Medicaid and meeting the health care needs of the underserved have gotten significant attention in recent years and rightfully so. Questions of coverage and funding loom large and threaten to destabilize state budgets coast to coast. Listen in on the conversations and you might believe incredible progress is being made, particularly when someone inevitably brings up “social determinants of health,” a sophisticated label for an unfortunate reality. For this particular population, the factors driving poor health outcomes are driven more by socioeconomic factors than inherent physical ones.
So now that we have labeled it, what really is being done to change the care paradigm for Medicaid and the underserved?
Perhaps unsurprisingly, not enough.
It’s frustrating, because this is an area where we have the opportunity to align our values with our actions. If we were to do so, we would deliver benefits across the board—for the patients, for taxpayers, and for society as a whole. Instead, providing better access to primary care for the underserved remains a battleground where altruistic ideas and social responsibility clash headlong with political ideology and economic reality.
For the states, it is an issue of funding and payment, and the approaches being taken to address the issue vary considerably. Consider models such as traditional fee for service (albeit at abysmal reimbursement rates) or managed Medicaid, which brings the capabilities and costs of insurance companies into the mix. In some cases more innovative engineering is designed to stimulate consumer-like behavior. All of these models move the financial risk around, but they do little to reinvent the underlying care model.
There are many things broken in how Medicaid and the underserved access and consume health care today. Problems persist on both the demand and supply sides.
On the demand side, people who are disadvantaged do not, as a rule, use primary care for preventive or wellness services as often as they should. As a result, there is a tendency to utilize the emergency department too much. And unmet needs often extend well beyond basic primary care into the need for behavioral health, oral health, and social services.
On the supply side, convenient and affordable primary care options for less affluent people are often scarce. Many private practices do not take Medicaid patients because of low reimbursement rates. The practices owned by not-for-profit health systems should have policies for accepting these patients as part of the health systems’ missions. Some do, but others limit availability through schedules and by other means. The federally qualified health centers convene the right kinds of services and are a true safety net, but they have limited resources.
A bleak picture. But there are some bright spots where innovation is being focused on the specific needs of the Medicaid and underserved populations. One notable example is the Southcentral Foundation, a Native Alaska health care organization, and its Nuka System of Care, which on a shoestring budget leverages a relationship-based approach to meeting the health care needs of that community. The Nuka care model includes integrated behavioral health, oral care, and family counseling. Another is the Cherokee Elder Care Program in Tahlequah, Okla. It is one of only 15 rural Programs of All-Inclusive Care for the Elderly (PACE), programs that provide comprehensive medical and social services to frail elderly individuals. The Cherokee program uses multidisciplinary care teams to help low-income seniors remain in their homes for as long as possible.
These models offer real inspiration—but let’s face it: Our vulnerable populations face needs that extend way beyond innovations in care models.
The challenge is not dreaming up the solutions; it is justifying the costs. The reality, though, is that there is a cost to keeping the underserved that way, whether that means funding integrated primary care to help people live healthier lives or footing the bill when people get care in the emergency department.
Hopefully, as care delivery innovation sweeps across other population segments with more compelling business cases, the principles will be applied to the needs of this population. It is incumbent on us all to ensure the underserved do not become unremembered.