Advancing Integrated Care For Dual-Eligible Individuals Through Multisector Plans For Aging

Advancing Integrated Care For Dual-Eligible Individuals Through Multisector Plans For Aging

This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid. The series is produced with the support of Arnold Ventures. Included articles are reviewed and edited by Health Affairs Forefront staff; the opinions expressed are those of the authors. Submissions will be accepted on a rolling basis until January 31, 2025.

While policy makers have sought solutions to integrate Medicare and Medicaid for decades, progress is still limited, as states are faced with several challenges, including:

Competing priorities. State Medicaid agencies must manage a long list of program issues and day-to-day processes. This includes program oversight across populations with diverse and often distinct needs (including new mothers, infants, young adults, older adults, dual-eligible individuals, and people with disabilities); processing program eligibility and enrollment; addressing information technology system challenges; certifying and regulating providers and health plans; providing for appeals, grievances, and hearings; collecting and submitting data to the federal government; and many other responsibilities. Currently, Medicaid agencies are also overwhelmed with the unwinding of the public health emergency further diverting attention from older adults and individuals with disabilities. Designing and managing a Medicare-Medicaid integrated program competes with these priorities.

Resource constraints. State Medicaid agencies are staffed to provide expertise in Medicaid policy and program design; however, integrated program design requires understanding Medicaid and Medicare policies, which are very different. Some philanthropies are funding direct technical support and resources for states to develop Medicare expertise and build leadership capabilities in Medicare policy, but these efforts alone cannot fully solve state capacity constraints. This lack of Medicare expertise, coupled with other resource limitations such as budgetary and staffing constraints or the lack of a “champion” on the issue, impedes a state’s ability to pursue Medicare-Medicaid integration.

Stakeholder buy-in and consensus. Stakeholder groups have varying and often competing interests in policies and programs that support older adults and people with disabilities. These stakeholders include the individuals enrolled in the program, their families, consumer advocacy organizations, medical and nonmedical providers, health plans, a state’s legislature, the governor’s office, and other entities. It can be difficult for states to bring together these sometimes-divergent perspectives and priorities, which can stall program design and implementation.

To address these challenges, a large number of states are implementing multisector plans for aging (MPAs), a “cross-sector, state-led strategic planning resource that can help states transform the infrastructure and coordination of services for their rapidly aging population, as well as people with disabilities.” Not only are MPAs resulting in state action on pressing aging issues, but they can also support a process by which states can navigate the infrastructure and political constraints that have historically prevented states from advancing Medicare-Medicaid integration efforts.

Multisector Plans For Aging Can Help States Address These Challenges

MPAs are a blueprint for states to help their residents age well, and as a result, can be a strong tool for Medicare-Medicaid integration.

State development of an MPA compels issue prioritization. An MPA requires the state to identify goals and objectives that focus on the well-being of not just existing older adults and individuals with disabilities, but also future aging generations. As such, an MPA naturally enables prioritization of program design for issues impacting dual-eligible individuals. In addition, an MPA can mandate action on a topic through an executive order, such as New York Governor Kathy Hochul’s executive order, which provided guidance on the MPA stakeholder advisory committee structure and responsibilities.

State development of an MPA implies there are state “champions” with interests that could align with Medicare-Medicaid integration. MPA development is driven by either executive or legislative champions, ensuring state-level leadership support from the outset. This positions MPA-related efforts for additional focus and resources from influential stakeholders on relevant topics, including integrated care for dual-eligible individuals. During the most recent gubernatorial campaign season and in an effort to demonstrate to voters which candidates might be champions for aging issues, AARP in Oregon asked candidates for their support of and commitment to a comprehensive state plan for aging. The winning candidate, now Governor Tim Kotek, described an MPA in her response, explaining the need for “a comprehensive plan, from housing to transportation to other issues, so people can age in a way that they can be successful, and we can all be successful.”

State development of an MPA brings together stakeholders to drive consensus and decision making. Public-, private-, and independent-sector stakeholders, along with state-level leadership, are typically part of an MPA process. Participants might include health plans and other organizations that provide coverage for dual-eligible individuals, providers, consumer groups, workforce advocates, and state lawmakers and officials, all with vested interests in aging and disability policy as well as Medicare-Medicaid program design. Convening these diverse perspectives and interests forces difficult conversations and produces consensus on key issues. For example, in 2022, Vermont held six listening sessions across the state, conducted a survey with 2,800 responses, and facilitated targeted focus groups with historically marginalized communities to engage stakeholders and gather input in support of MPA development. Stakeholders can also sign up for monthly updates along with meeting and comment notifications to continue to shape Vermont’s MPA.

The infrastructure developed through an MPA process can also help drive state-level decision making on related future key issues. For example, several states leveraged the relationships and collaborative processes resulting from the MPA process to guide state development of home- and community-based services (HCBS) spending plans for the enhanced Federal Medical Assistance Percentage made available through the American Rescue Plan Act of 2021. In California, several items in the state’s MPA (known as the master plan for aging) were addressed through the state’s HCBS spending plan, which largely impacts dual-eligible individuals, such as reducing the assisted living waitlist by 3,700 spots and the development of a grant program for direct-care workforce training.

State development of an MPA creates a mechanism for accountability and transparency. Using either legislation or executive orders creates a public framework for the MPA that advocates can use to hold a state accountable in its budgetary and policy decision making. In addition, states often create websites, dashboards, or other mechanisms to track progress on efforts related to MPA development and implementation. Best practices for MPAs also include identifying responsible state-level departments and agencies to further build accountability for progress. Although the MPA is still in development in Tennessee, a group leading the development of the MPA’s framework partnered with East Tennessee State University Center for Rural Health to create a data dashboard featuring state- and county-level data on aging; this data will inform future policy decisions. The group supporting the dashboard creation includes the governor’s administration, the Department of Health, the Department of Intellectual and Developmental Disabilities, the state Medicaid agency, AARP TN, and the Area Agencies on Aging and Disability.

Steps States Can Take To Advance Integration Using An MPA

States can leverage the existing stakeholder processes and infrastructure development for their MPA to focus specifically on advancing Medicare-Medicaid integration. Currently, 24 states are in different stages of MPA development (exhibit 1). MPA progress in states is changing rapidly, and the statuses reflected below are as of (June 22, 2023). For the purposes of these statuses, the following definitions apply:

• States with developed or implemented MPAs have a completed and publicly available plan, with implementation apparent through updates and activities reported by the state.

• States with legislation passed or executive orders have information on these efforts that is publicly available.

• States that are fostering development have introduced legislation, have state-led stakeholder processes/meetings/advocacy or state-led cross-department collaboration underway, or are part of the Center for Health Care Strategies Learning Collaborative.

Contact us

For questions, comments, or suggestions related to MPAs or the newsletter, please do not hesitate to contact us at MPA@westhealth.org.