On April 14, 2022, TCF director of health care reform and senior fellow Jamila Taylor responded to a request for information from the Centers for Medicare and Medicaid Services regarding equitable access to quality health care for Americans with Medicaid or CHIP health insurance. Dr. Taylor’s letter appears below.
Dear Secretary Xavier Becerra,
Thank you for the opportunity to respond to the request for identifying strategies to improve equitable access to quality health care for Americans utilizing the Medicaid and CHIP programs. The Century Foundation, a 100-year-old progressive, nonpartisan think tank, is home to a robust health care team that provides analysis and recommendations on how to improve health care in the United States. Our work investigates ways to expand access to health coverage for all people; make health care more affordable, efficient, and of the highest quality; and close health care gaps facing low-income people and people of color.
Social determinants of health play a major role in eligible individuals’ ability to enroll in Medicaid and CHIP. Barriers to equitable access span a range of social determinants, such as lack of safe housing, unemployment, or poor access to transportation. The COVID-19 pandemic has exacerbated many of these existing social determinants, deepening inequities and making the barriers to equitable health care access even harder to overcome. There are also knowledge gaps, largely due to inadequate access to health care-related information and support, especially among already marginalized communities, when it comes to understanding the process for enrolling.
These barriers have a disproportionate impact. As an organization committed to the pursuit of equity, improving access to health coverage for the most marginalized and those most at risk is a top priority. As of 2019, people of color were already more likely to be uninsured than their white counterparts, despite Medicaid and CHIP helping to fill in some of the coverage gaps. From 2020 onward, the economic fallout from the COVID-19 pandemic, such as job losses and unemployment, was felt disproportionately among Black and Hispanic communities.
Throughout the public health emergency (PHE), states are required to keep Medicaid beneficiaries enrolled. The latest extension of the PHE was on April 12, 2022. Once the PHE ends, the more than 80 million people enrolled in Medicaid and CHIP will have their eligibility redetermined and risk losing coverage. This risk will fall disproportionately upon people of color, specifically Black and Hispanic individuals, who have experienced stark health inequities over the course of the pandemic.
While structural racism is the major contributor to these long-standing health inequities that have now been exacerbated by the pandemic, there are policy actions that the Centers for Medicare and Medicaid Services (CMS) can take to yield improvements in equitable health coverage. The CMS objectives are a bold starting point for making these changes occur. Below is a compilation of information and policy proposals in response to the stated objectives to ensure equitable access to quality health care through Medicaid and CHIP.
Ensuring that Medicaid and CHIP Reach Those Who Are Eligible
Addressing Barriers in Enrollment and Retention for Pregnant and Postpartum Individuals
The expanded eligibility of pregnancy-specific Medicaid coverage is crucial in supporting the health and wellbeing of birthing people during and after the end of a pregnancy. In particular, strengthening the benefits and coverage period for pregnancy Medicaid will directly support communities of color, named as an interest group in this RFI. In 2019, 65 percent of births to Black individuals and 59 percent of births to Hispanic individuals were financed by Medicaid.
We appreciate the guidance released last year by your agency on the opportunity for states to extend postpartum coverage to one year under the option included in the American Rescue Plan. This guidance provided crucial information on eligibility and ensuring that pregnant people have access to full-scope coverage during the postpartum period. We urge CMS to continue encouraging states to take up the state plan amendment option to extend postpartum coverage as we await mandatory extension of coverage from Congress. In addition, we ask that CMS promote the Maternity Core Set voluntary reporting for state Medicaid and CHIP agencies as much as possible, especially the subset that will become mandatory in 2024.
Ensuring that Medicaid and CHIP Beneficiaries Have Consistent Coverage
Making the Redetermination Process Accessible for Those with Limited English Proficiency
In order for health care to be equitable, it has to be accessible to everyone. A base level of health literacy and the ability to understand and navigate the complex medical system is often needed just in order to fill out state-provided forms for Medicaid and CHIP coverage renewal. If there are language or literacy challenges that the beneficiaries experience, they may either fill out the forms incorrectly or not fill them out at all, resulting in potential loss of coverage. Individuals with limited English proficiency (LEP) disproportionately experience poor health outcomes and gaps in insurance coverage related to the challenges they have in comprehending health care information. Research shows that LEP individuals also make up a disproportionate share of the Medicaid population. This is an issue of racial and ethnic health disparities and racial equity in Medicaid access, as people of color are significantly more likely to have LEP than their white counterparts.
We applaud the existing CMS guidance on strategies that U.S. states and territories can adopt to maintain coverage of eligible individuals, including those with LEP, and urge CMS to continue encouraging states to translate key documents into multiple languages, allow for multiple modes of submission (including mobile, phone, online, and in-person), and engage with trusted community partners including community-based organizations and application assisters.
Enforcing Medicaid’s Free Choice of Provider Requirement
As the primary funding source for family planning for low-income individuals, Medicaid plays a leading role in equitable access to sexual and reproductive health care services. Medicaid beneficiaries have the legal right to receive family planning services, a mandatory benefit category, from the provider of their choice. However, many states have sought to deny Medicaid patients’ access to their trusted provider of choice, with the most recent successful attempt being Missouri’s budget bill that excluded abortion providers from the state’s Medicaid program, consequently disrupting coverage for beneficiaries. Attacks on Medicaid family planning services disproportionately harm those who are already more likely to experience sexual and reproductive health inequities. Due to systemic barriers and racism, Black women are 71 percent more likely to die from cervical cancer than white women, and Black and Latina women make up more than 80 percent of women living with HIV/AIDS. Access to Medicaid, including free choice of provider, is critical to closing these gaps.
Actions by states like Missouri that are clearly in violation of the Medicaid free choice of provider protections are unacceptable and unlawful. They also prevent Medicaid beneficiaries from having consistent coverage. We strongly urge CMS to enforce Medicaid’s free choice of provider requirement as soon as possible, to restore access to affordable family planning services for all.
Establishing Access to Timely, High-Quality, and Appropriate Care in All Payment Systems
Alternative Payment Models to Improve Maternal Health
Opportunities to align payment incentives with quality of care are particularly important for pregnant and postpartum people, and we appreciate the attention CMS is paying to addressing whole person care for these individuals. The Center for Medicare and Medicaid Innovation (CMMI) should use its existing authority to test alternative payment models for maternal health such as value-based care. Paying health care providers based on the health outcomes of patients will help address challenges with care quality, which tend to fall hardest on communities of color and in turn contribute to health disparities. Any value-based approach must put patient outcomes front and center, as they may fall by the wayside if the focus is solely on cost and safety. Additionally, maternal health homes and standards for equitable reimbursement for doula and midwifery care will improve patient outcomes while potentially lowering health care costs.
Research has demonstrated that continuous support from birth workers such as doulas improves maternal health outcomes. Doula care is also cost effective, with lower health care costs being associated with doula-assisted births. Doula care, particularly from community-based doulas, is also an underutilized means of reducing the alarming racial disparities that we see in maternal health outcomes. Despite this, doula care is rarely covered by insurance; only a handful of state Medicaid programs are reimbursing for doula care. CMMI could rectify this by testing a model of doula payment, without any further action from Congress. CMS can also support doula coverage by issuing clear guidance for waivers or state plan amendments to include doula services under Medicaid that would be approved barring other concerns, such as work reporting requirements.
Although the landscape of reimbursement for midwifery care is less patchworked than that of doula care, there are variations in restrictions on midwives, including requirements for supervision and differences in reimbursement based on certification. Research demonstrates that midwifery care can improve birth outcomes, increase the chances of a low-intervention birth, and reduce the odds of cesarean sections, which can have important implications for maternal morbidity. By testing a model for maternal health homes, CMMI could improve equity by supporting health teams composed of midwives in addition to non-clinical care like doulas, community health workers, lactation consultants, and translators.
Further, CMS should ensure that abortion care is covered to the fullest extent allowable by law. Abortion access is already out of reach for so many people, especially people of color and people struggling to make ends meet, both communities that are overrepresented among Medicaid recipients. Medicaid enrollees must be able to access—potentially life-saving—care in the cases where federal funding can be provided. Despite federal funding being required for abortion coverage in cases of life endangerment, rape, and incest, one state—South Dakota—has refused to comply with the law for several decades. CMS should take action to ensure that South Dakota is compliant in providing abortion care for the required exceptions. A 2019 GAO report identified a number of other limitations that need to be addressed in the coverage of abortion care, including states that are not covering mifepristone (used for medication abortion care) as required by law. As outlined by the report, CMS should also take action to ensure accurate reporting of abortion in states where discrepancies have been identified.
Data for Monitoring and Encouraging Equitable Access within Medicaid and CHIP
Reliable Data Collection and Reporting Disaggregated along Racial and Ethnic Lines
Consistent and accurate data are essential to ensuring equitable access to services among Medicaid and CHIP beneficiaries. CMS should consider requiring or recommending that states further disaggregate the data they collect to more accurately address negative health outcomes. The COVID-19 pandemic has made this clear: early in the pandemic, COVID-19 cases, hospitalization numbers, and deaths were not reported by race or ethnicity, masking the disparate impact the disease had on communities of color. Race and ethnicity data are still missing for nearly one in four patients, making disparities in vaccination status unclear.
In order to address health disparities, the data must be sufficient to identify them. To this end, CMS should require states to report data that is both disaggregated by race and ethnicity as well as by delivery system. Without data clearly broken out into these categories, inequities may be masked by the aggregation of patient experience. For example, a state’s Medicaid managed care plans may be severely inequitable along racial lines for providers accepting new patients, but if the fee-for-service portion of the program does not have this same problem, the managed care patients’ lack of access to needed care would be less obvious. This is especially true for states with significant differences in patient populations served between delivery methods.
Similarly, in states with heavy use of managed care organizations, CMS should require reporting by plan within the managed care system. Because managed care organizations are often sorted by geography, this would allow CMS to use existing data on the health history and trends of counties and communities, such as the information used to set rates for marketplace plans, to better understand the causes of health disparities. This approach would also provide strong comparison between managed care plans’ enrollees and other patients in the community.
In addition to using the existing standards for data reporting of race and ethnicity, CMS should encourage states to collect more specific data. The broad categories used throughout the federal government are a good start, but they can often mask inequities within these categories. The uninsured rate among the aggregate Asian population, for example, is around on par with that of the white population. When this data is disaggregated by national origin, however, broad disparities become evident: nearly 17 percent of Burmese parents were uninsured in 2018–19 according to a study conducted by the Urban Institute, compared to only around 3 percent for Japanese and Indian parents. Without granular data disaggregation, health disparities cannot be identified, much less eliminated.
Sufficient Medicaid and CHIP Payment Rates
Realigning Medicaid and CHIP Payment Rates to Reflect Value
Many necessary and important health services are undervalued by the fee-for-service Medicaid program, and as a result, managed care organizations carry this misvaluing of care into their payment rates as well. This undervaluing of care results in patients being unable to access the care they need. Previous research conducted by health care experts at The Century Foundation highlighted this issue in maternal health outcomes. In a 2020 report, TCF researchers interviewed many health care providers on their experiences with Medicaid reimbursement, and many highlighted that the low reimbursement for maternal health services under the Medicaid program resulted in many providers declining to serve Medicaid patients. Given the high proportion of births that Medicaid covers, especially among Black women, this is a major access concern. A patient’s value, as well as the accessibility and quality of their care, should not be based on the source of health insurance they hold. Medicaid reimbursement rates must be increased to those that are comparable to commercial insurers.
In conclusion, we hope that you find these policy proposals and information provided valuable as CMS continues to explore ways in which to improve health equity. With health and economic disparities worsened due to the pandemic, this moment offers a critical window of opportunity to ensure that all Americans have access to affordable and accessible health coverage. We stand ready to work with you in developing strategies to improve equitable access to quality health care for Americans utilizing the Medicaid and CHIP programs.
Jamila K. Taylor, PhD
Director of Health Care Reform and Senior Fellow