Although most often referred to as a single thing, Medicaid is actually 55 very different things, each with its own coverage qualifications, social and political philosophies, and service restrictions. The different ways in which structural racism influences some of these policy areas in 50 states and five U.S. territories was the subject of an April 15 virtual panel at the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI).

Entitled “Addressing Structural Racism in Medicaid to Promote Health Equity,” the event was moderated by Atheendar Venkataramani, MD, PhD, who emphasized the enormous impact the 57-year-old safety net health care program has on the lives of a quarter of the entire U.S. population.

“Medicaid is one of the country’s most important, if not the most important social program,” said Venkataramani, an LDI Senior Fellow and Perelman School of Medicine faculty member who is also Director of the Penn Opportunity for Health Lab. “The Medicaid program has been shown to have incredibly large benefits for individuals who participate over the life cycle from birth to adulthood and even into the next generation. In addition to its health benefit it also has numerous economic benefits, with individuals benefiting from Medicaid, showing increased economic activity, increased wages, and improved financial security within their households as well.”

The Federal/State Dilemma

The issue, he pointed out, is that at the same time the joint federal/state program provides states and territories flexibility to explore new ways to improve health care and equity, the same flexibility “may open the door” to structural racism that leads to very different kinds of access and outcomes for marginalized racial and ethnic groups.

Panelist Emma Sandoe, PhD, MPH, agreed.

“The fact that it’s a state-administered program really casts light on a lot of American problems, especially around race,” said Sandoe, the Associate Director of Strategy and Planning at North Carolina’s Department of Health Benefits – Medicaid. “We’ve seen the relationship with race and poverty reflected in things like the implementation of the Affordable Care Act in the 12 remaining states that haven’t expanded the Medicaid program.”

“Medicaid started during the Civil Rights Act era, a time when the Voting Rights Act was just passed, and there was a lot of pushback by southern states to a federalized program,” Sandoe continued. “So, the design of a state-run Medicaid program was part of a compromise with Southern states so they could continue to control the health care of their low-income populations.”

Policy Levers

Venkataramani asked, given this history and the current level of health disparities across the balkanized Medicaid landscape, what regulatory levers does — or should — the federal government have to address structural racism and its effects in Medicaid populations?”

Cara James, PhD, Former Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services (CMS), pointed to federal regulations, rulemaking, and funding encouragement.

“We can talk about guidance and demonstrations and grants programs,” said James, now President and CEO of Grantmakers in Health. “We have payment models; we have quality improvement mechanisms. We can look at contracts and put rules and regulations within them. In terms of guidance, we have already seen Medicaid educational letters go out to state directors about the flexibilities that already exist. There was one put out last year on the social determinants of health and how states can leverage their Medicaid program to address them.”

“We can look to FMAP (the federal medical assistance percentage per state) for ways to support and encourage states to upgrade technology and infrastructure to capture better data for better understanding of what’s happening in their programs,” James said.

“You’ve got leading states that are doing really innovative and interesting work to improve access and outcomes,” she continued. “Then you have those that are struggling to figure it out a little more. And finally, you have others that may need a little bit more encouragement. Unfortunately, when you start looking at racial disparities and the map of those that need a bit more encouragement, you see states that have disproportionately larger shares of communities of color in them.”

State Budget Tradeoffs

“So,” James concluded, “we need to be thinking about how to support those states at the front of it, how to provide services for those in the middle, and how to push those who are lagging behind. And we need to remember that states have to balance their budgets and have a finite set of resources. So, even with FMAP outlays, there are going to be tradeoffs that some states may not be able to make to get the resources their programs need.”

Answering the moderator’s question about what it would mean for the Medicaid program to be anti-racist and how such an effort could be measured, panelist Leighton Ku, PhD, MPH, noted: “Medicaid tries to be an anti-racist program but does not always succeed. An important point I take from some of my analysis is that we see some of these same inequities occurring in the private insurance world. That makes me think Medicaid in and of itself would have difficulty addressing those things when they’re more systemic beyond its program. That doesn’t mean Medicaid can’t try.”

“I think it is worth thinking about something unique that Medicaid can do,” continued Ku, a Professor and Director of the Center for Health Policy Research at George Washington University. “For instance, expansions in postpartum care and other efforts to increase services in the maternity spectrum to help deal with maternal mortality. Another thing to be targeted are areas where Medicaid has a disproportionate role, like inequities in long-term care within nursing homes. But in recently talking to a long-term care expert, it wasn’t clear to me that people understand very much what’s going on in long-term care. Researchers have not looked at that much, so there’s more work to be done there.”

The Medicaid Unwinding

“In the end, one of the most important changes that would help improve Medicaid is to get the program expanded in those states that haven’t yet done so,” Ku continued. “The other thing I warn about is ‘Medicaid’s unwinding.’ That refers to when the pandemic public health emergency ends, and the Medicaid moratorium on disenrollment will end. In the year after that happens, we expect to see very large reductions in Medicaid enrollment on the order of maybe 15 million people and it could be worse. HHS and the states need to be extremely careful in making sure they plan for this, have adequate resources lined up, and have CMS monitoring what is going on in the states and is prepared to step in if enrollment systems start breaking down.”

“This ‘unwinding’ is something the Medicaid cognoscenti are aware of,” said Ku. “But is there an awareness at a larger level that we are standing on the brink of millions and millions of people losing health insurance coverage?”

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