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Medicaid Payment and Delivery Reform: Insights from Managed Care Plan Leaders in Medicaid Expansion States

March 7, 2018

Issue: Managed care organizations (MCOs) are integral to Medicaid payment and delivery reform efforts. In states that expanded Medicaid eligibility under the Affordable Care Act, MCOs have experienced a surge in enrollment of adults with complex needs.Goal: To understand MCO experiences in Medicaid expansion states and learn about innovations related to access to care, care delivery, payment, and integration of health and social services to address nonmedical needs.Methods: Interviews with leaders of 17 MCOs in 10 states that have seen large Medicaid enrollment growth and have undertaken payment and delivery reforms.Findings and Conclusions: MCO leaders regard their ability to enroll and serve the Medicaid expansion populations as a signal achievement. They have focused on identifying and helping high-risk populations and addressing the social determinants of health. MCOs are testing value-based payment strategies that link payment with performance and are increasingly focused on engaging patients in their care. Leaders report common challenges: setting appropriate payment rates; managing members whose needs differ from traditional Medicaid beneficiaries; ensuring access to specialty care; and effectively implementing payment reform and practice transformation. All point to the need for a stable policy environment and a strong working relationship with state Medicaid agencies.

Strengthening Medicaid as a Critical Lever in Building a Culture of Health

January 17, 2017

Strengthening Medicaid as a Critical Lever in Building a Culture of Health is a nonpartisan study panel report which offers a series of steps that would enable Medicaid to leverage its unique role as an insurer to increase its capacity for addressing the underlying social determinants of health. The study panel was convened to assess the current and possible future role of Medicaid in building a Culture of Health. The panel included state Medicaid program directors, public health and health policy experts, health researchers, medical and health professionals, and health plan representatives.The panel discussed strategies that could increase Medicaid's potential to help move the dial on individual and population health, while improving health care quality and program efficiency. The findings are divided into two categories: those that can be accomplished administratively (without any further legislative action) and those that would require legislative change.The report also recognizes key challenges that Medicaid faces, including the high cost states already bear for insuring vulnerable populations, the chronic insufficiency of funding for social service programs that could partner with Medicaid to foster health, and the complexities of implementing innovative care delivery models, among others.While the current political landscape signals new policy discussions about the future of the program and its funding, the analysis and options included in this report recognize that health care coverage is a critical underpinning for improving health. Whether and how Medicaid might be changed, its role as an insurer is foundational; this report assumes that Medicaid will continue to be central to the health care safety net as an insurer of low-income, vulnerable populations.

Medicaid's Future: What Might ACA Repeal Mean?

January 12, 2017

Issue: Republicans in Congress are expected to repeal portions of the Affordable Care Act (ACA) using a fast-track process known as budget reconciliation.Goals: This issue brief examines how repeal legislation could affect Medicaid, the nation's health care safety net, which insured 70 million people in 2016.Findings and Conclusions: Partial-repeal legislation that passed Congress but was vetoed by President Obama in 2016 offers some insight but new legislation could go further. It could repeal the ACA's Medicaid eligibility expansions for adults and children but also roll back other provisions, such as simplified enrollment and improvements in long-term services and supports for beneficiaries with disabilities. Additionally, the Trump Administration could expand use of demonstration authority to introduce deeper structural changes into Medicaid, such as eligibility restrictions tied to work, required premium contributions and lock-out for nonpayment, annual enrollment periods, and coverage limits and exclusions. Together, these changes would have far-reaching implications for Medicaid's continued role as the nation's safety-net insurer.

Improving Community Health through Hospital Community Benefit Spending: Charting a Path to Reform

December 1, 2016

A new report recommends that the Trump administration take action to revise existing Internal Revenue Service policies governing community benefit spending by tax-exempt hospitals in order to encourage greater hospital involvement in activities that can improve health on a community-wide basis.Research increasingly shows the outsize importance of healthy communities to population health. Affordable and safe housing, safe and welcoming neighborhoods, access to nutritious food, strong child development programs and quality education together can lead to better health outcomes. Hospitals themselves have recognized the health impact of these broader social, economic and environmental conditions and as well as the value of their involvement in activities aimed at improving social conditions.Building on longstanding policies regarding tax exempt hospitals and community benefit spending, the report shows the incoming Trump administration can encourage greater hospital involvement in community-wide health by adopting a more flexible regulatory standard on what constitutes a community benefit. Produced by researchers at the George Washington University's Milken Institute School of Public Health (Milken Institute SPH), the report identifies a series of steps that the IRS can take, working in collaboration with public health experts drawn from across government and private institutions and organizations, to modify existing community benefit policies to encourage greater population health activities. Such a change would be wholly consistent with hospitals' own community health needs assessments (CHNAs), which focus on high-priority community health needs that extend beyond clinical health care.

Streamlining Medicaid Enrollment: The Role of the Health Insurance Marketplaces and the Impact of State Policies

March 30, 2016

In addition to expanding eligibility for Medicaid, the Affordable Care Act reformed the program's enrollment process, with the health insurance marketplaces playing a central role in the reforms. State-based marketplaces determine Medicaid eligibility, but federal regulations give states using the federal marketplace a choice either to allow the marketplace to make Medicaid eligibility determinations or to limit its role to assessing and referring applicants to the state Medicaid agency. This issue brief examines Medicaid enrollment data and finds that states that establish their own marketplaces realize higher Medicaid enrollment. In states that use the federal marketplace, Medicaid enrollment is higher when states have the marketplace determine eligibility. These findings underscore the importance of states' marketplace decisions regarding Medicaid enrollment.

Medicaid Benefit Designs for Newly Eligible Adults: State Approaches

May 11, 2015

The Affordable Care Act gives states the option of providing lessgenerous Medicaid coverage to adults who become eligible through the law's expansion of the program. Based on a review of the benefit design choices made by states that had expanded Medicaid by the end of 2014, we find that states have chosen to offer more generous coverage than what is required under federal law, either narrowing or eliminating the distinction between coverage levels for newly eligible adults and those for traditional adult beneficiaries, such as pregnant women, parents and guardians, or beneficiaries with disabilities. This suggests that states view the newly eligible beneficiaries as having the elevated health and health care needs that are common among low-income populations.

How States Are Expanding Medicaid to Low-Income Adults Through Section 1115 Waiver Demonstrations

December 19, 2014

In the wake of the Supreme Court's 2012 decision making state expansion of Medicaid to more adults optional under the Affordable Care Act, several states have received approval to combine such expansion with broader Medicaid reforms. They are doing so under Section 1115 of the Social Security Act, which authorizes Medicaid demonstrations that further program objectives. State demonstrations approved so far combine expanded adult coverage with changes in that coverage and in how the states deliver and pay for health care. These states have focused especially on expanding the use of private health insurance, requiring beneficiaries to pay premiums, and incentivizing them to choose cost-effective care. By enabling states to link wider program reforms to the adult expansion, Section 1115 has allowed them to better align Medicaid with local political conditions while extending insurance to more than 1 million adults who would otherwise lack a pathway to coverage.

Mitigating the Effects of Churning Under the Affordable Care Act: Lessons from Medicaid

June 17, 2014

Through a combination of three needs-based public programs— Medicaid, the Children's Health Insurance Program, and tax credits for purchasing private plans in the new marketplaces—the Affordable Care Act can potentially ensure continuous coverage for many low- and moderate-income Americans. At the same time, half of individuals with incomes at less than twice the poverty level will experience a form of "churning" in their coverage; as changes occur in their life or work circumstances, they will need to switch among these three coverage sources. For many, churning will entail not only changes in covered benefits and cost-sharing, but also in care, owing to differences in provider networks. Strategies for mitigating churning's effects are complex and require time to implement. For the short term, however, the experiences of 17 states with policies aimed at smoothing transitions between health plans offer lessons for ensuring care continuity

Examining the Evidentiary Basis of Congress's Commerce Clause Power to Address Individuals' Health Insurance Status

February 3, 2012

Outlines the issues involved in whether the 2010 Affordable Care Act's individual mandate is constitutional under the commerce clause, presents research literature on the effect of uninsurance on the broader economy, and reviews the lower courts' rulings.

Building a Relationship Between Medicaid, the Exchange and the Individual Insurance Market

January 25, 2012

Examines the federal-state government relationship under the Affordable Care Act, the importance of aligning enrollment and market policies across Medicaid and exchanges, and considerations for coordinating insurance affordability program markets.

Assessing and Addressing Legal Barriers to the Clinical Integration of Community Health Centers and Other Community Providers

July 15, 2011

Explains the legal framework governing collaborations between health centers and affiliates. Profiles partnerships developed within the framework to advance the centers' core missions by expanding patient services and access to medical information.

Aligning Forces for Quality: Disparities Reduction and Minority Health Improvement Under the ACA

June 16, 2011

Highlights reform provisions to reduce racial/ethnic health disparities, including requiring data collection, integrating minority health into national strategies, and funding efforts to increase minorities' representation in the healthcare workforce.