Better Health NOW Campaign’s Medicaid Policy Priorities

Life expectancy in the United States is decreasing, with chronic disease the leading cause of death and disability; the country’s suicide rates have increased 30% over the last two decades; overdose deaths continue to escalate, including a 94% increase among adolescents in recent years; and disparities in health and access persist across racial and ethnic groups as well as for those in rural areas.

What’s more, patients across the country are increasingly having trouble accessing the very people who consistently help to prevent and address these burdens: primary care.

Today, individuals and families can face major barriers to seeing a primary care clinician, including limited or no practices in their communities; long wait times—of several weeks or more—to be seen; and frequent disruption of coverage due to disenrollments and red tape.

Primary care is critical to better population health and more equitable outcomes.

To address crises in behavioral health, lifestyle-related chronic disease, and access to care, policymakers must work to strengthen primary care across the nation, with a particular focus on Medicaid and CHIP. There is no single silver bullet, but policymakers can rely on strategies that are backed by established and emerging research to support beneficiaries’ access to high-value, whole-person primary care.

These approaches include changing how, and how much, we pay primary care—by reporting levels of spending on primary care and pursuing population-based payment models. Strategies also address how care is delivered, including integrating behavioral health and community health workers, as well as promoting patient-centered medical home and community health center models.

Covering nearly 90 million people, the vast reach of Medicaid and CHIP—particularly as major sources of coverage for people of color and those living in rural areas—makes them a key vehicle for bettering the health of underserved communities. Medicaid covers nearly a quarter of individuals living in rural areas across the U.S.; over 60% of the program’s enrollees identify as Black, Hispanic, Asian American, or other persons of color; nearly half are children; 41% of U.S. births are paid for by Medicaid; and almost a quarter of its covered nonelderly adults report having a disability.

Despite its importance, per person spending on primary care in Medicaid is lower than in commercial insurance and has declined nearly continuously since 2014. Low Medicaid payment rates create barriers to care for patients as practices are forced to limit their Medicaid patient panels.

Unsurprisingly, then, Medicaid enrollees also disproportionately rely on the emergency department as their usual source of care, where care is focused on treating acute symptoms rather than prevention, chronic disease management, and ongoing relationships between patients and their care teams. As unwinding of pandemic-related continuous coverage requirements has proceeded in recent months, over 10 million Medicaid enrollees have lost their healthcare coverage – disrupting their access to affordable primary care.

The Better Health NOW! campaign calls on federal policymakers to pursue two immediate Medicaid-related policy goals:

• Support state Medicaid and CHIP programs in offering well-designed population-based payment models that include enhanced investment in primary care and strong alignments of payment and measurement approachments across payers.
• Promote and equip primary care to integrate whole-person health¹, especially integrated behavioral health care.

• Provide Guidance on Population-Based Primary Care Payment Models
  CMS should furnish, and regularly update, guidance to states regarding the design, adoption, and evaluation of primary care payment and payment models that facilitate equitable and timely access to comprehensive, continuous primary care for Medicaid and CHIP beneficiaries.
• Prioritize Primary Care - Behavioral Health Integration
  The Centers for Medicaid and CHIP Services should remove access, cost-sharing and payment barriers to wider adoption of integrated care approaches (e.g., limited coverage and payment for Collaborative Care and Primary Care Behavioral Health models) and promote the use of flexible population-based payment models.
• Promote Continuity of Coverage and Care
  Because pandemic enrollment “unwinding” has disrupted coverage for millions of eligible children and adults, CMS must reconnect those individuals with coverage and primary care in 2024. As CMS reviews state plans and proposed state demonstration projects, CMS should urge inclusion of continuity of coverage protections and assure beneficiaries are connected to a regular source of primary care. States should be required to report rates of enrollment, disenrollment and churn as part of the Annual State Scorecard.
• Track Primary Care Access and Investment
  CMS should implement strong primary care access standards that compare Medicaid primary care payment to Medicare and other payers. The Annual State Medicaid Scorecard should require states to report on both a) primary care spend and b) mix of primary care payment types.
• Develop Medicaid/CHIP CMMI Models
  The CMS Innovation Center should continue to facilitate development of and participation in prospective, population-based models, inclusive of models addressing the needs of broad populations as well as targeted Medicaid enrollee groups and aligned with other payers. These models should equip primary care with the support and financing needed to deliver and facilitate whole-person care inclusive of chronic and acute physical health, behavioral health, and maternal and child health while connecting patients to community resources addressing social needs as appropriate.