Episode Transcript:
Matt Salo
And ultimately what we really want is to improve the member experience. We want the Medicaid beneficiary to be able to look at their experience in Medicaid with a health plan and say, "I'm glad I'm in this plan. I like the care that I'm getting. This is meaningful to me."
Robert Traynham
Let's start off with an icebreaker, your favorite TV show or series?
Salo
So, my favorite TV show. I am rediscovering one of my favorite TV shows from a while back. “Lost.” This was like a groundbreaking show when it came out 10, 15 years ago. It had action, drama, intrigue, time, travel mysteries, polar bears, and kept me on the edge of my seat for six or seven years watching it. My kids are now old enough where they can watch it, and so I'm rewatching it with them, and it is a blast to kind of see it afresh from their eyes, through their eyes.
Traynham
Through their eyes. That's interesting. So, I'd love to chat with you for a few moments around the National Association of Medicaid Directors you started a couple of years ago. But most recently, your inspiration and drive behind Salo Strategies. Welcome through both.
Salo
So, I had the privilege of being the Founding Executive Director of the National Association of Medicaid Directors. And that kind of came into play because up until about 12 years ago, the state Medicaid directors were part of this larger umbrella group called the American Public Human Services Association. And it represented state Medicaid directors and then all the state kind of human services agencies. And quite frankly, the Medicaid directors never particularly liked that situation.
And things came to a head about 13 years ago, really with the passage of the Affordable Care Act, where the Medicaid directors looked around and said, "This is the most impactful piece of legislation ever in Medicaid. Where was our voice?" And they said, "It wasn't there. This situation isn't working. We want to try something different."
And I saw what they were missing, and I was able to sort of build something for them from the ground up. I wanted to really let their voices be heard. I mean, the state Medicaid directors in my mind were always the hardest working, most important folks in state government. And the thing that really set them apart from anywhere else in, in the ecosystem was their practicality and their pragmatism. And the responsibility of running a program that was 20, 30% of the state budget and served 70 million people, was the nation's long-term care program. And I knew that they deserved better, and they needed a voice on the Hill, but they also needed support amongst each other. And I was privileged to be given the opportunity to, to build that. Did that for about 11 years. And I kind of said, okay, I think I need, you know, in order to take that organization from where I built it to the next level, I need to pass the torch to someone who's got an incredible sense of vision and energy to do that. And was able to hand it off to Kate McAvoy, who's the current executive director who's just doing absolutely terrific things.
Traynham
And Salo Strategies, quickly.
Salo
So, yeah, I, you know, trying to think what do I do next? I had spent 30 years, working on behalf of state government, on behalf of state Medicaid agencies and, and the program. And I said, I need to be able to help the private sector better understand the public sector and better be able to come to the public sector with their solutions in a way that they could communicate and articulate clearly, succinctly, and to help that partnership, that public-private partnership, work better. And so that's what I get to do now.
Traynham
Matt, the health care system, as you know, is very large. It's very complex. What role does Medicaid play in this vast ecosystem we call health care.
Salo
Medicaid plays the most important role of any program in the U.S. health care.
Traynham
Why?
Salo
It is the safety net. It does so many things for so many people that most people don't even fully realize. Medicaid often gets thought of, “oh, that's just kind of a low-income program.” Right? Well, Medicaid covers almost 50% of the births in this country. Medicaid is the largest provider of mental health and behavioral health services in this country. And Medicaid is by far the long-term care program in this country. Prior to the pandemic, we covered about 72 million Americans. And then during the pandemic, Medicaid served as the first responder, and its coverage ballooned up to almost a hundred million Americans. Medicaid served to strengthen the physical, the behavioral, the social, and the financial health of American families in this country.
Traynham
Let's talk about Medicaid redeterminations and, specifically, what happened last year.
Salo
Yeah. So, as part of its surge, through the pandemic, Medicaid kind of suspended all of the rules around eligibility and throughout the entirety of the public health emergency, no one lost coverage in Medicaid for any reason. And that's why total eligibility went from 70 million to almost 100 million. Well, that was designed to be short-lived, that was designed to be temporary, and that when the public health emergency was over, the program was designed to right-size and go back kind of to normal.
And so that's really what, when we talk about redeterminations, when we talk about the unwinding of the public health emergency, that's the big piece. It's getting back to normal. To gear up eligibility systems, the workforce, and really, communication strategies, to try to touch 100 million beneficiaries across the country and say, "The rules that you got used to over the last couple years are now very, very different. And we're going to have to, you know, get real particular around who you are, where you live, what is your income, are you actually eligible? And we need people to engage and contact the state Medicaid agency and figure that out." And that's, you know, this has been the number one, two, and three top policy priorities for Medicaid directors in every state in the country.
Traynham
During Medicaid redeterminations, there was so much work that was done by AHIP and others with respect to language translation, with respect to some other, meeting people where they are. Can you walk us through some examples?
Salo
Yeah. So just overall, I would say that there's been an incredible partnership between Medicaid and AHIP and the health plans throughout the Medicaid eligibility redetermination process. They, they have been partners, and, you know, the plans have been force multipliers for the, for, for the states out there. One of the things that we found is that, you know, there's a, there's a real difficulty in trying to communicate to 100 million people that the rules around their eligibility are going to change, that they're going to have to start submitting a whole lot of paperwork and W2s and, and all this stuff. What we found is that you need to specifically target communications, messages, and outreach, not at a state level, not at a national, not at a national level, not even at a community level, but at a micro community level. You have to be able to work in a linguistically and culturally relevant way to reach, you know, an African American population, a Latino community, an Asian Pacific Islander community, an Appalachian community.
And working with the health plans, they have been able to figure out how do we go a couple of levels down and work with the community-based organizations, work with, you know, community health navigators, work with the people who are those trusted voices - might be faith-based organizations, might be community organizers, whoever it is. And to me, that investment and that work that's gone in to try to do a better job of communicating to the people we actually serve is going to pay off multiple fold. Because at the end of the day, that relationship is not just about your eligibility. That relationship is going to be key to addressing that individual, that family, that community’s health care trajectory, their outcomes, their access, their quality of life. When we can learn to speak with them in ways that they can hear the sky's the limit.
Traynham
Thousand percent. It's almost like meeting them where they are and speaking their language so that there is a conversation, there is an ongoing conversation that's authentic and that is trusted. And so if that's a clam bake, if that's a church Sunday picnic at the barbershop, it could be at the local community center. It is literally meeting them or us, or we where we are, which is so authentic.
Salo
Yeah. And it, it, it's not the kind of paternalistic, "Here, we're in government." "You come to us." It's no, we are here with you and we, we need to know what it is that you want, what it is that you need. And if that's this group of services, let's do it. If it's not that group of, okay, well let's not worry about that. And if it's something that hasn't traditionally been offered, okay, let's figure out how to get that.
Traynham
That's right. Matt, let's talk about innovation. And some of the innovative work that private health insurance, is doing in the Medicaid space. Can you give us some best practices or some examples?
Salo
Sure, sure. So I've always felt that Medicaid is very much a public-private partnership between state governments and health plans. You know, the vast majority of the 70, 80 million people in Medicaid receive their coverage through an MCO. And one of the great things around the managed care experience is that health plans are able to be more nimble. They are able to, you know, try pilots and demonstrations and, you know, innovative things that a state Medicaid agency, state government bureaucracy doesn't have the bandwidth to do.
So we are seeing health plans across the country lean in, in terms of providing coverage of the social drivers of health — housing, food security, transportation, et cetera. So anywhere you look in any kind of problematic part of the health care system, you're seeing a health plan in, or multiple health plans in one or more states innovating and trying to really push the envelope in terms of improving health care access, improving health care quality, bending down the health care cost curve. And ultimately what we really want is to improve the member experience. We want the Medicaid beneficiary to be able to look at their experience in Medicaid with a health plan and say, "I'm glad I'm in this plan. I like the care that I'm getting. This is meaningful to me."
Traynham
Matt, tell us about your work raising the awareness, perhaps maybe sitting at the intersection of the public sector and the private sector. I know you've done some work on this in the context of just really making sure that both sides, are speaking with each other.
Salo
Yeah. So, I think it's really important, for example, in my line of work to help the private sector understand the language that Medicaid speaks,
Traynham
— because sometimes things are lost in translation. —
Salo
Absolutely. So for example, one of the parameters that Medicaid has to deal with is states operate balanced budgets. Every state has to balance their budget every single year or on a biennium and Medicaid's often right in the middle of that. And if it's, if there's trouble balancing the budget, it's often because Medicaid's costs are growing. So there's a, there's a reluctance or a resistance to saying, "Oh, hey, let's try this innovative thing. It'll be good for people, but it's going to cost a lot of money." That's often not a flexibility that states can take advantage of because like, "Yeah. But if it increases costs, now, you know, we can't wait five years, 10 years, 20 years for this to pay off. We need to deal with the here and now."
Traynham
And in some instances, I think it's fair to say it's state law, they have to manage their budget. So there's perhaps some statutory requirements that the states have to adhere to.
Salo
Yeah. No, it's actually, it's in the constitution of every state in the country, I think, except for Vermont. And they do it just by, by force of habit anyway. So it, that's got to happen. You also have to deal with the fact that, state government tends to be very kind of differently organized.
You can have Medicaid that exists on its own with public health separate, or human services separate, or aging and disability, and intellectual developmental disabilities separate, or they can all be together or parts of them here and there. Which creates a lot of challenges from a leadership standpoint. You know, if I'm trying to do something to improve the health care for kids in the foster care system, which is a huge, huge challenge, getting two separate parts of government to work together towards a common goal where one of those parts may pay for it and the other part will benefit from it. That's part of the challenge. So it's the, it's the real world challenges of leadership in that.
Traynham
You would think that it would be simple, but clearly it's not.
Salo
It's clearly not. No. And you know, we've, we've had examples in the past of, you know, what I call kind of enlightened governance where there's somebody, there's a governor or a budget officer or somebody who looks out at all of these different silos and says, "I get it. I understand that if I spend more on Medicaid, I will save money in corrections." However, that is really rare.
Traynham
In your mind, what is the next big thing in health?
Salo
So I think the next big thing, and we are starting to see this percolate, is, and I've mentioned this a couple times now, it's justice-involved populations. We have had a disconnect in health care in this country for a very, very long time, where people who were otherwise eligible for Medicaid, the minute they enter the justice system, whether that's a jail, a prison, or even probation or parole, their Medicaid coverage is cut off. And, you know, it's one thing if it's like, okay, somebody going from where they are to a 30-year prison term, you can, you can shift and do that, but a lot of people are kind of going to go in and out of the system.
And that type of coverage loss and, and just kind of disharmony is extremely detrimental to the long-term viability of an individual's health care, their care coordination, their medication adherence, trying to treat individuals with mental illness and co-occurring substance abuse issues. We've got to figure out a way to create more continuity across those different, stages of, of that individual's life. So Medicaid is, is just starting to innovate there. It co- it brings some of the familiar refrains of, "Well, is this going to cost too much money? Is this going to cost the federal government too much money?" And we're starting to say, “Let's put those questions aside because these are some really significant, real-world problems that we have the opportunity to solve.”
Traynham
You know, Matt, I'm thinking through, the mom that just gave birth. I'm thinking of the person that maybe has type two diabetes. I'm thinking of the person that perhaps maybe has asthma or some other chronic illness where the continuity of care, not only from a physical perspective, but also from a mental perspective is so important. It really is about guiding greater health.
Salo
It is, it is. And I think in the broader standpoint, I mean, you know, I mentioned justice involved populations, you mentioned, postpartum issues. A lot of the similarities that I see, that I kind of step back and see, it's, it's transitions. People transitioning from one part of life to another. Whether that's, you know, a, a young woman who has, you know, a primary care physician, then she becomes pregnant, now she has an OB. She gives birth, and now she has to worry about a pediatrician, and then she's going have to transition again to another primary care physician. There's a lot of ways we lose people in those transitions. Kids in foster care, kids in justice involved, people in justice involved populations, or a frail senior who falls and goes from home to a hospital, to a rehab center, to a nursing home.
Traynham
Indeed, so thank you. Absolutely.
