Medicaid serves disproportionately high shares of racial and ethnic minorities. As of 2018, over 60 percent of its 73 million beneficiaries were identified as non-white. “The sheer volume of the program suggests that there is no meaningful pathway to national equity that does not involve the Medicaid program,” said Chima Ndumele from Yale University, who moderated the panel.

Inequities in the program persist, as documented by consistent evidence of disparities along various axes of oppression. Ndumele pointed out that to reduce disparities, “it is not good enough to have Medicaid that serves as just another insurance program.”

“Perhaps Medicaid that promotes equity does not need to be bigger but needs to be different to respond to the unique challenges of the population that it serves, he said.”

However, there are significant challenges to using Medicaid as a lever for improving equity that originate from the history and politics of Medicaid reform and have implications on the role of the federal government and the types of approaches to addressing inequity.

The Politics of Medicaid Reform

“All of the deepest challenges facing the program are political,” said Jamila Michener from Cornell University. Chief among them is “the extent to which beneficiaries are deserving or not deserving” of public assistance.

To illustrate how this logic of deservingness drives many aspects of the Medicaid program, she described the access barriers to Medicaid’s non-emergency medical transportation benefit (NEMT) as an example.

“Stringent rules regarding car ownership create obstacles for those who need to be able to use the NEMT benefit,” she said. These rules were erected because people believed that “enrollees would take advantage of the benefit by going to the liquor store, club, and other places, where they will display their lack of deservingness.”

This idea has been widely used as justifications for policies that curtail Medicaid’s benefits, like the work reporting requirement for Medicaid beneficiaries.

In addition, concerns about efficiency permeate debates about equity in ways that are detrimental to progress. Decisionmakers may not be enthusiastic about programs that are needed to improve equity because such programs come with costs (at least in the short term). This “economic and technocratic thinking” about equity has generated “so much pressure to prove cost-effectiveness, which is a challenge,” said Michener. As a result, stakeholders and researchers need to anticipate ideas like efficiency when making a persuasive case for equity.

Furthermore, opinions around Medicaid have become racially divided and polarized, making it difficult to form a strong national consensus about advancing equity. Beneficiaries lack representations in conversations on how the program should function, even though entities such as Medical Care Advisory Committees were created to foster inclusion within Medicaid’s decision-making processes.

However, “power can be built,” said Michener. The recent ballot initiatives to expand Medicaid in response to legislative resistance highlight how opportunities can be leveraged by “organizations and advocates to build power, especially among people who have the most at stake for Medicaid, we do see equity-enhancing progress,” Michener said.

To further create political power, stakeholders should incorporate beneficiaries’ perspectives in decision-making processes. Such efforts can be modeled after programs like the Federally Qualified Health Centers that are mandated by law to represent the patients being served by the centers and provide them with governance rights.

Federalism: A Positive or Negative Force in Medicaid Reform?

Navigating the political challenges on Medicaid necessitates engaging with the unique institutional feature of the program: federalism. Medicaid is a joint program that is administered by both federal and state governments. While the federal government provides substantial funding and oversight, there are considerable variations in the design and approach to the administration and delivery of services across states. Panelists had conflicting viewpoints about the value of this federalist structure in movements to advance equity.

“I’ve always viewed it as a great positive,” said Sara Rosenbaum from George Washington University. “The great advances in Medicaid came because of the desire on the part of forward-thinking states for financing mechanisms that would let them be far more equitable and design health care systems that work for their residents.”

She referenced Medicaid’s retroactive coverage as one of the “brilliant features” of the Medicaid program that was brought forward because of federalism.

Others had more skeptical and pessimistic views. For example, Tekisha Everette at Health Equity Solutions argued that “federalism has made it such that those who would most benefit from equity are not able to access it because states have the local domain and may or may not be favorable to equity-driven solutions in Medicaid. Embedded in our organization as a county are these longstanding values about who is and isn’t deserving, and to have that replicated within Medicaid is challenging,” she said.

Similarly, Michener questioned the prevailing notion that states are “laboratories of democracy.” She stated that states are more “observatories of democracy” because equity-enhancing practices in one state do not necessarily spill-over to other states because negative local attitudes about Medicaid languish momentum for reforms.

One antidote to this state-to-state variation is a more robust federal role in Medicaid that sets a high minimum floor for states to follow. Rosenbaum highlighted programs such as the Early and Periodic Screening, Diagnostic, and Treatment benefits for the children that set “unbelievably high standards.” They provide blueprints for structuring federal requirements that can pressure even recalcitrant states to support a level of equity that must be achieved for meaningful reductions in health disparities.

Path to Reform: Universal or Targeted Efforts?

There has been a longstanding debate about universal vs. targeted approaches to promoting equity within Medicaid. According to Rosenbaum, this “question of whether the off-the-shelf program works for everybody, or some people need a reasonable accommodation” is the foundation of the nation’s civil rights laws and, therefore, central to debates about equity.

One method for reasonable accommodation may be to use universal proxies such as geography or place, which may be more palatable in the current political environment (the recent litigation over reparations to black farmers demonstrates how targeting specific groups can be controversial).

However, there may be limits to what universal approaches can achieve in closing the racial and ethnic gap.

“We have never in the history of the U.S. fully admitted the impacts of racism in our country and actualized solutions based on this impact,” said Everette. “We can keep playing this game that universal programs that help everybody and utilitarian ethical principles are going to work for everybody when everything we have done shows they don’t.”

Instead, she advocated for “a targeted universalism” or identifying persons and populations that are most marginalized and devising solutions that benefit them specifically.

“It is interesting to discuss how to target in the context of Medicaid because Medicaid is itself a targeted program,” Michener said. “It really matters is who is being targeted. This goes back to the idea of deservingness.”

Ultimately, we need to challenge the stigmatization and marginalization of Medicaid beneficiaries and engage with the politics of targeting to build momentum for equity-enhancing initiatives that may bring transformative gains to the Medicaid program.

This blog post highlights quotes and learnings from the panel "Fireside Chat: Exploring the Opportunities & Challenges for Medicaid to Improve Health Equity" presented at the meeting "Harnessing Medicaid to Improve Health Equity: A Research and Policy Agenda" on Dec. 1 and 2, 2021. This meeting was co-hosted by Julie Donohue of the University of Pittsburgh, Susan Kennedy of AcademyHealth, Genevieve M. Kenney of the Urban Institute, Chima Ndumele of Yale University, and Kosali Simon of Indiana University.

Author, Researcher

Youngmin Kwon

Ph.D. Student - University of Pittsburgh 2022 NCHS Data Visualization Challenge Team Winner

Youngmin Kwon is a Ph.D. student studying health services research/policy at University of Pittsburgh. Read Bio

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