Medicaid & CHIP Payment & Access Commission Issues Public Comment on OMB Notice

WASHINGTON, July 10 -- Melanie Bella, chair of the Medicaid and CHIP Payment and Access Commission, has issued a public comment on the Office of Management and Budget notice entitled "Methods and Leading Practices for Advancing Equity and Support for Underserved Communities through Government". The comment was written and posted on July 6, 2021:

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On behalf of the Medicaid and CHIP Payment and Access Commission

(MACPAC), I am offering these comments on the request for information (RFI) noted above. As you may know, MACPAC is a nonpartisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children's Health Insurance Program (CHIP). These programs serve low to moderate income people who otherwise would likely be uninsured, thus making them underserved by definition. As we announced during the summer of 2020, MACPAC is also focusing on equity, infusing it throughout our work as noted in our recent recommendations to extend postpartum coverage, mitigate the effects of estate recovery policies, and strengthen the role of Medicaid in serving beneficiaries experiencing mental health crises (MACPAC 2020a, 2021a, 2021b, 2021c).

We are encouraged by the Administration's interest in making equity a governmentwide effort and urge ongoing sustained attention to combating institutional racism in health care and addressing racial and ethnic disparities in health care and health outcomes. The Medicaid program should be a key target for such work given that 60 percent of Medicaid's 81 million beneficiaries identify as Black, Hispanic, or other non-white race or ethnicity. Moreover, the research literature is replete with examples of disparities in access, quality, and care within the program (MACPAC 2021d).

The work of the Centers for Medicare & Medicaid Services (CMS) and state agencies that jointly operate Medicaid and CHIP should focus on both documenting specific disparities in health care and developing new opportunities to improve access to and the quality of care that beneficiaries receive. Below we highlight opportunities to improve data and opportunities for changes in program policies and operations that promote equity.

Focus on data needs

Given the RFI's focus on developing approaches to assessing equity and the use of data to inform strategies, it is important to prioritize efforts to improve reporting on race and ethnicity in the Transformed Medicaid Statistical Information System (T-MSIS), the only federal Medicaid data source for person-level information regarding eligibility, demographics, utilization, and spending. As discussed by MACPAC at our September 2020 public meeting, there are high rates of missing and unknown data for race and ethnicity in T-MSIS. An analysis of 2016 T-MSIS analytic files found that only 21 states had complete race and ethnicity data on 90 percent or more of their records. This is in contrast to age and gender information, which was complete for 99 percent of records for all states (CMS 2019).

Our analysis of more recent T-MSIS data (2018) continues to show high levels of missing or unknown data on race and ethnicity, in some cases worse performance than in 2016. Specifically, 11 states are missing race data for 10-30 percent of their enrollees and 5 states are missing more than 30 percent. In addition, 14 states have 10-30 percent unknown race data, and 7 states have more than 30 percent unknown race data. States with high levels of unknown data and those with high levels of missing data rarely overlap. In short, just 19 states had more than 90 percent of beneficiary records reporting an identifiable race and ethnicity.

Missing data may indicate several issues. Beneficiaries may not disclose their race and ethnicity when applying for or renewing coverage due to concerns about how the data might be used, and states may not report these data to CMS.

Moreover, data contained in T-MSIS may be inaccurate, given that in many cases, these data conflict with benchmarks such as the American Community Survey (ACS). This includes states reporting no or much lower rates of beneficiaries reporting various race or ethnicity categories than would be expected based on the ACS (MACPAC 2020b).

Insufficient and inaccurate data make it difficult to assess disparities, develop appropriate interventions, and monitor progress. CMS should place a higher priority of these fields in its data validation activities and support states in gathering these data. For example, the agency could provide technical assistance to states on approaches to capture data on race and ethnicity at enrollment, including proven methods that not only improve data collection but build trust with enrollees regarding the use of such data. The latter could improve completeness by addressing hesitancy regarding self reporting of race and ethnicity.

Moreover, CMS could do more to highlight the importance of these data by disaggregating key measures by race and ethnicity in its own data reports.

Focus on policies and practices that promote equity

While better data are crucial to the work of federal and state agencies in documenting specific disparities in health care, in the Commission's view, the work to develop and implement more equitable policies does not have to wait until data improvement efforts are complete or disparities can be measured with scientific precision. There are multiple areas of opportunity that could be addressed through subregulatory guidance, waiver opportunities, and technical assistance such as:

* developing more robust approaches to monitoring access, both generally as well as for specific services for which Medicaid plays a predominant role (e.g., behavioral health services, housing supports, and long-term services and supports);

* critically examining network adequacy and payment levels in relation to access;

* providing sustained attention to measure and address disparities in Adult and Child Core Set quality measures;

* making investments in outreach and enrollment efforts to reach those who are eligible but not enrolled;

* designing payment and delivery system policies that value improvements in equity as an outcome measure;

* focusing on efforts to reach and support beneficiaries whose primary language is not English; and

* considering how to improve cultural competency in program operations and policies, including state Medicaid programs themselves, their advisory committees, managed care organizations with Medicaid contracts, and providers serving the Medicaid population.

Such efforts should also consider other disparities including those affecting people with disabilities and those residing in rural areas.

Finally, as you are well aware, communities of color have been disproportionately affected by the COVID-19 pandemic. They have experienced higher rates of infections, hospitalizations, deaths, and lower vaccination rates. As the pandemic attenuates, plans to unwind emergency authorities and return to normal operations should be designed to ensure that people of color are not disproportionately affected by activities such as the resumption of regular eligibility redeterminations or the ending of waiver flexibilities. In addition, state policies regarding use of telehealth have the potential to improve access for this population assuming appropriate attention to the availability of technology and sufficient connectivity. The way in which these activities are managed will be an important test of how CMS will prioritize equity considerations.

Thank you for your attention to MACPAC's input. If you have additional questions, please feel free to reach out to Anne Schwartz, MACPAC's executive director at anne.schwartz@macpac.gov.

Sincerely,

Melanie Bella, MBA

Chair

Cc: Chiquita Brooks-LaSure, Centers for Medicare & Medicaid Services

Daniel Tsai, Centers for Medicaid and CHIP Services, CMS

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References

Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services. 2019. Quantifying the distribution and completeness of select demographic variables in 2016. Brief #4121. https://www.resdac.org/sites/resdac.umn.edu/files/4121_Demographic_Variables.pdf.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2021a. Chapter 2. Advancing maternal and infant health by extending the postpartum coverage period in Report to Congress on Medicaid and CHIP. March 2021. Washington, DC: MACPAC. https://www.macpac.gov/publication/advancing-maternal-and-infant-health-by-extending-the-postpartum-coverage-period/.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2021b. Chapter 3. Improving Medicaid estate recovery: improving policy and promoting equity in Report to Congress on Medicaid and CHIP. March 2021. Washington, DC: MACPAC. https://www.macpac.gov/publication/medicaid-estate-recovery-improving-policy-and-promoting-equity/.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2021c. Chapter 2. Access to mental health services for adults covered by Medicaid in Report to Congress on Medicaid and CHIP. June 2021. Washington, DC: MACPAC. https://www.macpac.gov/publication/access-to-mental-health-services-for-adults-covered-by-medicaid/.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2021d. Racial and ethnic disparities in Medicaid: an annotated bibliography. April 2021 fact sheet. Washington, DC: MACPAC. https://www.macpac.gov/publication/racial-andethnic-disparities-in-medicaid-an-annotated-bibliography/.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2020a. Update from MACPAC: Responding to the public health crises of COVID-19 and racism. June 27, 2020 press release. Washington, DC: MACPAC. https://www.macpac.gov/news/update-from-macpac-responding-to-the-public-health-crises-of-covid-19-and-racism/.

Medicaid and CHIP Payment and Access Commission (MACPAC). 2020b. Presentation before the Medicaid and CHIP Payment and Access Commission, September 24, 2020. Washington, DC. https://www.macpac.gov/publication/federal-datasources-for-analyzing-racial-and-ethnic-disparities-in-medicaid-and-chip/.

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The notice can be viewed at: https://www.regulations.gov/document/OMB-2021-0005-0001

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