The Trump administration is embarking on a basic change to Medicaid that for the first time evaluates states based on the health of millions of Americans and the services they use through the vast public insurance program for the poor.
Seema Verma, administrator of the federal Centers for Medicare and Medicaid Services, announced on Monday an initial version of a “scorecard” that compiles and publicizes data from states for both Medicaid and the Children’s Health Insurance Program (CHIP), a companion for youngsters in working-class families.
This first scorecard includes state-by-state information showing that, on average, just over half the women on Medicaid are getting care while they are pregnant and after giving birth. Only three in five babies get checkups during their first 15 months, and less than half of children and teenagers have preventive dental visits.
These and other measures show wide variations among states, though the initial version does not explicitly rank them. The scorecard also makes public for the first time measures of governments’ performance, such as how long both state and federal health officials take when states request “waivers” to deviate from Medicaid’s ordinary rules.
For now, the Trump administration is not attaching any consequences to how states fare, but Verma said that could change over the next few years as CMS refines and adds to the scorecard and members of Congress assess what it shows.
For now, “this is a conversation starter,” she said during a briefing for reporters. Even though Medicaid pays for roughly half the nation’s births, “have we ever had a conversation about [how states vary in] birth outcomes?”
The scorecard is part of a fundamental recalibration of the power relationship in Medicaid between the federal government and states. Since the program was created in 1965 as part of Lyndon Johnson’s War on Poverty, both have shared responsibility for paying for and defining the eligibility and benefits.
Medicaid now covers more than 67 million individuals, while CHIP covers nearly 6.5 million.
In the Trump era, federal health officials have been eager to give states more flexibility over Medicaid’s rules and benefits. Most significantly, the administration told states this year that it will allow them to require people to work or participate in other forms of “community engagement” to qualify for the program.
More recently, Verma also has said that such flexibility must be accompanied by heightened federal efforts to keep tabs on how well each state’s Medicaid program is functioning.
“With all the flexibility must come accountability,” she said Monday. “We must be honest with ourselves and honest with our stakeholders . . . about how well we are doing.”
Verma worked for years as a consultant to states’ Medicaid programs before coming to Washington early last year to run CMS, a major branch of the Department of Health and Human Services. She first broached the idea of a scorecard in a speech in November to states’ Medicaid directors, saying it was “a historic opportunity to transition from merely following federal rules and processes to focusing on achieving positive health outcomes — tangible results that will improve the lives of our beneficiaries.”
Following her announcement on Monday, Matt Salo, executive director of the National Association of Medicaid Directors, noted that states have for years measured and tried to improve the quality of their own programs. He called the federal effort to centralize such efforts “commendable.”
But data “that can be great internally to show how a state is doing don’t necessarily lend themselves” to comparisons among states. Salo said. For instance, states differ significantly in the proportion of their Medicaid residents covered by managed-care plans. In measuring the health of those beneficiaries, he said, the data look very different for a state such as Arizona, which enrolls everyone on Medicaid in managed-care plans, than for states that enroll only healthier adults in the plans.
And states that have expanded Medicaid under the Affordable Care Act to include people living above the poverty line are likely to have better health results than states that admit only residents in severe poverty, Salo added.
The scorecard’s initial information is based on states that voluntarily report a series of measures about the health of their Medicaid and CHIP enrollees. It shows, for instance, that the percentage of adults on Medicaid with high blood pressure under control as of 2016 varied from 26 percent in Louisiana to 72 percent in Rhode Island. The percentage of children ages 3 to 6 on Medicaid and CHIP who were getting adequate doctors’ care varied from 48 percent in Alaska and Idaho to 86 percent in Massachusetts.
Verma did not specify what additional information will be in later scorecards, but she said federal officials might be interested in how many people on Medicaid are working or volunteering, regardless of whether a state has imposed work requirements in its program.
The big takeaway, Salo said, is not the specifics of this “1.0 [version]. It is 2.0. . . . What measures are going to be used? What are the implications? What is that going to do?”