How Can Medicaid Transformation Steer Toward Health Equity? A Look at the Evidence
Health equity means that everyone has a fair and just opportunity to be as healthy as possible. We know, however, that our country falls short when it comes to achieving health equity. There is evidence of large and pervasive disparities in both health and health care affecting low-income groups, African-Americans/Blacks, American Indians/Alaska Natives, Hispanics/Latinx people, some Asian subgroups, immigrants, people with disabilities and LGBTQIA+ persons.
Addressing health equity should be a core goal of all health system transformation initiatives. Medicaid can be a particularly powerful avenue for advancing health equity. For one thing, Medicaid is a key source of health coverage for many of the populations that face significant health disparities. Also, the flexibility of Medicaid’s benefit structure offers advantages; when deployed in the service of improved outcomes, this flexibility can enable innovative approaches that reduce disparities. However, the same flexibility can be used to impose barriers to care that worsen the health outcomes of the most vulnerable populations. It is, therefore, important for advocates to keep a watchful eye on any proposals to change the Medicaid program.
We’ve been looking to identify evidence of successful care delivery innovations in Medicaid that could potentially improve health equity. (For a great overview of how the health sector can advance health equity, please see this recent Robert Wood Johnson Foundation report.)
We see five potentially promising areas of focus: (1) innovations to address social needs; (2) condition-specific programs to reduce disparities, such as for asthma; (3) partnerships with community-based organizations and community providers such as community health workers, peers and doulas; (4) efforts to engage the community in setting program priorities and design; and (5) initiatives to improve cultural competency, workforce diversity and language access. We briefly describe each of these five areas and highlight the operational components needed to ensure that payment better supports adoption of these care delivery innovations.
Innovations to address social needs
We’ve seen states, Medicaid managed care plans and health care providers take on a range of approaches to identify and address the social factors that affect the ability of Medicaid beneficiaries to be healthy. This includes screening for social needs as part of clinical care delivery, making social service referrals, and directly addressing social needs through provision of food, transportation to medical appointments, and housing-related services. As the number of different models for this work grows – seemingly exponentially – we rely on the researchers at the Social Interventions Research & Evaluation Network (SIREN) to help keep an eye on which interventions are most promising. Their evidence library is a great place to start to find programs and approaches that are worthy of replication and scaling.
Condition-specific interventions to reduce disparities
Some providers have implemented interventions focused on addressing disparities in specific conditions where certain racial, ethnic or other demographic groups experience far worse outcomes. For example, some providers have deployed comprehensive treatment approaches for childhood asthma, that include providing air filters, pillow covers, air conditioners and other supplies designed to mitigate environmental factors that often worsen asthma. We appreciate the work of Advancing Health Equity to share systematic reviews of promising interventions and find it a great resource for understanding existing evidence with an eye toward implementation. Systematic reviews available on their website have assessed the potential for interventions focused on asthma, cancer, depression, diabetes, cardiovascular health and HIV. Critically important work to reduce maternal mortality and improve birth outcomes is also on-going. (For a sampling of possible state strategies, see this summary).
Partnership with community-based organizations and providers
Many states have built provisions into their Medicaid programs for health systems and plans to work with community-based organizations to provide social services. These services often relate to social needs interventions, and we find SIREN a great source of the latest research and evidence on the effectiveness of these interventions. We’ve also seen tremendous opportunity to incorporate community health workers, peers, doulas and similar providers with strong community connections and relevant lived experience into care models. For example, the Penn Center for Community Health Workers brings together cutting-edge research on effective community health worker programs for improving health of low-income populations.
Engaging the community in setting program priorities
Some state delivery system innovations have explicitly incorporated community engagement in establishing program design and implementation. Several states that participated in demonstration projects to improve care for Medicare-Medicaid beneficiaries, for example, have established consumer-led implementation councils to advise on program design and implementation. The demonstrations also required health plans to set up consumer advisory structures, and we’ve documented progress and outcomes from these advisory committees. Oregon’s Medicaid coordinated care model was unique in establishing not only strong consumer advisory structures, but explicitly connecting that advisory structure to community health improvement, and in supporting these advisory structures with technical assistance through its Transformation Center.
Improving cultural competency, workforce diversity and language access
Clinicians’ behavior and clinical decisions may be influenced by conscious or unconscious bias, resulting in potentially dangerous implications for patients’ health. Experiences of discrimination based on race, sexual orientation or disability in health care encounters – both overt and subtle – can undermine patients’ trust, satisfaction with care and provider-patient communication, and result in adverse health and health care outcomes. In addition to interpersonal racism, structural racism in health care institutions further contributes to health inequities.
The County Health Rankings provide a nice summary of the evidence for cultural competence training for health professionals, as well as the gaps in understanding its impact on patient outcomes. The Rankings also summarize evidence for the use of professionally-trained medical interpreters. A helpful guide from Finding Answers: Disparities Research for Change illustrates how an approach to addressing culture should go beyond cultural competence training. The American Hospital Association’s Equity of Care Campaign includes resources for hospital and health system leadership to increase collection and use of race, ethnicity, language preference and other socio-demographic data, increase cultural competency training, increase diversity in leadership and governance, and improve and strengthen community partnerships.
Operational Needs to Support Clinical Innovations that Address Health Equity
Even as these innovations are happening in clinical care, changes to payment and policy infrastructure needed to support them aren’t keeping pace. Making these innovations more widespread will require attention to the following components:
- Data: Making sure that the right data is available to help identify and address health disparities. While the Affordable Care Act included provisions to help advance the collection of data about race, ethnicity, sex, primary language and disability status, there remain important gaps in the actual collection of this data and its availability in ways that are timely and actionable for providers.
- Measurement: Ensuring that we know how to measure the outcomes that matter. This includes first determining that we have the right quality measures and, then, that we tackle important challenges in studying interventions that are happening in the real world and in real time. Because real-world interventions often don’t allow for a perfectly matched control group, it can be hard to understand which outcomes are due to a given intervention, versus a result of underlying changes happening in the study population or in the environment.
- Risk adjustment: We still have relatively weak tools for understanding how to compensate providers who care for patients who face higher barriers to health. If payments are not properly adjusted, they might inadvertently penalize providers who are caring for patients with more complex health and social needs, and “bake in” historical disparities such as poor access to medical services that result in underutilization of needed services.
- Care delivery infrastructure: As health systems are seeking to work more closely with community-based organizations, we have to acknowledge the differential in power and resources between health care systems and the very under-resourced community-based services infrastructure. We need to be careful that relationships between health systems and community-based organizations serve to strengthen the fabric of community-based services, and doesn’t displace or further weaken this sector.
For advocates and policymakers, tackling health equity through Medicaid transformation is an important goal in the new decade ahead. We are continuing to push for identification and expansion of successful models, and evolving the tools necessary for successful scaling. We appreciate your input and partnership as we continue this work together.