A Fresh Look at Medicaid

Most of my clinical time is spent in an academic outpatient internal medicine practice. However, every other Tuesday afternoon, I work alongside third-year medical students in a free clinic for people who are uninsured. To maintain continuity of care, I have been able to transition several of these patients into my practice if they obtain insurance, which is typically our state’s Medicaid program. While the care delivered in the free clinic is often evidence-based, compassionate, and fairly comprehensive, it is beholden to the donation of time and finances by specialists, hospital systems, and philanthropists. Once a patient obtains health insurance, he or she has greater security in their health care, including access to specialists, preventive screenings, and a larger prescription formulary. I am able to manage chronic conditions more effectively with improved access to resources, and I have witnessed the positive impact this level of care has on someone’s health trajectory. Additionally, the value of Medicaid for the health of our community was recognized by voters in my state in 2020 when we passed State Question 802, which expanded Oklahoma’s program under the Affordable Care Act.

However, Medicaid may not be utilized to its fullest potential, as shown by Ndumele and colleagues in a recent Annals paper (1). Although the program was initially created as “supplemental insurance coverage for the temporarily indigent,” its current use as long-term insurance for most beneficiaries is evident with the data shown in the study. Among the 1.23 million patients who received Medicaid in Michigan at the beginning of the study, 53% remained enrolled by the end of the 10-year period. This included 49% of adults without disabilities. There were frequent disruptions in care, but on average, these patients were enrolled for two thirds of the duration of the study. These data were obtained before the COVID-19 pandemic when federal law prevented the disenrollment of beneficiaries. It was uncertain if coverage was lost because of disenrollment or death, so these numbers may even be an underestimate. Although this paper highlighted only 1 Medicaid program, it is reasonable to assume this information can be applied to most states because of federal mandatory eligibility groups. Several of my own patients have been enrolled in Medicaid without a significant lapse in care since establishing with me over 5 years ago.

The gripping nature of poverty and lack of economic mobility in our society is reflected in this persistent use of Medicaid for most low-income beneficiaries. The authors argue that this understanding of the program’s use should encourage greater strategic, proactive investment in Medicaid programs to better serve those who use it for long-term coverage. When looking at those factors that influence health outcomes, such as the social and structural determinants of health, Medicaid programs may be leveraged for innovation in health care delivery and scope of coverage. For example, expansion of health care coaching or care management programs that target those with the highest risk for poor health outcomes may connect people with existing or newly created services that address lack of available healthy nutrition, affordable childcare, career training and education stipends, mental health services, and transportation to work, shopping, and health care appointments. Reimbursement rates that encourage home visits for those at greatest risk for repeated hospitalizations could lead to long-term savings (2). By focusing on truly improving health outcomes for low-income beneficiaries through upstream interventions, Medicaid can also serve as a driver for social change.

While innovative programs may take time to develop and implement appropriately, there are low-barrier changes discussed in the article that would improve the program’s effectiveness as a long-term insurer. Competitive reimbursement rates for primary care physicians and specialists would help address the shortage of clinicians who accept Medicaid as an insurance. Also, simplifying and reducing the frequency of recertification for adult enrollees would minimize the unnecessary disruptions in care that remain common.

Medicaid has improved the health of my patients and many other Americans. It is time we take a fresh look at how it can grow as a long-term solution to reducing health inequities in our communities.

References

1. Ndumele CD, Lollo A, Krumholz HM, et al. Long-term stability of coverage among Michigan Medicaid beneficiaries. A cohort study. Ann Intern Med. 2023;176:22-28. [PMID: 36469920] doi:10.7326/M22-1313
2. Mattke S, Han D, Wilks A, et al. Medicare home visit program associated with fewer hospital and nursing home admissions, increased office visits. Health Aff (Millwood). 2015;34:2138-46. [PMID: 26643635] doi:10.1377/hlthaff.2015.0583