Washington’s Medicaid Chief Examines the Future of Medicaid and Health Reforms

MaryAnne Lindeblad oversees Washington State’s Apple Health (Medicaid) program, which serves more than 1.8 million residents. She also chairs the National Academy for State Health Policy’s executive committee and is a National Association of Medicaid Directors board member. Lindeblad took time recently to talk to NASHP about the future of Medicaid and health care reform.

Many state officials are despairing at the prospect of federal cuts to Medicaid, can innovation save the day?
We have no choice but to innovate and find different models for delivering and paying for health care. Historically, Medicaid programs often responded to budget pressures by cutting rates, cutting eligibility, cutting services, or contracting out the management of services to a managed care plan. We have exhausted those approaches. We need to find other tools to cover our (low-income) population in a way that is effective and produces the desired outcomes, and one opportunity is to look at other countries for models.

Which countries?
I recently had the opportunity to participate in a webinar with health officials from Spain. We could learn from their system of treating individuals with chronic care needs, some of which we are beginning to implement in Washington. I also believe we must focus more on the social determinants of health, including housing, employment and food security, and provide more robust behavioral health care.

(Note: Spain’s complex care plan uses interdisciplinary primary care teams to coordinate care among specialists, social workers, nursing facilities, home care aides, mental health providers, caregivers, and the patient, which has generated a marked decrease in hospital admissions. Team member receive bonuses, tied to performance measures, based on individual care plans. It also permits program flexibility across regions to meet specific populations’ health care needs.)

What is Washington doing to reform the health care delivery and payment system?
We have about 85 percent of our enrollment in one of our five managed care plans. In 2016, we began integrating behavioral health services into our managed care delivery system. We started in one region in the state in 2016 and will complete the whole state by January 2020. Already, we have seen improved outcomes and reduced hospitalization by having one care manager serve as a point of entry into the health care system for our highest needs, highest risk individuals. Our integrated systems are more responsive to our members’ needs. We are also beginning to build in social determinants of health into our managed care contracts and delivery systems in order to hold providers more accountable for things that directly affect people’s health, such as housing, food security and job and educational opportunities.

We also implemented a robust health home program and to date, we are seeing improved health outcomes and significant cost savings especially for our dual-eligible population.

How effective is your value-based payment (VBP) initiative, which replaced a traditional fee-for-service model with one that rewards providers for delivering quality care?

As a part of our 1115 Medicaid transformation waiver, we require our health plans serving our Medicaid population to move to VBP arrangements. By the end of 2018, we expect to have at least 50 percent of services paid through a value-based arrangement and our goal is to reach 90 percent by 2021, with commercial markets reaching 50 percent by 2021.

We have 1.8 million people in our Medicaid program, 370,000 state employees and retirees, and we will soon add 250,000 teachers in 2020. When purchasing for this many covered lives, our Health Care Authority is well-positioned to drive innovation across the state in both publically- and privately-purchased health care.

Is VBP delivery reform currently your most potent tool?

It is certainly one of our major tools among an array of options including improved care coordination, chronic care management, and integration to name a few. Because we were able to obtain a 1115 transformation waiver, we have an opportunity to test a number of tools over the course of the next four years. In addition, as a part of our Healthier Washington initiative, we are engaging our nine accountable communities of health to bring together leaders to improve health care resources, population health, and whole-person care. They are a great way to meet local needs and engage individuals from multiple sectors at a community level in identifying community health related needs and local solutions.

What do you think of the Medicaid work requirements?
It is difficult to find and keep a job if you have untreated health issues so I would rather invest in programs that provide access to quality and accessible health care first and provide the supports to maintain health. In addition, as a part of our 1115 waiver, we have added supported employment services for individuals that may need some additional supports to both find and keep jobs.

What keeps you up at night?
Being able to maintain the level of access and health insurance coverage that we currently have.

We still have an uninsured rate of around 6 percent in Washington and continue to have a successful (Affordable Care Act) insurance exchange. Can we maintain that level of insurance coverage? What will happen to Medicaid and our exchange in the future? If those programs are rolled back, we will lose ground and it will be more difficult to maintain the gains we have seen in our state. We will be back to seeing emergency rooms visits going up, hospital bad debt rising again, and fewer individuals having routine access to primary care.

We also need to make sure we have a workforce that can meet the demands of the populations we serve. We have many gaps today, especially in behavioral health and primary care. We need to address these shortages and look to how we can best use mid-levels and work our health care professionals to the top of their license.

This is a pivotal time in health care – we have a tremendous opportunity to change how we deliver health services and improve the health of those we serve. We cannot waste it.


Hear Lindeblad speak at NASHP’s 31st Annual Health Care Policy Conference, Aug. 15-17, 2018, in Jacksonville, FL

Raising the Bar: Value-Based Purchasing to Address Population Health State health policymakers are identifying innovative mechanisms to address the social determinants of health by including new requirements or incentives within value-based purchasing and contracting arrangements. This session highlights how states are using value-based payment roadmaps and Medicaid managed care contracting as levers to increase health and well-being and to control costs. Officials from three states discuss their models, share strategies, and identify practical ideas to address the social and economic factors that influence health through value-based purchasing.

Also, read more about accountable health models:  States Develop New Approaches to Improve Population Health Through Accountable Health Models