Advancing State Models to Influence Federal Policy

The pandemic accelerated trends moving the delivery of care into the home or community. Without proper funding, however, care at home may remain the province of better-resourced individuals and families. While access to services like palliative care has increased within hospitals across the country and access to hospice services has increased, there is a gap in accessing care for people with serious illnesses at home and in the community. Furthermore, people at the highest risk for unmet needs, underserved populations, and those on Medicaid access these services even less, often due to the lack of resources, variability in the delivery of services, and lack of awareness about the availability of this type of care.

C-TAC Approach to Address the Problem:

  1. Federal advocacy to improve equity and access across states: C-TAC is collaborating with the Center for Medicaid Services (CMCS) and the Center for Medicare and Medicaid Innovation (CMMI) to advocate for definitions and standards that would ensure all people with serious illnesses are engaged in their care, assessed for need, and have high-quality services available to them, regardless of their ability to pay. C-TAC is also advocating for the adoption of patient-reported outcomes measures and methods to identify people with serious illnesses so that states and commercial payers have a roadmap for model implementation.
  2. Peer Learning and Action Network: C-TAC is partnering with Harvard Petrie Flom Law Center, the National Academy of State Health Policy, and Votive Health to develop a peer learning and action cohort of state policymakers interested in addressing the unmet needs of people with serious illness. This network of state payers can accelerate the dissemination of data and best practices and advise C-TAC on our federal advocacy agenda.
  3. Mobilizing state coalitions: C-TAC has strong partnerships with local and state coalitions to identify the needs of people with serious illnesses and pilot innovative models that can be used to address them. Building from the data and analytics collected through the ACT Index, C-TAC will provide the data and resources that our coalition partners need to advance and seek funding to support local initiatives. This includes advancing state benefits and care models, increasing public awareness of services, expanding provider training, and improving infrastructure for providers and CBOs to meet the need.

Information relevant to the issue

Medicaid, the federal/state program of health care for people of low income, has the potential to address equity issues through waivers or plan amendments. For example, Medicaid will pay for some community-based services designed to enable underserved populations to have more person-centered serious illness care and better outcomes. Actions at the state policy level to make services more available, such as Medicaid waivers and state plan amendments, can achieve the goal of improving equity, access, and outcomes for underserved populations with serious illnesses.

States can test models faster to assess, coordinate, and deliver care. These results can scale models and benefits faster across state Medicaid agencies, and influence policy at the federal level. Successes may improve programs such as Medicare, using authority and flexibility under current law. Opportunities to streamline or fast-track federal waivers or approvals can be identified. Additionally, policies can be explored to provide federal grants or other resources for community-based organizations to develop the needed infrastructure to deliver such services at the local level, especially in underserved areas.

States are innovating new models of care within their Medicaid programs to support people with serious illnesses and improve health equity. Currently, Hawaii is leading this effort, implementing improved benefits for people with serious illnesses. At least 15 other states are actively working on a Hawaii-like approach, and others have expressed interest. These states are taking action to pass legislation or take other policy measures to implement programs and waivers to expand access to services like care coordination, palliative care, and advance care planning in the home and community settings.

Regardless of the policy route chosen, state policymakers and other stakeholders must explore, address, and gain consensus on the following key issues:

  • Defining the population
  • Defining the services
  • Qualifying providers
  • Setting reimbursement
  • Monitoring and evaluating outcomes

Calls to Action

  • Develop a standard definition of palliative care services and the minimum standards that should be required for all palliative care benefits filed under waivers or state plan amendments.
  • Allow dual-eligible beneficiaries (individuals who receive both Medicare and Medicaid benefits) to be able to access palliative care services benefits filed by states without the need to prove budget neutrality to the Medicaid program (focusing on the total cost of care reductions across both Medicare and Medicaid for dual-eligible members).
  • Increase ARPA funding for states to build the necessary infrastructure to expand workforce capacity, data and technology integration, and engagement efforts for home and community-based services.
  • Streamline the approval process for states filing waivers or state plan amendments for palliative care services.
  • Provide education for Medicaid directors and state leaders on palliative care services and their opportunities to reduce costs and improve quality.