On November 4, 2022, TCF senior policy associate Vina Smith-Ramakrishnan and TCF health care policy fellow Thomas Waldrop responded to a request for information from the Centers for Medicare and Medicaid Services regarding challenges in accessing healthcare and advancing health equity. Their letter appears below.

Dear Secretary Xavier Becerra,

We appreciate the opportunity to respond to this request for information (RFI) on strategies that successfully address drivers of health inequities, including opportunities to address social determinants of health and challenges that underserved communities face in accessing comprehensive, quality care. The Century Foundation (TCF), a 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 faced by low-income people and people of color. Like the Centers for Medicare and Medicaid Services (CMS), TCF seeks to advance health equity.

Navigating the health care system and accessing comprehensive health care can present unique challenges. Barriers to equitable access can include social determinants of health, affordability, and knowledge gaps. The COVID-19 pandemic has exacerbated many of these existing barriers, deepening inequities and making equitable health care access even harder to achieve.

These challenges in accessing health care 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. People of color are disproportionately likely to rely on Medicaid for health coverage in comparison to their white counterparts. Recent studies have shown that LGBTQ+ patients experience disparities in sexual and reproductive health care and outcomes. These include facing structural barriers to contraceptive care, being more likely than their straight and cisgender counterparts to be uninsured, and experiencing discriminatory treatment by health care providers.

Throughout the COVID-19 public health emergency (PHE), states have been required to keep Medicaid beneficiaries enrolled as a result of accepting increased funding under the Families First Coronavirus Response Act. The PHE was recently extended on October 13, 2022, until January 11, 2023. Once the PHE ends, the federal government has estimated that roughly 15 million individuals will have to leave Medicaid and CHIP, with 7 million of those losing coverage due to bureaucratic obstacles, not due to eligibility.

Once the public health emergency ends, the federal government has estimated that roughly 15 million individuals will have to leave Medicaid and CHIP, with 7 million of those losing coverage due to bureaucratic obstacles, not due to eligibility.

With millions at risk of having their eligibility redetermined, the risk of losing coverage will fall disproportionately upon people of color, specifically Black and Hispanic individuals, who have experienced stark health inequities over the course of the pandemic. Navigating the pending unwinding of the PHE will require careful consideration of health equity.

There are a number of actions that CMS can take to yield improvements in equitable access to quality healthcare and expand upon past and ongoing efforts going forward. We applaud this RFI as a lever for positive change. Below is a compilation of information and policy proposals in response to the RFI for public input on accessing healthcare and related challenges and advancing health equity.

Accessing Health Care and Related Challenges

Challenges of Accessing Reproductive Health Services

Equitable access to reproductive health services has always been out of reach for too many in the United States, but following the U.S. Supreme Court’s decision to remove the constitutional right to abortion in Dobbs v. Jackson Women’s Health Organization, this crisis continues to worsen at an alarming rate. The abortion bans that have gone into effect since the Dobbs decision will have stark health equity implications. States with higher numbers of abortion restrictions are the same states with poorer maternal health outcomes that disproportionately harm communities of color. Roughly half of all American Indian and Alaska Native women of reproductive age in the United States live in states where abortion trigger bans and pre-Roe bans have now gone into effect. Three in ten Hispanic and Black women also live in these states. More than half of all abortion patients identify as people of color. This is due to racism at both the individual and the structural level. A long history of racist practices and coercion in the health care system targeting people of color’s sexual and reproductive health and rights as well as reported discrimination by health care providers have resulted in medical mistrust.

TCF applauds the CMS clarifying guidance on the Emergency Medical Treatment and Active Labor Act (EMTALA), reaffirming that health care providers will be protected when giving legally-mandated, life- or health-saving abortion care in emergency situations, and requiring that hospitals provide all patients with appropriate medical care, including abortion care, regardless of the state laws applying to specific procedures. This reiterates a right to abortion care in emergency situations for those who need it, in effect across the country. CMS should also ensure that abortion care is covered to the fullest extend allowable by law in all forms. For example, because the manufacturers of mifepristone—one of two drugs making up the most common regimen for medication abortion care—participate in the Medicaid Drug Rebate Program, all state Medicaid programs are required by law to cover mifepristone in cases of life endangerment, rape, and incest (in alignment with the abortion exceptions recognized by the Hyde Amendment). We urge CMS to take action in cases where states are noncompliant in providing abortion care for the required exceptions.

CMS plays a leading role in equitable access to sexual and reproductive health care services through Medicaid, the primary funding source for family planning for low-income individuals. However, more is needed in order to achieve equitable access to full-spectrum reproductive health care, especially when considering that those most impacted by the Dobbs decision disproportionately rely on Medicaid to finance their health care. Being able to receive family planning services from a provider of their choice is a legal right for all Medicaid beneficiaries, and a patient’s ability to see a provider that they trust can be a major factor that plays into the health care they are able to access. We urge CMS to enforce Medicaid’s free choice of provider requirement.

Being able to receive family planning services from a provider of their choice is a legal right for all Medicaid beneficiaries, and a patient’s ability to see a provider that they trust can be a major factor that plays into the health care they are able to access.

Challenges of Accessing Maternal Health Services

We greatly appreciate the attention that the Biden–Harris administration has dedicated towards the U.S. maternal health crisis: specifically, the 2021 guidance released by your agency on the opportunity for states to extend postpartum coverage to one year under the option included in the American Rescue Plan, and the 2022 CMS Maternity Care Action Plan along with the White House’s Blueprint for Addressing the Maternal Health Crisis.

In the U.S. nearly half of all births are covered by Medicaid, and roughly two-thirds of Black women giving birth have their births covered by Medicaid. As your agency has made clear, health coverage throughout the postpartum period is critical to saving lives and ensuring healthy mothers and families, closing this gap for Medicaid enrollees is particularly urgent. With over 80 percent of pregnancy-related deaths being preventable, and the majority of deaths occurring more than a week into the postpartum period, the need to ensure postpartum coverage has never been clearer. While more than half of states have now extended coverage, we urge CMS to continue encouraging states to implement extended coverage through state plan amendments as we await mandatory and permanent extension of Medicaid coverage to one year postpartum from Congress. This will continue to expand the number of women and birthing people who are able to access quality maternal health care in the postpartum period.

Advancing Health Equity

TCF applauds the Biden—Harris administration’s inclusion of advancing health equity in its programs, especially its prioritization of health equity in its strategy priorities for the Center for Medicaid and CHIP Services. Meaningful access to health coverage that meets the needs of patients is critical to achieving true health equity. In addition to the final regulations issued for open enrollment for 2023, CMS can take additional steps to promote health equity in coverage.

Recommendations for CMS Areas to Address Health Disparities and Advance Health Equity

CMS should work with states to ensure that Medicaid and CHIP provider networks are both sufficient in size and scope as well as culturally competent. Because network adequacy standards are established at the state level, CMS’s role will likely consist of guidance to states, rather than explicit regulations. Part of this guidance should include working with marginalized populations directly when designing network standards to ensure that networks truly meet the health needs they feel that Medicaid and CHIP can address.

The impact of creating culturally competent networks is well-documented. For example, as part of Colorado’s public option legislation, the state Division of Insurance held listening sessions to ensure that the health needs of specific populations, including disabled patients and rural patients, were met as the public option’s network adequacy standards were created. This led to the inclusion of doulas and other providers that disproportionately benefit patients of color. Promoting this approach as states design their networks in coming years will help ensure that patients have access to the providers they feel comfortable seeing and that are prepared for the unique challenges different communities face.

Feedback on Enrollment and Eligibility Processes

In addition to ensuring that networks for Medicaid and CHIP include the providers that patients need, it is also critical to ensure that patients are easily able to enroll and renew their coverage with as few hurdles as possible. TCF applauds the guidance provided to states on how to work through their renewal processes as the COVID-19 public health emergency (PHE) unwinds. Below are additional steps that we believe will help further improve this process.

CMS should work with states to increase the amount of automatic redeterminations of eligibility. Ex parte renewals are an effective way to ensure that eligible patients remain enrolled in Medicaid without onerous administrative requirements. In particular, as the PHE is likely to end in the near future, working with states to improve ex parte renewal rates will help avoid massive disenrollment once states are permitted to do so.

CMS should also issue regulations requiring states to include text messaging as a primary form of communication around eligibility. Pilot programs in states have proven effective in using text messages as a method to improve response rates, especially with respect to renewal. For example, Louisiana’s pilot program sending text messages to beneficiaries resulted in a 10-percentage-point increase in successful Medicaid renewals. This regulation should also include a requirement that text messaging contact be opt-out, rather than opt-in, for beneficiaries that have provided a cell phone number. Many states have already adopted this strategy for the PHE unwinding, and requiring it for future Medicaid enrollment and renewals will help ensure that Medicaid beneficiaries continue to benefit from its use after the PHE has passed.

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. Access to reproductive health care, maternal health, and other health care through Medicaid and CHIP are more critical than ever in light of the loss of the federal right to abortion and the upcoming end to the PHE. We are ready and eager to work with you in developing strategies to improve equitable access to quality health care for Medicaid and CHIP enrollees.

Vina Smith-Ramakrishnan
Senior Policy Associate

Thomas Waldrop
Health Care Policy Fellow