In Celebration of CMS’ Call to Medicaid and CHIP Action: It’s Both Great and Not Enough

Having served until very recently as a Medicaid and Children’s Health Insurance Program (CHIP) director in Connecticut, it was with a sense of excitement and then growing delight that I read Center for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure and Director Daniel Tsai’s Health Affairs blog post “A Strategic Vision for Medicaid and the Children’s Health Insurance Program (CHIP)” this morning. It is nothing short of a clarion call for building on Medicaid’s many historical successes.

What is particularly heartening about their approach is that, at its core, it champions Medicaid and CHIP as integral, successful federal-state partnerships in 56 states and territories. These partnerships have not only enabled health care coverage for a historically unprecedented 80 million people, but also have supported children and teens, helped working-age adults gain and maintain employment, promoted self-sufficiency among older adults and people with disabilities, and prevented burnout among family caregivers. Inherent in this framing is the idea that Medicaid’s status as an entitlement program is sound and should be maintained.

In their blog post, the administrator and director make specific, actionable commitments to elements of the programs that represent immediate-term opportunities. These include:

• broadening the lens around coverage to encompass not only eligibility expansion but also post-COVID maintenance of eligibility, simplification and automation of current eligibility processes, development of a “uniform minimum access standard,” and more;
• taking action to eliminate longstanding racial and other disparities; and
• supporting innovation and whole-person care through Section 1115 waivers and attention to achieving true behavioral health parity.

While issues of access, experience of care, and disparities in outcomes are longstanding, two aspects of the administrator and director’s approach distinguish it from previous federal policy direction. Most fundamentally, this vision statement conveys that Medicaid and CHIP are about the people who are served. For the first time in my experience with the programs, CMS has squarely identified the need to prioritize direct engagement with the people who receive services. Second, as compared with the general population, the approach underscores that Medicaid and CHIP disproportionately serve people of color and individuals with disabilities. I also suspect that this is true of LGBTQIA+ individuals, although the data have never been collected. In promoting specific work on equity, CMS is for the first time saying how much these folks matter.

For the first time in my experience with the programs, the Centers for Medicare and Medicaid Services has squarely identified the need to prioritize direct engagement with the people who receive services.

It is almost unfair not to simply stop and dwell in the significance of the above. But I won’t, because even though those commitments are auspicious, CMS must also immediately translate its plans into the federal support and implementation strategies that states will require to fulfill them. This will necessarily involve:

• continued use of a strengths-based, person-centered, culturally capable approach in model design and implementation;
• specific commitments of funding in eligibility systems to accommodate automation of processes, expanded collection of demographic data points, and implementation of new processes for older adults and people with disabilities;
• expansion of the Center for Medicaid and CHIP Services’ (CMCS) existing, successful toolkit approach to encompass other areas of focus and investment, such as social drivers of health;
• provision of capital to seed adoption of the member engagement, practice transformation, and data systems modification aspects of implementing value-based accountable care models, particularly if the goal is to engender multi-payer arrangements; and
• creation of sustainable solutions for what comes after the huge bump of American Rescue Plan Act (ARPA) funds.

Continued use of a strengths-based, person-centered approach in model design and implementation

To achieve progress, officials must acknowledge the need to know more about the specific demographic features of people served by Medicaid and CHIP; engage the people being served in the design and implementation of the programs; and wrap eligibility systems and care models around their needs. That said, state work in these areas has remained strikingly surface level. I say this without judgment, but all too often, directors feel great distance from folks served by the programs and remain challenged in how to make meaningful connections that could yield useful information about actual experience.

In Connecticut, my colleague Dawn Lambert, who led long-term services and supports (LTSS) rebalancing work, has partnered for almost 15 years with a leadership group predominantly composed of people who receive those services. This body directly reviewed and shaped the operations manual for the Connecticut Money Follows the Person and Community First Choice initiatives and supports State Plan Amendment (SPA) processes. Creating these opportunities required effort and time, accommodation of schedules and travel needs, and at its core, care, concern and integrity about who was involved and how.

To meaningfully support such engagement, CMCS could:

• offer specific guidance and technical supports around engagement with members and advocates at the local level, with a particular emphasis on under-represented voices (e.g., BIPOC and LGBTQIA+ folks);
• strengthen the threshold requirements for public comment on waivers and SPAs;
• promote the use of experience of care, life satisfaction indices and other means (e.g., focus groups) of directly capturing the personal narratives and lived experience of people as they use program services; and
• raise up examples of state best practice.

Specific commitments of funding for eligibility system, data collection, and access and cultural competency improvement

Eligibility. Building on the extensive guidance and support that CMCS has provided with respect to the COVID-19 public health emergency (PHE) requirements for continuity of coverage, the administrator and director acknowledge the enormity of the challenge that lies ahead as states resume full responsibility for adjudicating eligibility for their programs.

Further, they call out what we all know: countless people served by Medicaid and CHIP regularly migrate on and off coverage, often for administrative reasons that are remediable at a systems level. I learned this grim lesson firsthand after we implemented a major primary care–based shared savings initiative in Connecticut. After its first full year of implementation, we observed a totally unacceptable level of attrition from members’ attribution the practices in the care delivery model because people were required to be Medicaid eligible on a continuous basis and lost eligibility at some point in the year.

Data collection. The administrator and director also acknowledge the deficits of our current approach to collection of demographic information. The current options for people to describe their race and ethnicity are inadequate. Moreover, I am not aware of any state that is uniformly collecting sexual orientation or gender identity (SOGI) data. As a member of the LGBTQIA+ community, it is particularly painful to me that those who self-identify in that way are effectively invisible.

Access and cultural competency. It is exciting to see CMCS commit to development of a “uniform minimum access standard” across states. While it will certainly be a challenge to come to agreement on the details, such a federal standard is long overdue. In addition, it is great to see the administrator and the director acknowledge that the care that people access should meaningfully address their needs through linguistic capability, lived experience, and cultural capacity. Finally, CMCS’ efforts around promotion of the use of home- and community-based services (HCBS) are exemplary and should be perpetuated.

That said, states will need specific commitments of technical assistance and funding for this work, in the following areas:

• eligibility systems modification to support:
  • collection and analytics on race, ethnicity, language, disability, and SOGI data; and
  • implementation of a Modified Adjusted Gross Income-like household approach for eligibility determinations of older adults and people with disabilities, which CMS has signaled; and
• real and actionable means of fulfilling competency in serving people of different races, ethnicities, cultures, and orientations, such as:
  • development and dissemination of toolkits to support providers in promoting equity (see a great Connecticut example);
  • enhanced match for tools like Culture Vision, which should be embedded within practice flow and electronic health records.

Expansion of CMCS’ toolkit approach  

CMCS has done a phenomenal job of producing toolkits, such as the PHE and HCBS pieces, that have been of great value to states. CMCS has also produced several illuminating and actionable State Medicaid Director letters that illustrate authority pathways and options to address social drivers of health (e.g., transition and tenancy-sustaining services; supports for individuals being released from justice settings). Still, there are immediate opportunities to expand this approach in support of:

• CMS’ stated goals around policy principles and criteria for 1115 waivers;
• behavioral health parity;
• nursing home quality of care and cost accountability; and
• other social drivers of health, such as transportation needs.

Provision of capital to seed adoption of care delivery and payment reform

In both the Health Affairs blog post, and their August 12, 2021 statement, the CMS authors reaffirm the agency’s commitment to adoption of whole-person focused, accountable care models. It is particularly gratifying to see their commitment to examine and articulate the principles and criteria for waivers, specifically building out the statutory criteria for research and demonstration waivers to encompass explicit attention to access and improved quality, as well as uptake of value-based payment, among other aspects of care delivery. Events of recent years indicate that it is essential for CMS to set these expectations for applicant states, and then rigorously and consistently hold them to those requirements.

Further, it is about time that CMS and Medicaid programs make progress in behavioral health parity. The reality is that low reimbursement rates and gaps in the coverage array have inhibited progress in this area. While the substance use disorder (SUD) waivers and ARPA opportunities for mobile crisis are genuinely meaningful, they are voluntary and rely on state self-actualization.

All too often, the central inhibiting factors in progress when it comes to behavioral health parity are funding and lingering failure to treat behavioral health services as an essential component of value-based payment arrangements. To address this, CMS could usefully:

• build on commitments made in the August statement to align Medicare and Medicaid around specific value-based payment opportunities in primary care that treat Medicaid as a true thought partner, acknowledge and address current access gaps and disparities, and embed provision of behavioral health services; and
• create new waiver opportunities to invest seed capital in the practice transformation, training, expanded care team, and modification of data systems and analytic capacity that are needed to promote success.

Creation of sustainable solutions after ARPA

ARPA funding to states and localities is a tremendous boon, but all states are grappling with what happens next. Setting aside the many challenges of making strategic decisions on investments of this burst of money within a highly compressed time frame, CMS should be organizing dialogue and technical assistance around sustainability through the toolkit approach described earlier and through creating state affinity groups. Not all states are equally situated here. Some have the budget reserves and existing policy impetus to build out novel approaches and reform. In others, ARPA funds are gap-filling longstanding areas of underinvestment. Helping states sustain the projects initiated with ARPA funding is in the interest of the federal government because perpetuating investments in social drivers of health and economic security will continue to optimize Medicaid spending.

Before closing, I must offer specific and heartfelt thanks to CMCS for all that it has done to support states through the COVID-19 PHE. Thanks to CMCS for its outstanding work in promoting the use of PHE authorities, and the rapid cycle within which it approved state requests. Thanks for unprecedented access and transparency in weekly state calls, frequently asked questions documents, and never letting a single question on the nuts and bolts of emerging guidance go unaddressed. And thanks for asking Medicaid and CHIP directors about their experience and acting on that feedback.

While CMS remains appropriately focused on supporting people and states through the COVID-19 PHE, the administrator and director signal in their blog that they are also thinking ahead in a truly catalytic way. Their agenda is specific and real with incredible potential. And it has a compelling focus on the millions of people served by Medicaid and CHIP. All that said, CMS can immediately build on this by:

• maintaining relentless focus on improving services for Medicaid and CHIP members, notably by: identifying, measuring, and remedying racial disparities; expanding the array of evaluation tools routinely used by Medicaid programs to assess members’ lived experience;
• using its well-established and valuable technical assistance channels (Innovation Accelerator Program, toolkits) to address key areas of focus;
• providing enhanced funding for eligibility services modernization, cultural competency tools, and practice transformation, all of which will contribute to keeping people continuously covered and capably served;
• enlisting state comments and maintaining momentum on development of its proposed uniform minimum access standard; and
• engendering a true applied partnership between Medicare and Medicaid in support of value-based payment, with an emphasis on primary care.