Strengthening access to care in Medicaid needs time and partnership

Earlier this month, NAMD was pleased to offer our federal partners at the Centers for Medicare and Medicaid Services (CMS) our members’ perspectives on how to best move the Medicaid and CHIP programs forward in providing robust, high-quality services to the people we collectively serve. While the path forward may be longer than CMS envisions, the commitment of Medicaid’s leaders across the states and territories to build stronger, more comprehensive programs is readily apparent in the conversations we had to formulate our comments.

In these comprehensive comments across both the proposed rules on access and Medicaid managed care programs, NAMD elevated key themes as well as technical feedback on detailed aspects of CMS’s proposed policies. Since these comments together total over 50 pages of feedback, we lift up here some of the key points that hold true across both of our letters. And of course, you can read our full comments for all the details.

CMS’s goals are Medicaid programs’ goals

CMS discusses in its rulemaking its goals around better measuring, assessing, and improving access to critical services in Medicaid and CHIP. In this, state and territories are entirely aligned with our federal partners. Each of the diverse populations Medicaid serves, including children, pregnant women, families with lower incomes, and people with disabilities, deserves high-quality services that help them live their healthiest life.

Now is the time to reflect on Medicaid’s current capacities across the nation, understand the opportunities for improvement, and make thoughtful plans and investments to achieve those goals. During the COVID-19 pandemic, Congress provided resources to let Medicaid programs step up and cover more people than ever before. States and territories made major investments in telehealth, reshaping how services are delivered, and made targeted investments in key areas of their programs to ensure core services remained available – particularly behavioral health services and home- and community-based services that support people living with disabilities.

Now that the worst of the pandemic is behind us, we can reflect on where the health care system remains fragile and needs more support. It’s clear that not everyone can easily access the care they need. Whether it’s rural communities that lack specialty care options, people with limited English proficiency who have a hard time navigating the complexities of the system, or any number of other challenges, there is room for improvement to make it easier to get Medicaid coverage and to use that coverage. Medicaid leaders are right there with CMS in making this happen.

Getting It Right Takes Time and Flexibility

Medicaid is a dynamic partnership between the states and territories who administer the program within the parameters set by the federal government. This arrangement means that, while NAMD’s members are directionally aligned with what CMS envisions, that alignment must be paired with enough lead time and a spirit of flexibility to meet states and territories where they are today. Every Medicaid program has different resources to work with, different sets of service providers in their jurisdictions, and varying strategic priorities. The saying “when you’ve seen one Medicaid program, you’ve seen one Medicaid program” rings especially true here. In Medicaid, there truly is no one-size-fits-all approach.

Further, it can’t be overstated how much Medicaid leaders have on their plates over the coming years. First and foremost, there’s the “unwinding” of the pandemic-era Medicaid continuous enrollment requirement (see more NAMD resources on unwinding here). This is a program-wide, all-hands-on-deck effort that is taking up the vast majority of Medicaid leaders’ time, and is critically important to ensuring people retain Medicaid coverage or obtain other coverage. Completing this will take us well into 2024. Medicaid leaders are also working on phasing out pandemic-era flexibilities and transitioning to more permanent authorities, which will also take time and resources to successfully manage.

On top of this, Medicaid leaders are navigating additional federal requirements set in statute by Congress that have big implications for their work. Examples include implementing 12 months of continuous coverage for children by Jan. 1, 2024 and standing up pre-release screenings for juveniles in justice settings by Jan. 1, 2025. Both of these efforts are required by Congress in legislation passed in December 2022 and will need investment of resources in new policy approaches and systems design.

What does all of this have to do with CMS’s proposals around access? Simply put, the staff and resources that are focused on unwinding and implementing Congressional requirements are the same staff and resources that are key to implementing the ambitious proposals CMS put forward. By NAMD’s assessment, no fewer than six of CMS’s proposals across its two proposed rules entail a major systems lift. Those who know Medicaid systems know that they don’t turn on a dime – these are some of the biggest procurements that state and territorial governments make, with appropriations, federal approvals, procurement, and design that take years to successfully implement. Tens of millions of state and federal dollars go into this work. It simply can’t be rushed.

It’s for this reason that NAMD’s core message to CMS on these rules is that we’re with you, but give us the time to be thoughtful, strategic, and get this right the first time around. Across the board, our members asked for more time and more guidance to achieve the aims CMS has for the Medicaid program – aims which we all share.