Medicaid: The 6|18 Initiative

Emily Blanford 10/3/2019

healthy happy adults


The U.S. health care system is undergoing unprecedented change as policymakers work toward a system that is more effective and efficient. Major trends in health care, including moving toward paying for value and health outcomes rather than just volume of services provided, offer opportunities to purchase and deliver preventive services. The 6|18 Initiative was developed by the Centers for Disease Control and Prevention (CDC) to better link the health care sector, particularly payers like Medicaid, and public health sectors. It provides a shared focus on evidence-based interventions and preventive services that can improve health and control costs.

Medicaid is a publicly financed program that provides health insurance for millions of low-income Americans, including low-income adults, children, pregnant women, elderly adults and people with disabilities. With Medicaid accounting for nearly 30% of total state spending, state policymakers continually look for ways to reduce its costs. Medicaid clients are more likely than privately insured individuals to suffer from chronic conditions. With chronic conditions being among the costliest to treat and manage, Medicaid beneficiaries and state budgets may benefit from better-coordinated care and evidence-based approaches to services.

This policy brief outlines the CDC’s 6|18 Initiative, including the common conditions targeted and evidence-based interventions, and describes opportunities and barriers for states in implementing these proven strategies in their Medicaid programs.

What is CDC’s 6|18 Initiative?

The 6|18 Initiative was developed to provide health care purchasers, payers and providers with rigorous evidence about high-burden health conditions and the associated evidence-based, practical strategies that have the greatest health and cost impact in a short period of time. The name “6|18” comes from the focus on six common, preventable health conditions and 18 evidence-based interventions to prevent and manage these conditions.

6 | 18 initiative map

The 6|18 Initiative targets six chronic conditions: tobacco use, high blood pressure, inappropriate antibiotic use, asthma, unintended pregnancies and Type 2 diabetes. The CDC selected these conditions because they affect large numbers of people, significantly impact individual health, and drive high health care spending. In addition, there are proven evidence-based strategies to prevent or control these conditions. 

The prevalence of these conditions in the Medicaid population underscores the potential value of using proven and practical strategies to improve health outcomes and reduce costs. The 6|18 Initiative is now in its third year, and the CDC has partnered with 34 state, local and territorial Medicaid and public health department teams to speed implementation of the identified interventions. Participating Medicaid and public health teams took part in technical assistance and collaboration opportunities, including peer-to-peer support, webinars and quarterly calls, all of which help with understanding and sharing the best ways to apply 6|18 strategies across different sectors.

The following sections contain details regarding common and costly conditions and strategies for preventing and managing these conditions using Medicaid programs and the 6|18 Initiative.


Reducing Tobacco Use

According to the CDC, tobacco use is the leading cause of preventable disease, disability and death in the United States. Nearly 35 million U.S. adults smoke cigarettes. Tobacco use is particularly high among Medicaid beneficiaries, with nearly 25% using tobacco compared to only 11% of those with private insurance coverage.

Comprehensive Medicaid coverage of cessation benefits with minimal out-of-pocket cost is identified by the CDC as a proven strategy for helping people quit using tobacco. However, Medicaid coverage of tobacco cessation services varies by state. All 50 states cover some form of tobacco cessation services, but not all cover the full spectrum of services. For example, all states cover nicotine replacement therapy gum and patches, and most states cover group and individual counseling, but only about half of the states provide phone counseling services.

In many states, Medicaid may have limitations on length of treatment, prior authorization requirements, cost-sharing requirements and limits on number of attempts to quit per year. These policies may make it more difficult for beneficiaries to successfully quit tobacco use. The 6|18 Initiative is supporting efforts to provide full access to tobacco cessation services in state Medicaid programs. South Carolina has seen some success with this approach, which is highlighted in the State Examples section of this brief.

Controlling High Blood Pressure

About 1 in every 3 adults—75 million—have high blood pressure. Most adults are aware of and treat their high blood pressure, but only about half have their blood pressure under control.

One key strategy identified by the CDC for controlling high blood pressure is self-measured blood pressure (SMBP) monitoring. Typically, a person's blood pressure is monitored at regular appointments in a clinical setting. But SMBP monitoring allows people to track their blood pressure outside of the clinical setting, commonly at home. The Community Preventive Services Task Force has found strong evidence that SMBP monitoring, with team-based clinical support and when used in conjunction with other measures such as counseling, education and web-based supports, is effective in improving blood pressure outcomes.

Simplifying the treatment regimen and minimizing out-of-pocket costs can also help. For example, many individuals are currently treated with two different medications to manage their blood pressure. Fixed-dose combinations, when two or more drugs are combined in a single tablet, may help with adherence by reducing the amount of pills a person takes each day.

According to the CDC, all Medicaid programs fill almost all blood pressure prescriptions with a copay of $5 or less, but only about 10% of blood pressure medication was a fixed-dose combination. While some states, like Rhode Island and Connecticut, used the 6|18 Initiative to implement evidence-based strategies, Medicaid coverage of  services still varies widely, particularly for SMBP monitoring.

health blood pressure

Improving Antibiotic Use

The CDC estimates that roughly 30% of antibiotics used in hospitals are unnecessary or prescribed incorrectly, which can contribute to the growing problem of antibiotic resistance. The CDC estimates at least 2 million illnesses and 23,000 deaths can be attributed each year to antibiotic-resistant infections. A growing body of evidence demonstrates that hospital-based programs dedicated to improving antibiotic use, commonly referred to as “Antibiotic Stewardship Programs” (ASPs), can optimize the treatment of infections and reduce adverse events associated with antibiotic use.

ASPs are designed to ensure that people in a hospital or other inpatient health care setting receive the correct antibiotic at the right time and for an appropriate duration. These programs involve interdisciplinary teams that work to improve prescribing of antibiotics and continuously review prescribing practices and outcomes. One strategy to improve prescribing practices includes frequent auditing and feedback regarding clinician antibiotic prescribing practices and giving providers data on their own antibiotic prescribing practices.

Most hospitals are already required to have ASPs by the Joint Commission, an independent nonprofit entity that accredits hospitals. However, many hospitals that participate in Medicare and Medicaid are not accredited by the Joint Commission because they are only certified by the Centers for Medicare & Medicaid Services (CMS). Through the 6|18 Initiative, the CDC has been working with CMS to modify the conditions of participation for hospitals in both Medicaid and Medicare to require the adoption of ASPs. The initial rule, proposed in June 2016, has not yet been finalized. Efforts to implement this requirement through CMS are likely to continue. In the absence of federal regulations, some states, like Kansas, have used the 6|18 Initiative to enact requirements for all Kansas hospitals to adopt ASPs.

Controlling Asthma

health girl asthma

More than 24 million Americans have asthma, affecting 1 in 12 children and 1 in 14 adults, according to the CDC. People with low incomes are disproportionately affected by asthma and most low-income children with asthma are enrolled in Medicaid or the Children’s Health Insurance Program.

One way to manage asthma is using the National Asthma Education and Prevention Program (NAEPP Guidelines). The goals of the NAEPP are to raise public awareness regarding the seriousness of asthma, teach people to identify its signs and symptoms, and enhance the quality of life of people with asthma. The NAEPP develops guidelines and tools for patients and clinicians, including recommendations for reducing the impacts of asthma through well-developed treatment and action plans and guidelines for initial diagnosis and ongoing follow up.

Analysis of claims data shows that patients who have been treated according to NAEPP Guidelines have proportionately fewer ED visits and are hospitalized less often. Providing ongoing NAEPP Guidelines-based medical education to primary care physicians has been shown to increase dispensing of asthma controller medication by 25%. While increased dispensing of appropriate medications and better adherence to these medications could lead to higher up-front costs, these costs may be offset by fewer ED visits or hospitalizations.

State Medicaid coverage of asthma management services often includes prior authorization requirements and copayments, which can create difficulties for some beneficiaries when accessing needed services. In addition, reimbursement policies regarding beneficiary education and in-home services are inconsistent, and requirements for these services offered through Medicaid managed care organizations vary. But there is the potential for cost savings and improved health outcomes within the Medicaid program by providing comprehensive coverage. For example, Rhode Island’s Home Asthma Response Program (HARP) saw a 75% reduction in asthma-related hospital and emergency department costs.

Preventing Unintended Pregnancies

According to the Kaiser Family Foundation, on average, Medicaid paid for 50% of births in the U.S. The CDC estimates that about 50% of all pregnancies are unintended and these pregnancies increase the risk for poor maternal and infant outcomes.

Medicaid provides family planning coverage with no out-of-pocket costs to beneficiaries, but Medicaid programs are not required to cover all FDA-approved family planning options. Providing access to the full range of contraceptive options is a key 6|18 strategy, with a particular focus on increased use of Long-Acting Reversible Contraception (LARC) as a proven strategy to reduce costs and unintended pregnancies.

Contraceptives that are incorrectly or inconsistently used may still lead to unintended pregnancies and avoidable expenses. Because LARC requires no user effort after insertion, the potential for inconsistent or incorrect use is eliminated. Improved use of LARC among women ages 15 to 44 may generate health care cost savings by reducing unintended pregnancies despite higher up-front costs.

According to the CDC, offering LARC methods to clients at no cost in Colorado Title X-funded clinics, compared with offering all other methods on a sliding-fee scale, resulted in a 19% increase in use of LARC among 15- to 24-year-olds. Over the course of Colorado’s initiative from 2009 through 2016, Colorado’s birth rate decreased 54% for teens and 30% among women ages 20 to 24.

The Colorado Medicaid program also worked to unbundle payment for LARC from other services to further increase LARC use in the state. Previously, payment for labor and delivery costs were provided as an up-front prospective payment and did not consider the actual costs associated with the LARC insertion process. Unbundling payments provides an incentive for providers to provide LARC insertion while the beneficiary is already in their care, avoiding the need for a subsequent appointment.

Preventing Type 2 Diabetes

health diabetes

Approximately 30 million people in the U.S. have diabetes and about 84 million Americans have prediabetes, according to the CDC. Adults with prediabetes are at higher risk for developing Type 2 diabetes and other serious health problems, including heart disease and stroke. The CMS estimated that Medicare would spend an additional $42 billion in 2016 on beneficiaries with diabetes. More than 90% of people with diabetes have Type 2 diabetes; fortunately, Type 2 diabetes can be prevented or delayed with appropriate lifestyle changes.

The only evidence-based approach to diabetes identified through the 6|18 Initiative is expanding access to the National Diabetes Prevention Program (National DPP). The National DPP is designed to help individuals make the lifestyle changes needed to avoid Type 2 diabetes. The yearlong program focuses on behavior changes, managing stress and peer supports, with regular opportunities for direct interaction with a lifestyle coach and peers. According to the CDC, studies have shown adopting lifestyle changes like those supported by the National DPP lifestyle change program may reduce the risk of developing Type 2 diabetes by 58% in adults with prediabetes.

Information from the National Association of Chronic Disease Directors (NACDD) indicates that as of 2018, only seven states had some form of Medicaid coverage for the National DPP lifestyle change program. But through the 6|18 Initiative, many states, like Georgia, Kentucky, North Carolina and Utah, have been working to expand coverage of the National DPP lifestyle change program in their Medicaid programs.

State Examples | Conclusion

In 2016, the first year of the 6|18 Initiative, nine states that already had significant efforts underway in addressing these common conditions were selected to participate in the initiative. The experiences of two of those states are highlighted below.

South Carolina

Through the 6|18 Initiative, South Carolina’s Medicaid agency, the Department of Health and Human Services (DHHS), and its public health agency, the Department of Health and Environmental Control (DHEC), worked together to improve access to and use of tobacco cessation benefits for its Medicaid population. South Carolina already had a comprehensive tobacco cessation benefit for pregnant women and the 6|18 Initiative helped support South Carolina’s efforts to provide comprehensive coverage to all Medicaid beneficiaries.

South Carolina public health staff worked with Medicaid managed care organizations (MCOs), particularly medical directors, to make the case for covering all tobacco cessation medications and counseling services without barriers. Public health staff also worked with the MCOs to standardize the services offered across all MCOs in the state. Because of these efforts, South Carolina was able to successfully implement a comprehensive, standardized tobacco cessation benefit within the Medicaid program that eliminated copays and prior authorization requirements.

Public health staff and Medicaid program staff also worked closely together to raise awareness of the comprehensive services and educate providers and Medicaid beneficiaries. In addition, through 6|18 Initiative support, South Carolina was able to obtain federal Medicaid funds to provide part of the money needed to support its Quitline telephone counseling option. South Carolina was recognized by the American Lung Association for these efforts to provide comprehensive coverage and increase access to services.

New York

New York focused on unintended pregnancies in its effort with the 6|18 Initiative. The New York State Department of Health’s Office of Health Insurance Programs (Medicaid agency) and the Division of Family Health (public health agency) worked to reduce the state’s unintended pregnancy rate by increasing access to and use of effective contraception, particularly LARC.

Like South Carolina, New York already had success in reducing unintended pregnancy prior to joining the 6|18 Initiative. The 6|18 Initiative provided support to New York to revise its reimbursement methodology to encourage use of LARC. Specifically, New York modified its reimbursement to Federally Qualified Health Centers (FQHCs) to unbundle the payment for LARCs to reimburse for the actual cost associated with LARC insertion. New York worked with MCOs to similarly separate payment of LARC from an inpatient delivery stay to further encourage the use of LARC immediately after delivery but before discharge from the hospital.

Through this work, New York also identified a significant need for education and awareness in the provider community regarding the use of LARC devices. The 6|18 Initiative provided support to New York to develop a team to train providers in the appropriate use of LARC and educating providers regarding myths about the devices. These provider outreach efforts encouraged appropriate and timely contraception counseling and stocking of LARC devices on the labor and delivery floor. Through these efforts, the New York Department of Health developed a crucial partnership with the local chapter of the American College of Obstetricians and Gynecologists to further improve access to and use of LARC devices.


healthy happy women outside

The CDC conducted a study of the 6|18 Initiative that included interviews with participating Medicaid and public health officials. The interviews indicated the initiative led to increased collaboration and information sharing as well as provided supports needed to make meaningful progress toward goals. Developing these relationships and collaborations allowed state teams to more effectively target and apply policies to improve the health of Medicaid beneficiaries while also reducing costs.

Lessons learned include the discovery by public health officials that Medicaid coverage and reimbursement is an important concern for successfully implementing public health strategies. And Medicaid officials and providers were able to learn the science and rationale behind these interventions, to more fully support their work in revising Medicaid coverage and reimbursement options.

State policymakers can continue to leverage 6|18 Initiative strategies to improve health outcomes in their states while also reducing Medicaid costs. An important way that state policymakers can impact Medicaid program performance and efficiency is through benefit coverage decisions and service delivery options. The 6|18 Initiative’s practical strategies and supports provide a framework for Medicaid benefit coverage and service delivery options to accelerate the adoption of these proven strategies within Medicaid programs.

States involved in the 6|18 Initiative continue to work to fully integrate these interventions and strategies in their Medicaid programs. State policymakers can provide leadership to encourage and foster the cross-section collaborations necessary for the success of these interventions and policies. Through these collaborations, state policymakers can further tailor Medicaid policies and strategies, as well as overall public health strategies, to the needs of their states.

For more information regarding the 6|18 Initiative, please visit:

This project is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) under grant number 1 NU38OT000312-01-00, Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Health. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by CDC, HHS or the U.S. Government.