The Impact of Medicaid on Public Health: A Conversation with Georgetown’s Joan Alker

December 16, 2019|4:13 p.m.| ASTHO Staff

As a public health official, it is important to understand the dynamic role Medicaid plays in your jurisdiction. This includes the interactions between governmental agencies, perspectives of multiple payers, and the impact on those receiving care. Medicaid and public health shouldn’t operate in silos – but instead in closer partnership to achieve optimal health outcomes.

Our guest blogger is Joan Alker, executive director and a co-founder of The Georgetown Center for Children and Families (CCF), and a research professor at the Georgetown University McCourt School of Public Policy. Alker discusses how state health officials can work with their Medicaid programs to improve overall health. During ASTHO’s annual Washington Week, we will host a "Leading in Government" workshop for health officials to explore various programs, policies and opportunities for the future.

What is the leading cause of the increased number of uninsured children between 2016 and 2018?
Between 2016 and 2018, the number of uninsured children rose by more than 400,000. This reversed a long-standing positive trend and erased many of the gains achieved for children after major provisions of the Affordable Care Act (ACA) took effect.

A number of policies and other actions have made it harder for families to enroll and renew their child’s public coverage – primarily Medicaid but also through the Children’s Health Insurance Program and the ACA marketplaces. These decisions include cuts and delays in enrollment outreach funding, fostering a climate of fear and hostility toward immigrant and mixed status families that discourages parents from seeking coverage for their eligible children, and additional red tape barriers that make it harder for children and their families to gain and maintain coverage. It is particularly troubling that the child uninsured rate increased at a time when the economy is relatively strong and children should be gaining coverage. A recession will surely worsen these trends.

How does the Affordable Care Act improve coverage for children, particularly in rural areas?
Children living in rural areas and small towns rely on Medicaid more than urban areas due to the fact that overall poverty rates are higher and the types of jobs available, such as agriculture or small businesses, are less likely to offer health insurance.

A “welcome mat” effect created by Medicaid expansion helped many children gain health coverage in both rural and urban areas as their parents became eligible for Medicaid coverage. States that expanded Medicaid are clearly outpacing those who haven’t in meeting the health coverage needs of both rural and urban children. Children living in non-expansion states are being left behind and are about twice as likely to be uninsured than children in expansion states. And those states that haven’t expanded Medicaid are seeing much higher rates of hospital closures in rural areas – which affects the access that women in rural areas must needed labor and delivery services as well as prenatal and postpartum care.

How can we better leverage Medicaid and Public Health programs for children?
Medicaid is the nation’s largest single source of health insurance covering births and children. It covers a range of public health services, from prenatal care to immunizations to lead screening. Medicaid payments for these services free up scarce public health dollars for other populations and services.

For states where traditional Medicaid expansion isn’t a political reality, what can be done to expand coverage for kids?
I don’t think there are many states where traditional Medicaid expansion isn’t a political reality. Ballot initiatives to expand Medicaid in conservative states such as Idaho, Utah and Nebraska all passed, and now we see movement in Oklahoma and Missouri on this front. And recent gubernatorial elections in Kentucky and Louisiana saw pro Medicaid expansion candidates win. But it may take a few years. In the meantime, states can examine which kids in their states are uninsured and why – there are likely procedural changes they can make to simplify the enrollment and renewal processes. And they may need to expand eligibility for the Children’s Health Insurance Program (CHIP).