The COVID-19 pandemic continues to expose cracks that exist within the U.S. health care system, particularly in its ability to serve vulnerable populations. With marginalized communities often lacking essential needs in areas such as housing and food security, having disproportionate involvement in the criminal justice system, and experiencing other stressors related due to systemic social deprivation, they have experienced poorer outcomes for COVID-19. For example, American Indians are 5.3 times, Black Americans 4.7 times, and Hispanic Americans 4.6 times more likely to be hospitalized compared to their white counterparts due to COVID-19 and Black Americans have 2.1 times the mortality rate compared to their white counterparts. Furthermore, despite the lack of gender identity & sexual orientation data collection as it relates to COVID-19 disease burden, LGBTQ individuals are more likely to have chronic conditions and behavioral health disorders, which are significant considerations for the impacts of the pandemic on an individual.
Millions of Americans have lost employment or substantial portions of their income due to the outbreak’s impact on the economy and have become newly eligible for Medicaid. As the primary insurer for low-income populations in the United States, the program is positioned to serve a critical role in reducing health disparities across all facets of COVID-19 care. In response to stay-at-home orders and other precautions that have limited standard health care delivery, state Medicaid programs have made significant policy changes to ensure access to care for enrollees, including those newly eligible. These changes have been made across various policy areas, including changes in coverage for telehealth, adjustments in premium and enrollment fee requirements, modifications to home health requirements, removal of prior authorization, and many others.
Now more than ever, researchers and state policymakers must collaborate to eliminate health disparities with Medicaid policies. As the pandemic tests the health care system and shifts the way it thinks about health care disparities, it is crucial to bring together these Medicaid stakeholders who can identify, prioritize, and complete timely impact analyses of the effects of COVID-19 on vulnerable populations.
Though the pandemic has impacted the full health care delivery system, it has uniquely affected the Medicaid program in some of the following areas:
Eligibility and Enrollment
The pandemic has delivered the most devastating blow to the economy since the Great Depression. As a result, millions from sectors in which people of color and lower incomes are overrepresented are facing temporary or permanent unemployment. With this wave of unemployment, states are seeing increases in the number of individuals who are eligible for Medicaid. Many states are responding by reassessing their Medicaid policies and/or implementing waivers to ease the process of enrollment and expand eligibility for newly unemployed individuals. However, with the growing number of newly eligible beneficiaries, states must analyze and address the impacts on Medicaid utilization, payment, and costs.
Substance Use Disorder (SUD) Prevalence and Treatment
The pandemic is also expected to coincide with a rise in SUD prevalence and overdose rates. While many seeking SUD treatment are now experiencing additional social and financial stressors triggered by the pandemic, Medicaid SUD treatment providers are also facing fiscal barriers in providing care to patients. State Medicaid programs are being challenged to ensure continued access to medication for opioid use disorder (MOUD) and counseling, specifically via telehealth. The pandemic’s effects, likely severe, on SUD prevalence and treatment have yet to be fully understood.
Telehealth
Fears of virus transmission quickly gave rise to a transformed method of care delivery. As the pandemic has progressed, the Centers for Medicare & Medicaid Services (CMS) temporarily expanded services allowed for delivery through telehealth and reduced barriers to access. Despite changes in policy, there remain barriers to accessing care in many rural communities where broadband access may be limited. Furthermore, the transition to telehealth may have adverse effects on treatment adherence and care outcomes. Looking forward, state Medicaid programs will be tasked with conducting evaluations of telemedicine services impacts on cost, utilization, and outcomes to inform decisions on retaining or reverting certain policy changes.
Managed Long-Term Services and Supports (MLTSS)
MLTSS serves a subset of Medicaid enrollees who have social, physical or cognitive impairments that require support services (in homes, intermediate care facilities, or long-term care facilities) to maintain an optimum level of function. Often these enrollees have chronic conditions that increase their vulnerability to the impacts of COVID-19. As states enact policies to limit outside contact with those in congregate living or at home requiring caregivers, these social distancing precautions may directly impact the quality of care that MLTSS patients receive. To further complicate this, state MLTSS programs vary widely and some states have implemented home and community-based services (HCBS) waivers to expand eligibility criteria, increase utilization limits, and eliminate premiums and cost-sharing requirements to assist in the retention of MLTSS coverage. The range of Medicaid policies to address the unique needs of the MLTSS population during the pandemic serves as an essential topic area for further research.
COVID Enhancement Awards
To begin to explore how Medicaid stakeholders can examine the impact on beneficiaries and the program, PCORI has awarded COVID-19 enhancements to AcademyHealth’s two state-facing learning networks, the Medicaid Medical Directors Network (MMDN) and the State-University Partnership Learning Network (SUPLN). These enhancements hope to leverage partnerships with policymakers, researchers, and other Medicaid stakeholders to identify COVID-19-related health policy priorities and develop the necessary research agenda to guide state-driven impact analyses. With PCORI’s COVID-19 enhancement, the MMDN will consider and prioritize Medicaid policy priorities that have surfaced from this crisis including, but not limited to, the areas highlighted above. SUPLN state-university researchers will concurrently provide vital guidance on the specific research questions and analyses their state Medicaid partners, including the Medical Director, should evaluate to address their immediate COVID-19-related policy actions and next-stage priorities as the pandemic evolves. SUPLN and MMDN, representing a diverse subset of 44 state Medicaid programs, will contribute to PCORI’s current COVID-19 programming and research and assist in disseminating PCORI priorities and products.
AcademyHealth’s Evidence-Informed State Health Policy Institute (ESHPI) serves as the home for these two networks and cultivates collaboration across the networks of health policy researchers and practitioners to promote data-driven, evidence-informed state policy and programs. ESHPI will foster the sharing of innovative state approaches to address the COVID-19 pandemic and help answer the question: where do we go from here?