How Medicaid's mission creep is undermining real health care

How Medicaid’s mission creep is undermining real health care

Most doctors, myself included, know that a patient’s zip code predicts their life expectancy. National life expectancy would undoubtedly increase with less poverty and more cheap nutritious food, stable housing, sanitation and exercise. But it is a mistake to assume that the health care system can solve these societal problems.

The federal government wants Medicaid to improve the “social determinants of health” (SDOH). Unfortunately, the use of an agency designed to fund medical care for the poor to tackle a wide range of complex social problems has led to “mission drift”. It’s just not feasible.

For example, in a recent Centers for Medicare and Medicaid Services (CMS) roadmap, states are tasked with addressing “social, economic, and environmental factors that affect health outcomes for Medicaid and CHIP populations.” Programs should seek to improve “access to nutritious food, affordable and accessible housing, quality education and meaningful employment opportunities”. That takes a lot out of a funding program.

Some states are eager to oblige. New York recently proposed using Medicaid to eliminate barriers to health such as “poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair wages, education and quality housing, safe environments and health care”. California’s new CalAIM project provides housing assistance and employment assistance to Medicaid recipients. The actual delivery of health care seems almost an afterthought.

These proposals are like trying to boil the ocean. New York State says Medicaid should consider “all physical and behavioral health and social factors that impact a patient.” There are already many ministries with big budgets specifically in charge of these things. Each listed SDOH already has its own federal and state government agency.

Just because a person’s housing affects their life expectancy does not mean that a Department of Housing and Urban Development should become subordinate to Medicaid or duplicate its efforts. Coordination, not duplication, is what is needed.

Patients sign up for health insurance to see a doctor when they get sick, not for a voucher for the farmer’s market. The US healthcare system does the “taking care of sick patients” part quite well. He is not responsible for the country’s low life expectancy. We excel in the treatment of major diseases, cancers and trauma.

Mission creep will unwittingly damage the very areas in which American health care excels. A burgeoning bureaucracy already includes an ever-increasing number of employees (mainly administrators) to handle the same number of patients. Asking doctors, hospitals and Medicaid administrators to tackle jobs, housing, education, discrimination and the environment will only make things harder, especially with a Medicaid underfunded and overburdened.

Medicaid’s growth is already unsustainable, having covered only 6.8% of the population in 1970 and over 25% in 2020 (consuming 3.3% of GDP). In addition, Medicaid monopolizes an average of 16% of state budgets. These numbers predate the COVID-19 pandemic, which led to increased enrollment and spending.

Mission creep also means more metric fastening. So-called “value-based payment” (VBP) has seeped into medicine for over a decade now, and CMS is now encouraging it to address social factors. Intended to reward quality care providers, the VBP has proven to be plagued with unintended consequences, such as worsening mortality at facilities that attempt to meet statistical benchmarks.

The US government has already spent $1.3 billion to develop measures, and medical practices spend $15 billion a year to publish them. Institutions also spend money fiddling with metrics, so much so that recorded “improvements” have been exposed as byproducts of coding risk adjustment. This ends up helping the best-resourced institutions, while hospitals serving low-income patients are the worst off.

There are better ways to spend limited Medicaid resources.

Start with the payout parity. Compared to private insurance, Medicaid reimburses providers for treating its patients with pennies on the dollar. Those who enroll in Medicaid seek access to doctors, nurses, hospitals and therapists. Underpayment of providers compromises this access. Reimbursing frontline health care workers at a level that shows the government’s commitment to Medicaid patients, rather than spending on other agencies’ responsibilities, must be the priority.

Second, instead of arbitrary measures, Medicaid should implement programs that put patient choice first. Over 75% of Medicaid recipients have annual health care expenses of less than $7,000. These low-cost patients could be covered by the private insurance market with relatively inexpensive subsidies or vouchers.

In a highly competitive market with more financing options, these relatively healthy patients could choose a plan that meets their individual needs. Some plans may even offer SDOH coverage. Letting patients choose whether their voucher money goes to SDOH is much fairer than the forced approach.

Medicaid mission creep must be reversed. The system is already stretched. Low payment rates keep suppliers away. Increasing the burden of the program will only make matters worse. Reform should come by prioritizing patient choice and bottom-up solutions. This is the real path to fairness.

Anthony DiGiorgio, DO, MHA, is a neurosurgeon, assistant professor at the University of California, San Francisco School of Medicine, and author of upcoming research for the Mercatus Center at George Mason University. He is also an Affiliate Professor at the Institute for Health Policy Studies at UCSF. Follow

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