Samantha’s hands trembled as she held the letter from the Texas Health and Human Services Commission, the words on the page blurring. She had always been a woman who had stared down adversity with a steely gaze and an unwavering determination. As a single mother, she had juggled the demands of two part-time jobs, each one a delicate balancing act between the needs of her family and the unyielding realities of a world that cared little for the struggles of the working poor.

But as she read the cold, bureaucratic language informing her that her children’s Medicaid coverage was being terminated, she felt a sense of helplessness that threatened to overwhelm her. The letter was a cruel reminder of her precariousness, a stark illustration of the ways in which the system could giveth and taketh away with equal indifference. For a moment, she allowed herself to imagine the worst-case scenarios: medical bills piling up, sleepless nights spent worrying about her children’s health, impossible choices between putting food on the table and paying for doctor’s visits. But with a deep breath and a renewed sense of purpose, Samantha squared her shoulders and prepared to do what she had always done: fight.

For years, Samantha’s two children, Jayden and Aria, had relied on Medicaid for their basic health needs. Jayden, who was just five year sold, had been born with a chronic respiratory condition that required regular check-ups and medication. Aria, now eight, had always been a healthy child, but Samantha knew that access to preventive care was crucial for keeping her that way.

The letter stated that due to a slight increase in Samantha’s income, her family no longer qualified for Medicaid. She stared at the numbers in disbelief—the raise she had fought so hard for at her job as a cashier had pushed her just over the eligibility threshold. It felt like a cruel twist of fate.

Determined to maintain her children’s health insurance, Samantha gathered all the necessary documents and made her way to the local Medicaid office. She took a day off from work, losing precious income in the process, and waited in line for hours, surrounded by other anxious parents and individuals who were also fighting to keep their coverage.

When she finally reached the front of the line, Samantha explained her situation to the caseworker, hoping for some kind of resolution or exception. But the caseworker simply shook her head and handed Samantha a stack of forms to fill out, instructing her to provide even more detailed information about her income and household.

For weeks, Samantha navigated the complex bureaucracy of the Medicaid system, submitting paperwork and making countless phone calls to try to reinstate her children’s coverage. But despite her best efforts, Jayden and Aria remained uninsured for several months.

During that time, Samantha was forced to make difficult decisions about her children’s health care. She skipped Jayden’s routine check-ups, praying that his condition wouldn’t worsen without regular monitoring. When Aria came down with a severe case of the flu, Samantha hesitated to take her to the doctor, knowing that the out-of-pocket costs could devastate her already-tight budget.

Samantha’s story is not an isolated case. Millions of Americans have experienced similar disruptions in their Medicaid coverage, often due to small changes in their circumstances or bureaucratic errors. These gaps in coverage can have serious consequences for patients’ health and financial stability, forcing them to make impossible choices between paying for basic necessities and accessing medical care.

The COVID-19 pandemic heightened the importance of Medicaid as a safety net for low-income Americans. The Families First Coronavirus Response Act, passed by Congress in response to the public health emergency, temporarily prohibited states from disenrolling Medicaid beneficiaries until the end of the emergency period. This provision, known as the “continuous coverage requirement,” helped ensure that millions of Americans maintained their Medicaid coverage throughout the pandemic, even if their income or employment status changed.

As states continued to unwind the continuous coverage requirement and resumed normal eligibility determinations, the threat of coverage loss loomed large for many Medicaid beneficiaries. The “Medicaid unwinding” process resulted in millions of Americans being disenrolled from the program, often for reasons like “procedural denials.”

As of March 2024, at least 6.4 million people nationwide lost Medicaid coverage due to the unwinding. A significant portion of these coverage losses were due to procedural denials, meaning that eligible individuals were disenrolled because they did not complete the renewal process, not because they were no longer eligible for Medicaid.

Procedural denials can occur when Medicaid enrollees do not receive their renewal paperwork, are unable to complete the forms on time, or when the state loses track of the submitted paperwork. These denials are particularly concerning because they indicate that eligible individuals are losing coverage due to administrative barriers rather than changes in their eligibility status.

The unwinding experience underscores the importance of continuous coverage policies, such as 12-month continuous eligibility, which can help prevent coverage gaps and ensure that eligible individuals maintain access to care. By reducing the frequency of eligibility redeterminations and minimizing the risk of procedural denials, these policies can promote better health outcomes and reduce the administrative burden on both enrollees and state Medicaid agencies.

Medicaid’s funding structure is a partnership. The federal government matches state spending on Medicaid, with the matching rate varying based on a state’s per capita income. In 2021, the federal matching rate ranged from 50% to 77%, with poorer states receiving a higher match.This funding structure has allowed Medicaid to expand and adapt to changing needs over time, but it has also created disparities in coverage and access across states.

Eligibility for Medicaid has evolved significantly since the program’s creation. Initially, Medicaid coverage was tied to eligibility for cash assistance programs, such as Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI). Over time, Congress expanded eligibility to include pregnant women, children, and people with disabilities who did not qualify for cash assistance. These expansions were driven by a recognition that these populations had unique health needs and often lacked access to affordable coverage.

One of the most significant eligibility expansions came with the passage of the Affordable Care Act (ACA) in 2010. The ACA allowed states to expand Medicaid coverage to adults under age 65 with incomes up to 138% of the federal poverty level, regardless of disability, parental status, or other factors. As of 2024, 40 states and the District of Columbia had expanded Medicaid under the ACA, while 10 states had not.

Medicaid’s role in covering low-income populations is particularly evident in its coverage of births. In 2023, Medicaid paid for 42% of all births in the United States, with the percentage varying widely across states. In some states, such as New Mexico and Louisiana, Medicaid covered more than 60% of births.

The story of Sarah, a 24-year-old Black woman from Georgia, illustrates the critical role that Medicaid plays in ensuring access to pre-natal care and delivery services, as well as the challenges that many low-income women face in navigating the healthcare system.

Sarah had been working part-time at a retail store and attending community college when she found out she was pregnant. She had no health insurance and knew she would need coverage for prenatal care and delivery. She applied for Medicaid and was relieved to find out she qualified based on her income.

However, Sarah faced numerous barriers to accessing care. She lived in a rural area with limited transportation options and had to rely on friends and family to drive her to appointments. She also had difficulty finding a provider who accepted Medicaid and who she felt comfortable with. As a Black woman, Sarah had heard stories of other women of color who had experienced discrimination and dismissive attitudes from healthcare providers.

Despite these challenges, Sarah began receiving prenatal care in her second trimester. However, she missed several appointments dueto transportation issues and felt that her concerns about pain and swelling were not taken seriously by her provider. At 32 weeks, Sarah developed severe headaches and blurred vision and went to the emergency room, where she was diagnosed with preeclampsia, a serious pregnancy complication characterized by high blood pressure.

Sarah was admitted to the hospital and underwent an emergency cesarean section to deliver her baby, who was born prematurely and required a stay in the neonatal intensive care unit (NICU). Medicaid covered the costs of Sarah’s hospitalization and her baby’s NICU stay, which would have been financially devastating for her family otherwise.

As a physician, I would argue that Sarah’s story might have been different if Medicaid had covered doula services in her state. Doulas are trained professionals who provide emotional, physical, and informational support to women during pregnancy, childbirth, and the post-partum period. Research has shown that doula support can improve birth outcomes, reduce the likelihood of costly complications, and increase patient satisfaction.

Like many states, Georgia did not cover doula services under Medicaid. Sarah felt that having a doula would have helped her navigate the healthcare system, advocate for her needs, and provide the culturally competent support she needed. She also believed that a doula could have helped her recognize the signs of preeclampsia earlier and seek medical attention before it became a crisis. Sarah’s story is just one example of the complex and often challenging experiences that many Medicaid beneficiaries face in accessing care. While Medicaid provides critical coverage for low-in-come populations, it is not a panacea for addressing all of the barriers to care that these populations face.

How will Medicaid balance the need to cover more vulnerable Americans, while maintaining budgets? One of the most significant strategies for addressing this issue for Medicaid state officials over the past few decades has been to push the problem into the private sector, through managed care. Medicaid managed care refers to the delivery of Medicaid benefits through contractual arrangements between state Medicaid agencies and managed care organizations (MCOs), which are private health plans like Aetna, United Healthcare and Centene that agree to administer Medicaid health plans in exchange for a fixed monthly payment from the government per enrollee—essentially fix-ing the budget for the state, while offloading some choices of benefits and coverage to private companies.

States contract with MCOs to provide Medicaid services to beneficiaries, paying them a fixed monthly amount per enrollee, known asa capitation payment. The capitation payment is risk-adjusted based on the expected health needs of the enrolled population, taking into account factors such as age and health status. MCOs are then responsible for providing all covered services to their enrollees within the capitation payment amount.

The growth of Medicaid managed care has been driven by an argument that the approach could control costs, improve quality, and increase access to care. By contracting with MCOs, states can shift financial risk to private plans and create incentives for them to man-age care more efficiently. MCOs theoretically also have the potential to improve care coordination and quality by providing a more integrated and comprehensive approach to care delivery. But evidence to date does not suggest that the managed care approach has achieved these objectives. Additionally, the growth of Medicaid has posed anticipatable challenges. One of the biggest challenges has been ensuring that MCOs provide adequate access to care, particularly for beneficiaries with complex health needs. States have struggled to hold MCOs accountable for meeting network adequacy standards and ensuring that beneficiaries have access to the full range of services they need.

The growth of MCOs has been accompanied by the proliferation of different types of Medicaid managed care arrangements, each with its own unique set of rules and requirements. For example, some states have implemented specialized managed care plans for beneficiaries with long-term services and supports (LTSS) needs, while others have created separate plans for beneficiaries who are dually eligible for Medicaid and Medicare (known as Dual Eligible Special Needs Plans, or D-SNPs).

The complexity of Medicaid managed care can be overwhelming for beneficiaries, who may struggle to navigate the different plans and understand their options. It can also be challenging for providers, who may have to contract with multiple plans and navigate different payment and authorization requirements.

Despite increased complexity, as of 2023, approximately 72% of Medicaid beneficiaries, or 57 million people across 41 states received their care through managed care plans. The percentage varies widely across states; some states, such as Hawaii and Tennessee, have fully transitioned their Medicaid programs to managed care, while others, such as Connecticut and Vermont, have maintained a mix of managed care and fee-for-service arrangements.

To ensure that these MCOs provide high-quality care and meet performance standards, states use various tools in their contracting process and impose sanctions when MCOs fail to meet their obligations. One notable example of a state holding MCOs accountable is Florida. In 2022, the state imposed sanctions on Sunshine Health Plan, one of its Medicaid MCOs, totaling $9.1 million. These sanctions were in response to over 100,000 instances in which the MCO delayed payments or failed to pay providers altogether. That year alone, the state took action against MCOs more than 200 times for contract violations, with total fines amounting to $23.1 million.

Florida’s actions demonstrate the importance of states using their contracting process to set clear expectations for MCOs and holding them accountable when they fall short. The state’s managed care contracts included specific requirements related to timely provider payments, and the use of financial penalties sent a strong message that non-compliance would not be tolerated.

Another state that has taken a proactive approach to MCO oversight is California. The state’s Department of Managed Health Care (DMHC) has imposed significant fines on MCOs for a range of issues directly impacting enrollees, such as denials of services, failing to pay for necessary medical treatment, and failing to acknowledge and respond to member grievances. For example, after an Independent Medical Review Determination, Blue Cross of California Partnership Plan was fined $1.2million for failing to authorize coverage for medically necessarily services in a timely manner.

In addition to financial penalties, California’s Department of Health Care Services (DHCS) recently announced sanctions on 22 MCOs for poor performance on quality measures related to children’s and women’s preventive services. This action demonstrates the state’s commitment to using a variety of tools, including performance-based incentives and penalties, to drive improvements in the quality of care delivered by MCOs.

While states like Florida and California have taken significant steps to hold MCOs accountable, there is still room for improvement in terms of transparency and public reporting. Currently, federal regulations do not require timely public reporting of sanctions imposed on MCOs, and a proposed rule that would have mandated such reporting was ultimately withdrawn in the early 2000s.

However, there are signs of progress on this front. Some states, such as Arizona and California, have begun to release sanctions information as they impose them upon MCOs, making this data more readily available to the public. Additionally, starting in 2023, most states will be required to release annual reports detailing their sanctions information and other oversight activities to their Medical Care Advisory Committees and Long-Term Services and Supports (LTSS) stakeholder groups.

As more states prioritize transparency and public reporting of MCO sanctions, it will be easier for advocates, policymakers, and beneficiaries to understand the actions being taken to ensure accountability and drive improvements in the quality of care delivered through Medicaid managed care. While the financial penalties imposed on MCOs to date may not be sufficient to drive systemic change, they represent an important step in the right direction and underscore the critical role that states play in overseeing the delivery of Medicaid services.

As they seek to evolve beyond the limitations of incentives and penalties, state governments have increasingly used a previously-hidden aspect of Medicaid’s structure and design: the Section 1115 waiver. Section 1115 of the Social Security Act allows states to waive certain federal Medicaid requirements and test new approaches to delivering and financing care at the state level. State governments have used 1115 waivers to implement a wide range of initiatives, from expanding eligibility to implementing work requirements and premiums.

To obtain an 1115 waiver, a state must submit a detailed application to the national Centers for Medicare and Medicaid Services (CMS), outlining the proposed waiver and how it will further the objectives of theMedicaid program. The waiver application process typically involves a public comment period, where stakeholders can provide input on the proposed waiver. CMS then reviews the application and works with the state to negotiate the terms and conditions of the waiver. If approved, the waiver is typically granted for a five-year period, with the possibility of renewal.

One of the most successful examples of an 1115 waiver is the Oregon Health Plan (OHP), which was first implemented in 1994. The OHP waiver allowed Oregon to expand Medicaid eligibility to a broader group of low-income adults, many of whom would not have otherwise qualified for Medicaid. The waiver also established the Oregon Health Plan Standard, which provided a more limited benefit package to eligible adults who still did not qualify for traditional Medicaid.

The OHP waiver was built around a prioritized list of health services, which ranked services based on their effectiveness and cost. The prioritized list was developed through a public process that involved input from healthcare providers, consumers, and other stakeholders. Services at the top of the list, such as preventive care and chronic disease management, were given higher priority for funding, while services at the bottom of the list, such as certain elective procedures, were not covered.

The OHP waiver also established coordinated care organizations (CCOs), which are locally governed, community-based organizations that are responsible for providing integrated physical, behavioral, and dental healthcare to Medicaid beneficiaries. CCOs are paid a global budget to provide all necessary care to their enrollees, and are held accountable for meeting specific quality and performance metrics.

The OHP waiver has been credited with improving access to care, reducing uncompensated care costs, and improving health outcomes for Medicaid beneficiaries in Oregon. The waiver has served as a model for other states looking to implement similar reforms, withseveral states using 1115 waivers to expand eligibility, implement value-based payment models, and test new approaches to care delivery and coordination.

The use of 1115 waivers is not without controversy. Critics argue that some states have used waivers to implement policies that are not in the best interest of Medicaid beneficiaries. There are also concerns that the waiver process lacks transparency and accountability, and that CMS has been too willing to approve waivers that do not further the objectives of the Medicaid program.

For example, in June 2018, Arkansas began requiring certain Medicaid beneficiaries aged 19-49 years old to report at least 80 hours of work or other qualifying activities each month to maintain their coverage. Those who failed to meet the requirement for three months in a calendar year could be disenrolled from Medicaid for the remainder of the year, potentially losing coverage for up to nine months.The impact of the Arkansas work-reporting requirement was swift and severe. In the first seven months of implementation, over 18,000 people—nearly 1 in 4 of those subject to the requirement—lost their Medicaid coverage. Only 11% of those who were disenrolled in 2018 regained coverage the following year, suggesting that many may have become uninsured.

The loss of coverage had serious consequences for beneficiaries’ health and financial well-being. In focus groups conducted by the Urban Institute, participants who had been disenrolled reported worsening health conditions, higher stress levels, and difficulties maintain-ing employment due to untreated medical issues. Half of Arkansas residents aged 30-49 years old who lost Medicaid or marketplace coverage in 2018 reported serious problems paying off medical debt, and most delayed necessary care or skipped medications due to cost.

The Arkansas policy also failed to achieve its stated goal of promoting employment. A study published in Health Affairs found no significant changes in employment or hours worked among Medicaid beneficiaries subject to the requirement between 2018 and late 2019. Focus group participants indicated that most were already working or actively seeking work, but faced barriers such as lack of transportation, limited job opportunities, and health issues that made it difficult to maintain steady employment.

The Arkansas experience revealed serious flaws in the design and implementation of the work-reporting requirement. Many beneficiaries were unaware of the new rules or confused about whether they applied to them, leading to widespread coverage losses due to “procedural denials” rather than failure to meet the work requirement itself. The online reporting system posed significant challenges for those without reliable internet access or computer literacy skills, and even the addition of a phone reporting option did little to alleviate these barriers.

Perhaps most troubling, the Arkansas policy failed to effectively protect vulnerable populations who should have been exempt from the requirement, such as those with disabilities or serious health conditions. Some beneficiaries who qualified for exemptions were not identified through the state’s data matching process and lost coverage as a result. Others struggled to navigate the complex and time-limited exemption process, which required frequent recertification and provided little guidance or support.

The shortcomings of the Arkansas work-reporting requirement did not go unnoticed by the courts. In 2020, a federal judge struck down the Arkansas waiver, along with similar policies in Kentucky and New Hampshire, ruling that they did not further the objectives of the Medicaid program. The decision dealt a significant blow to efforts by some states to use 1115 waivers to reshape Medicaid in ways that restrict access to coverage.

The Arkansas experience serves as a stark reminder of the risks inherent in using 1115 waivers to impose work-reporting requirements or other eligibility restrictions on Medicaid beneficiaries. While proponents argue that such policies promote personal responsibility and self-sufficiency, the evidence suggests that they are far more effective at causing harm than at achieving their stated goals.

Despite these concerns, 1115 waivers remain an important tool for states looking to innovate and improve their Medicaid programs. As states continue to grapple with the challenges of rising healthcare costs and increasing demand for services, the use of waivers and other flexibilities will likely continue to play a significant role in shaping the future of Medicaid.

As Medicaid has evolved over the years, the program has expanded coverage to different segments of the population and added new services. In the early days of Medicaid, coverage was primarily limited to low-income families with children, the elderly, and people with disabilities. However, over time, Congress has expanded eligibility to include pregnant women, children in higher-income families, and adults without dependent children.

Under the ACA, Medicaid has also added new services over time. For example, in the 1980s, Congress required states to cover certain preventive services for children, such as immunizations and well-child check-ups. In the 1990s, Congress expanded coverage for pregnant women and added new services for people with disabilities, such as personal care services and home and community-based services.

Medicaid administrators decide which services to cover based on a combination of federal requirements and state priorities. The federal government sets minimum standards for coverage, but states have flexibility to cover additional services and set their own payment rates. States can also use waivers to test new approaches to coverage and care delivery.

In recent years, there has been a growing emphasis on value-based care (VBC) in Medicaid. VBC is a payment model that rewards health-care providers for the quality and outcomes of care, rather than the volume of services provided. This contrasts with traditional fee-for-service (FFS) models, which pay providers based on the number of services they deliver, regardless of the outcomes.

The goal of VBC is to incentivize providers to deliver high-quality, cost-effective care that improves patient outcomes. For example, under a VBC model, a primary care provider might receive a bonus payment for helping patients with diabetes improve their blood sugar control, rather than simply being paid for each office visit or procedure.

VBC has been adopted to varying degrees in Medicaid programs across the country. Some states have implemented comprehensiveVBC models that cover a wide range of services and populations, while others have focused on specific areas, such as behavioral health or long-term care. As of the time of this writing in 2024, at least 38 states have implemented some form of VBC in their Medicaid programs, with 25 states planning to expand their VBC efforts in the future.

One of the key benefits of VBC is that it allows for greater flexibility in care delivery. Under traditional FFS models, providers are often limited in the types of services they can provide and the ways they can coordinate care. With VBC, providers have more flexibility to tailor care to the specific needs of their patients.

For example, consider the story of Maria, a 58-year-old woman with type 2 diabetes. Maria had been struggling to manage her diabetes for years, despite taking multiple medications and seeing her doctor regularly. Her blood sugar levels were consistently high, and she was at risk for serious complications, such as heart disease and kidney failure.

Under a traditional FFS model, Maria’s doctor might have focused on prescribing more medications or ordering more tests, without addressing the underlying factors contributing to her poor diabetes control. However, under a VBC model, Maria’s doctor was able to take a more holistic approach to her care.

The doctor referred Maria to a registered dietitian who helped her develop a healthy eating plan that fit her cultural background and food preferences. The dietitian also connected Maria with a local community food delivery service where she could access fresh, affordable produce.

In addition, Maria’s doctor prescribed her a continuous glucose monitor (CGM) that allowed her to track her blood sugar levels in real-time. The doctor also referred Maria to a pharmacist who specialized in diabetes management. The pharmacist taught Maria how to use her insulin properly and helped her develop a plan to take her medications consistently. These services ultimately cost less than heart disease medications or dialysis for kidney failure.

Thanks to this comprehensive approach to care, Maria was able to get her diabetes under control. Her blood sugar levels improved, and she felt more energetic and confident in her ability to manage her health.

However, despite the promise of VBC, there are still significant barriers to widespread adoption in Medicaid. One of the biggest challenges is that many VBC models are still based on FFS payment structures, with only small incentives or bonuses tied to quality and outcomes. These “value veneers” do little to truly transform care delivery and may even create additional administrative burdens for providers.

Another barrier to VBC adoption in Medicaid is the fragmented nature of the healthcare system. Many Medicaid beneficiaries receive care from multiple providers and payers, each with their own payment models and incentives. For a healthcare system or provider group to fully embrace VBC, they need to have a critical mass of patients covered under similar payment models. However, for many providers, Medicaid represents only a small portion of their patient population, making it difficult to justify major changes to their care delivery models.

This is particularly true for Federally Qualified Health Centers (FQHCs), which serve a large number of Medicaid beneficiaries. FQHCs are reimbursed through a prospective payment system (PPS), which is essentially a form of FFS payment. Under PPS, FQHCs receive a fixed payment for each patient visit, regardless of the services provided or the outcomes achieved.

While FQHCs have a deep commitment to serving Medicaid populations, the PPS payment model can make it challenging for them to adopt VBC approaches. Many FQHCs rely on a patchwork of grants and other funding sources to provide additional services, such as care coordination or patient education, that are not covered under PPS. However, these funding sources are often temporary and disease-specific, making it difficult to sustain these services over the long term, or reach a broad household or neighborhood in the way many prevention interventions require.

To truly transform care delivery for Medicaid populations, it will be necessary to integrate these additional services into the Medicaid payment system. This will require a shift away from FFS and PPS payment models and towards more comprehensive VBC approaches that incentivize providers to deliver high-quality, coordinated care that improves patient outcomes.

The flow of funds in Medicaid has become increasingly complex overtime, with multiple layers of intermediaries and contractual arrangements. At the top of the chain are taxpayers, who provide the funding for both the federal and state governments. The federal government then distributes funds to the states based on a formula that takes into account factors such as the state’s per capita income and Medicaid enrollment.

From there, states have a variety of options for how to manage their Medicaid programs. As more states contract with MCOs to provide services to Medicaid beneficiaries, the MCOs, in turn, contract with healthcare providers to deliver services to their enrollees with varying payment rates, quality metrics, and other requirements. Some MCOs may have narrow networks of providers, while others may have more expansive networks. Adding to the complexity are other intermediaries, such as pharmacy benefit managers (PBMs), which manage prescription drug benefits for many Medicaid programs. PBMs negotiate with drug manufacturers to obtain discounts and rebates, and they also influence formularies that determine which drugs are covered under a particular plan.

In some states, there are also “carve-outs” for certain services, such as behavioral health or dental care. In these cases, the state contracts with separate entities to provide these services, rather than including them in the capitation payments to MCOs. This can lead to further fragmentation of care and confusion for patients and providers.

The complexity of the Medicaid system can be frustrating for patients, who may not understand why certain services are covered while others are not. It can also lead to delays in care and other barriers to access.

Consider the story of John, a 45-year-old man with diabetes who recently enrolled in Medicaid. John had been struggling to afford his insulin and other medications, and he was excited to finally have coverage. However, when he went to the pharmacy to fill his prescriptions, he was told that his insurance had rejected the request from the pharmacy to have his prescription filled.

Confused and frustrated, John called his primary care provider (PCP) to ask what was going on. The PCP explained that the particular brand of insulin that John had been prescribed was not on the formulary for his Medicaid plan. In order to get the medication covered, the PCP would need to fill out a prior authorization form and providedocumentation of medical necessity.

John was left waiting for his medication while his PCP navigated the complex prior authorization process. In the meantime, John rationed his remaining insulin, putting his health at risk.

John’s story is not uncommon in Medicaid. Providers often face significant administrative burdens when trying to get services and medications approved for their patients. These burdens can be particularly acute in Medicaid, where rules for getting coverage are more complex, yet reimbursement rates to providers are systematically lower than inMedicare or commercial insurance.

Providers may need to spend hours completing forms or on the phone with MCOs or PBMs trying to get prior authorizations approved. They may also need to fill out extensive paperwork and provide detailed documentation of medical necessity. These administrative tasks can take time away from patient care and lead to burnout among providers.

The complexity of the Medicaid system can also make it difficult for states to hold MCOs and other intermediaries accountable for the quality and cost of care. With so many different entities involved in the delivery of care, it can be challenging to track outcomes and ensure that taxpayer dollars are being used effectively.

To address these challenges, there is a growing recognition of the need for greater simplicity and integration in Medicaid. This could involve streamlining the contracting process between states, MCOs, and providers, and creating more standardized payment models and quality metrics.

It could also involve greater use of technology to facilitate communication and care coordination among different providers and payers. For example, health information exchanges (HIEs) between provider’s health record systems can often help ensure that all members of a patient’s care team have access to the same information and are working towards the same goals. Sharing data back and forth directly between providers and health plans remains a novel concept between two parties often viewed as opponents on payment rate negotiations, yet arranging such transfers may help facilitate easier knowledge transfer and less barriers to getting required information from covered medications to better contact information, and to achieve shared accountability for patient outcomes and costs.

Ultimately, the goal of Medicaid should be to provide high-quality, accessible care to some of the most vulnerable members of our society. To achieve this goal, we need a system that is simple, transparent, and patient-centered. This will require ongoing efforts to streamline bureaucracy, reduce administrative burdens, and promote greater collaboration and coordination among all stakeholders in the Medicaid system.