New York’s Medicaid program provides health insurance to nearly seven million New Yorkers, and it is a critically important way for people to get healthcare. On this episode of Policy Outsider, we discuss why the administration of the Medicaid program—that is, how it is staffed, how it procures services, how it captures, analyzes, and acts on its data—is so important to delivering effective outcomes. The discussion also emphasizes areas of potential improvement of the program’s administration and highlights why right now—in the middle of the most significant health policy reforms since the Affordable Care Act—might actually be the best time to rethink how we administer this $100 billion program.
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Joel Tirado 00:05
Welcome to Policy Outsider presented by the Rockefeller Institute of Government. I’m Joel Tirado. New York’s Medicaid program provides health insurance to nearly seven million New Yorkers, and it is a critically important way for people to get healthcare. On today’s show, we’ll discuss why the administration of the Medicaid program—that is, how it is staffed, how it procures services, how it captures, analyzes, and acts on its data—is so important to delivering effective outcomes. The discussion also emphasizes areas of potential improvement of the program’s administration and highlights why right now—in the middle of the most significant health policy reforms since the Affordable Care Act—might actually be the best time to rethink how we administer this $100 billion program. Our guests are: Rockefeller Institute President Bob Megna, Rockefeller Institute Senior Fellow for Health Policy Courtney Burke, The United Hospital Fund (UHF) President Oxiris Barbot, and UHF Senior Vice President for Policy and Program Chad Shearer. That conversation is up next.
Joel Tirado 01:27
all right, we’ve got a full house. I have Bob, oxiris, Courtney, Chad, thank you all for being here. I’m going to jump right into this and Bob, we’re going to start with you the Rockefeller Institute and the United Hospital fund collaborated to hold two forums this summer on Medicaid administration. Why did you feel it was important to hold these forums, and why the focus on Medicaid administration specifically?
Bob Megna 01:57
Well, I think the state of New York spends an enormous amount of money on the Medicaid program. First of all, it’s probably the biggest program in state government, vying for the top spot with education aid that we provide through K through 12 institutions, and it’s been growing over time. So Medicaid has been a growing program. We haven’t significantly changed the way we administer the program in a long time, and there are always issues in such a big, complex program. So when the opportunity came up to work with the folks from UHF, it just seemed like a great topic. And when you have experts like the folks from UHF and Courtney, I think it was something that’s the kind of thing the Rockefeller Institute likes to to take on.
Joel Tirado 02:57
Yeah, and thank you. Bob and aksiris, the UHF has a Medicaid Institute, right? So you, you all have, you know, a lot of folks who are focused on this issue. So could you share a little bit about why from the UHF perspective, you were interested in talking about administration specifically?
Oxiris Barbot 03:17
Yeah, absolutely. So UHF has been paying attention to Medicaid since it was rolled out in 1965 but even more acutely over the last 20 years, through our Medicaid Institute. And you know, the work has encompassed both policy analysis as well as various convenings in collaboration with stakeholders across the state and both within and outside of government. But to build on what you know, Bob sort of laid out, we thought it was especially important to have this, these convenings now because, you know, we’re living in a time that is challenging Medicaid ability to continue covering people who need that health insurance coverage. And you know, Medicaid administration is not a sexy topic, and so we thought that it would be most important for us to create space so that as the legislature, as our state partners, are thinking about the ways in which we can make sure Medicaid continues to meet its mission. You know, they’re looking at all the potential levers, and we don’t leave the administration of the program out, because it doesn’t tend to get all of the sexy attention.
Joel Tirado 04:44
So Courtney, you know, building a little bit on what Axios said there, talking about the stakeholders that the Medicaid Institute works with, inside and out of state government. You yourself have worked in many of these positions, both in and out. So. So you know from your vantage point, why does Medicaid administration
Courtney Burke 05:06
matter? Well, as Bob pointed out, it is one of the largest programs that government funds in the state, but it also impacts 7 million people as beneficiaries, 1000s of providers, payers, employers who want to keep their employees healthy. So it touches the state and the citizens in many different ways, and so you want the program to work well for people, so making sure that they have a good experience with the program also making sure that providers get paid timely, that what they get paid is the right amount, but then making sure that the program can also innovate, innovate in the future. There’s a lot that’s involved in administration, and for such a big, important program, we felt like it was time to talk about all the ways that administration matters in the paper, and happy to be talking about it with you today. Yeah, so,
Joel Tirado 06:08
oh, Chad, I see so you might have have something to jump in.
Chad Shearer 06:11
I just jump in and have like, who these people are? You know, we’re talking about the kids that are in school with your kids, and this is the way they get their health insurance coverage. We’re talking about individuals with disabilities who, in many points, rely on the Medicaid program to live. They would not be alive without Medicaid coverage. And we’re talking about a lot of older New Yorkers who are receiving long term services and supports that aren’t covered by the Medicare program. And I think a lot of people forget that that population is one of the largest populations covered by Medicaid. So it’s people we all know care about and love who are impacted by effective Medicaid administration.
Bob Megna 06:57
You know, roughly half the state’s population is on one form or another, the programs that have just been described,
Courtney Burke 07:06
and I think, I think it’s a timely conversation to have, because some of the biggest changes that have happened to the Medicaid program are about to occur over the course of the next couple of years, and So making sure that you have the right administrative apparatus in place to effectively implement those changes is going to be really important going forward. That’s right.
Joel Tirado 07:30
So the changes that are coming down from the one big, beautiful bill, Act, which was passed in, let’s just say, over the summer. I can’t remember I can’t remember if it was July, August, at this point, the deliberations were going on for for quite a while in the early summer, and those, those changes that are coming down through the big, beautiful bill will have some serious impact on how the Medicaid program is run. We should talk a little bit about what some of those big changes are. So Courtney, why don’t we just start with you?
Courtney Burke 08:08
Yeah, sure, I would. I would bucket it into two big areas. One is the changes that are going to happen to people’s coverage that are important to look at what’s going on. And the second bucket would be the financial impacts of the changes. So I’ll talk about some of them, but there’s a there’s a lot of them, so I know others will want to chime in on on the coverage side. Most immediately, next year, there are going to be some changes to who is covered, and there will be a significant number of people impacted who are getting certain types of coverage through the state. They tend to be people who are residing here legally, but who are non citizens. These are deferred action Childhood Arrivals, what are known as Pru call people residing under color of law. The potential for changes in their coverage is going to be important, but then there’s going to be additional changes to coverage that are rolled out after that. Many of them related to work requirements, but also ones related to how often people have to have their coverage redetermined, and when it is determined that they have have coverage, how far retro retroactively that that coverage is there for them. So there’s already been analysis done, and some of this was done by the federal government, of the impacts on the number of people who are potentially going to lose coverage and when people become uninsured or need to get insurance from another source that impacts the larger marketplace of insurance overall. So I think watching what is going on with that is really important. And then on the financial side, and this is where you know, everybody else should chime in, including Bob, who’s a former budget director, there’s also a number of changes in how the state is going to get paid and what it’s going to get. Paid for, and that’s going to be in the billions of dollars, and the state is estimating what that amount will be by year, but it’s significant in its overall impact on the on the state. So maybe I’ll toss it over to Bob to chime in as a former budget director.
Bob Megna 10:16
Well, you know it Courtney is right. I defer to the experts on this call on the health care aspects largely, but I can tell you, the money aspects are pretty large, and they will have a significant impact on how the state does its budget. And I think that takes this out of the Medicaid realm and throws it across all state services because to the extent the state has to backfill some services the feds are taking away that will affect all aspects of the state’s budget in a kind of vulnerable Time for the state. So you can start with Medicaid, but often it that translates into a much wider thing which affects all of the kind of state.
Oxiris Barbot 11:12
Yeah, I think one of the ways in which it helps me to think about, you know, what’s going on and how to keep it all straight, because there’s so many moving pieces, is really like the cascading effect, right? Like there are going to be measures that are going to directly impact members that are currently receiving medicaid services, the way that Courtney laid out. And then there’s going to be a whole other bucket of measures that are going to impact the way in which healthcare currently gets financed using Medicaid dollars, that are going to more directly affect hospitals and providers, but that will ultimately affect those same individuals. I think one of the things we also shouldn’t lose sight of in terms of, like, you know, Chad, laying out who the people are that are going to be affected. I think what, what concerns me the most is that the degree to which Medicaid underwrites a lot of what happens in health care, these cuts, this cascading event, isn’t going to be just limited to the people that are currently receiving medicaid services. Ultimately, it’s going to affect all of us, and so that’s why I think it’s important for us to talk about what’s coming down the pike, and, you know, bringing up potential ideas that we can help highlight the ways in which Medicaid can be more effectively administered. Because, you know, we’re going to want to make sure that we’re paying attention to dotting the I’s and crossing the t’s on all of the legal requirements that are going to be coming down the pike with regards to, you know, workforce redetermination. And and then there’s going to be a lot of workforce capacity issues to make sure that, you know, for example, people that are going to lose coverage through the expansion, ACA expansion, and that will end up coming to Medicaid are able to come to Medicaid, and those that are potentially going to lose Medicaid coverage, we do everything we can to minimize, you know, losing coverage there. So I don’t know if that helps clarify or just really illustrates the greater complexity, but there’s a lot riding on the line for the state of New York, and I think that’s why it’s so important for UHF to be partnering with an entity like Rockefeller and Courtney’s leadership on this really has been invaluable to make sure that we bring this conversation to the people that you know should be hearing it and can contribute to helping us move forward.
Joel Tirado 14:01
You are square on the type of thing that I that I want to pursue. And I would go even a little bit further on this to ask the question, you know, what does it look like? Let’s go to let’s go to extremes here, to try and illustrate some points, an extremely poorly run Medicaid administration, compared to an extremely efficiently run one, where are the sort of where do we see the impacts there of the effective administration? So like a poorly run system is not going to be able to do XYZ, whereas an efficiently run system is going to be able to do XYZ. And I know this is difficult always to point to some of the specifics, but if anyone can provide some examples, I think that does give you know, a real sense of why this is important. Courtney, I see you.
Courtney Burke 14:59
Chad Shearer 17:11
yeah, and just kind of how, how those three might play out in practice, connecting it back to, say, the example of the work requirement that’s upcoming, we’re going to have to create kind of a whole new system to meet the legal requirements, and people are going to have to go through that system and, you know, prove that they meet the requirements. And it takes an efficient, you know, set of people, contractors and data, to be able to even make that process work for somebody so a great state, you know, and New York will probably be at the front of this because they care about this issue. Will continue to have more people covered because their administration is going to allow them to put the processes in place that are going to be necessary. A bad state, more people are going to be uninsured because their administration is not going to or maybe at times even is trying to encourage people to fall through the coverage crack. So at the end of the day, it really impacts those people that are interacting with the program. And just going back to the previous conversation, I would be remiss not to mention that most people on Medicaid do work, are in school or are caring for somebody. So we’re putting, you know, new processes in place to effectively require people to prove what we already know about them, and unfortunately, that takes an effectively administered program so that we don’t have more uninsured people in New York,
Oxiris Barbot 18:46
right? And so to build on that just a little bit further, there have been states, for example, like Georgia, that have implemented work requirement systems in the past, and what we’ve learned there is they spent an additional unbudgeted $30 million right? So the question for New York State is going to be, if we’re going to have to invest that kind of money to implement a system to do work requirements, the way that they need to do does it make sense to throw that money into the existing pot, the way in which Medicaid is currently administered. Or do we want to take the opportunity to reimagine how it is that we can have a Medicaid program that’s run differently?
Joel Tirado 19:36
Well, we’ve brought up other states, and that was going to be a direction that we were going to go. So you know, what are, what are some other states doing? You know, I think oxiris, your examples is not one where we’re looking to point to Georgia as the model for how we might want to run our program, right? But what are other states doing that, that New York could. Adopt, either at a small scale or in terms of, like a larger restructuring.
Courtney Burke 20:08
I’d like to throw out two to get us started, but I know Chad, you’ve worked nationally, so I’m sure you have some ideas too. I wanted to point to some interesting things that I thought might be examples that New York would want to look at. The first is Massachusetts, because the way that they have it set up, they have mass health which oversees the that’s what’s their basically, their Medicaid program. They have a Health Policy Commission, which is an independent commission that helps to keep things transparent and accountable, but they also have a center for health information and analytics, which is really helpful for showing the data, showing where they’re improving, showing where they need to improve. And it would be great to have similar functions here in New York to help with improving the program. The other thing I wanted to point out was wash I think it’s Washington State, Apple Health. Not only do they have an authority that runs their program, but their own employees who work for the state are part of that system, so that it almost as as having skin in the game with their own employees. I think it helps them want to run the program even better, to make sure that their employees are getting the coverage they need and they’re getting the outcomes that are best for people. And they’re also keeping an eye on cost. You know, there’s many other ways that things can be structured, but I wanted to start with with those two. And if Chad, if you’re hoping, you would want to add to that?
Chad Shearer 21:41
Yeah, I think, I think the other kind of thing that I’ve seen working across the country, and this is in states as interesting as, you know, Oklahoma and Arizona, as with some of the states like Washington and Massachusetts, you know, structures that find ways to make it easier to address some of those issues that Courtney talked about in terms of the most effective elements of administration that could be improved, either through a commission system or some different type of governance that gets them out of some of the things like specific state procurement rules or different staffing structures, or not having to rely on, you know, all these consultants Oklahoma as an example, where, you know, it’s a it’s an authority that is actually of, you know, the community. It is the stakeholders that make up the board and the public private entity is, you know, subject to the the board oversight, as opposed to, you know, legislative or gubernatorial oversight. Don’t get me wrong, state government is still deeply involved at every level, but the accountability lies in a slightly different place, and with that potentially comes some some flexibility. So there are other models out there. I’m not convinced that wholesale going to any of those models is the right approach for New York, but I think there are things to learn from across the country, and not just in the states where you would normally think, Oh, we’re going to look at what Washington, Oregon, California, are doing? There are other states to look at
Oxiris Barbot 23:23
and just to build on that. You know, Courtney had brought up the the challenges of procurement within the existing system. I think there are states out there that have looked at ways of combining activities across the health continuum to increase their purchasing power in, you know, the the environment. And so I think that could also be another component of thinking about, how do we want the system to look like on the other end, I don’t think that either UHF or Rockefeller is invested in a particular, you know, governmental structure per se, but I think an infrastructure that allows the state to maximize its purchasing power when it comes to procuring health services, I think is a really important driving priority.
Bob Megna 24:18
I would only add one thing, which might be a small thing, but I think it’s something we often aren’t thinking about, which is we’re often asking the providers of healthcare to change what they’re doing, or to deliver in a different way, or to deliver in a cheaper way, or, you know, who’s failing and who’s succeeding. And as you change that kind of operating environment, I think you also have to change how you’re administering the probe, administering the program, to meet that. So I think that you can’t say I’m going to change how I want. Healthcare to be provided, but I’m not going to change how I’m administering. I think those two things go together, and they have to be kind of fit together. You know, as one
Joel Tirado 25:12
thing, Bob, I’m going to stick with you. For those who don’t know your resume, you were, at one point, the executive director of the through a authority is that what they call it over there, whatever the top leadership role is, and so you have some authority experience, and that’s come up in the conversations that were held over the summer. What are some of the advantages that you see as advantages and disadvantages to an authority structure for Medicaid administration.
Bob Megna 25:42
Well, every authority in the state has lots of public authorities. They’re usually set up for a specific purpose. The Thruway Authority is set up to administer day to day operations of the thruway, which includes, you know, keeping it open and keeping it safe. But it also includes, you know, construction projects to keep it long term viable, and there’s a tolling structure. And so it’s kind of outside the state’s tax system. It generates its own revenue, and it kind of operates within that kind of shell to keep that limited objective going, which is to keep the Thruway open, thriving, safe. You know, the MTA is a much larger version downstate of the same thing, which is mass transportation in the downstate region covering, you know, a wide swath of both the suburbs and New York City’s transportation network. So and then there are other smaller authorities that are doing different things. I think the the one thing that keeps them, you know, that’s in common is there separate entities from the state? They’re managed, typically by an outside board. Typically it is the government that appoints them, the governor, in many cases, but not always, that appoints the members to those boards. So they have a close affiliation with the state, but they have some separation from the state. They’re not a panacea. The idea that they’re totally outside the operation of state rules and state contracting, you know, segments is is really not true. I think they often, you know, would complain about many of the same things that state agencies and state entities complain about. But there is an element, I think, of being separated from the state, that sometime is an advantage, sometimes not. So I can see why this would come up in the conversation of health care provision, to kind of give it some of that independence, to have the board kind of have more of an input into how, you know, Medicaid was administered. But again, all of those political considerations that you think about often, would still be part of the process. Right? Who would appoint the board members? If it was the governor appointing the board members, you know, how would she choose those members? What would their backgrounds be? What would their role be in, you know, administering the program, who would you hire and how would you structure the day to day operations of the authority? So I think there’s a lot of questions, and I think everyone on the call has kind of hit the main point, which is we’re not necessarily saying a public authority the way the MTA works is the right answer for Medicaid. But there may be elements of the public authority structure that might be something folks would want to look at in improving Medicaid administration.
Joel Tirado 29:16
You know, I think I want to give you all the opportunity to sort of make a little bit of a case for not a specific change, but the case for changing how the administration of this program is done. And maybe because I’ve started with Courtney this time, I’ll start with Chad,
Chad Shearer 29:36
yeah, I think you know, it’s not just the changes that are coming down legislatively. There have been a mass of federal guidance to state Medicaid directors, and it will continue over the next few years. And each one of those kind of directives presents an opportunity. For the state to think about, are we structured the best way possible to do what we have to do to respond to what is coming at us from the federal government, and if not, if we can make even some small incremental changes along the way that help us both meet what we have to do so that the federal government continues to pay us, but also improves the way our program is managed and improves how we interact with the individuals that we serve. I think it’s an opportunity for a win, win, and it’s and it’s not just the big cuts. It is the litany of directives coming at the program, you know, from an administrative perspective every day, from the feds.
Oxiris Barbot 30:56
You know, the way that I look at it is we are and as I started at the beginning, we’re in a turbulent time, and changes are coming at us, left and right, and I’m a firm believer that during what feels like chaotic times is the best opportunity to put in place creative measures, right? And another way of saying that is, I always say it’s better to jump than to be pushed right, and sooner or later, they’re gonna have to be changes in the way in which Medicaid is administered. The question is whether we want to be a part of a conversation that helps to move that forward in a rational way, or whether we want to wait until it all hits the fan and then have a reactionary approach to, you know, whatever the changes are that that might be necessary. Because I think in in either situation, there’s going to have to be like what ultimately may feel initially like tectonic changes, but in the long run, will will really just be overdue changes to the way in which this huge program is run. I think, you know from my experience in covid, one of the things that we would always say is the status quo is killing us, and I think that this is an opportunity to really reimagine the status quo and say we can’t go on forward, you know, the way that we’ve been doing it, because it’s not the same reality that we’re living in anymore.
Courtney Burke 32:31
I would say there’s never been a more important time to have this conversation than when major changes are happening to the program. I reflect back on my time in government, when we were standing up the Affordable Care Act, which was probably the last time that there was this level of significant change. And the state did some creative things to help get the New York State of Health, which is the market place, the state’s insurance exchange, up and running by using a method to hire people, people more quickly and effectively, sort of as a, as a, as as Project people. And had we not had that flexibility, I don’t think the state would have had the same success in covering as many people as it did. And there was a lot of preparation and work that went into that. I think we’re at another moment in time where that is the case, and so go forward, we’re going to have to do all the things that were mentioned earlier on this call, in terms of complying with all of the rules and regulations that Chad mentioned are coming out from the federal government. It’s not only that, but even before that happens, we’re in the middle of an innovation with the Medicaid program through what’s known as a research and demonstration waiver. There’s a lot that’s going on just with that waiver to roll out a whole system of supports for people who have health related social needs that alone requires a lot of manpower. And then there are other transitions happening with other big programs, like the consumer directed Personal Assistance Program, there’s going to be the work requirements that are that are coming down the pipe, changes in the insurance coverage, changes in the financing. You really need to have adequate staffing, agile procurement, and good data analytics and outcomes on what’s happening to the program while all of that change is happening. So to get all of that, it’s essential, I think, that we’re having this conversation in a timely way.
Bob Megna 34:29
I think often, whether you want to change or not, during times when there are radical changes being foisted upon you, you’re forced into that situation. So it’s always good to be at least a little thoughtful about, you know, using it as an opportunity to do things that maybe you’ve wanted to do for a long time. But I would take one step backwards here and say something else even before. For these changes. It’s not like we were doing things perfectly, right. We had significant problems. Health outcomes, I think, across the board, are not what we’d like them to be in New York, especially for some of our Medicaid population. And so I think there’s always room for improving how you’re running a program that half the people in the state have a stake in their health care. And so I think it’s something you always should be looking at, but maybe in these kinds of times, it gives you the extra push to get where you want to go. You
Joel Tirado 35:44
Thanks again to Bob Megna, Courtney Burke, Oxiris Barbot, and Chad Shearer for joining us on the show for this timely conversation on how New York State’s Medicaid program is administered. If you liked this episode, please rate, subscribe, and share. It will help others find the podcast and help us deliver the latest in public policy research. All of our episodes are available for free wherever you stream your podcasts and transcripts are available on our website. I’m Joel Tirado; until next time.
Joel Tirado 36:18
Policy Outsider is presented by the Rockefeller Institute of Government, the public policy research arm of the State University of New York. The Institute conducts cutting-edge nonpartisan public policy research and analysis to inform lasting solutions to the challenges facing New York state and the nation. Learn more at rockinst.org or by following RockefellerInst. That’s i n s t on social media. Have a question comment or idea? Email us at [email protected].
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