MACPAC highlights cost, quality challenges in serving vulnerable populations

The Medicaid and CHIP Payment and Access Commission highlighted the health needs and cost challenges in providing care to the diverse and vulnerable populations of Medicaid beneficiaries in its June 2015 report to Congress. The report also examines a new approach in supplemental payments in the Delivery System Reform Incentive Payment (DSRIP) programs, the coverage of adult dental benefits, Medicaid’s role in providing health services to individuals with behavioral health diagnoses and children and youth receiving child welfare assistance, and the use of psychotropic medications under Medicaid.


The MACPAC, a non-partisan legislative branch agency, provides policy and data analysis that form the basis of its recommendations to Congress, HHS, and the states on issues relating to Medicaid and the Children’s Health Insurance Program (CHIP). The statute authorizing the MACPAC outlines areas of analysis, including payment, eligibility, enrollment and retention, coverage, access to care, quality of care, and the MACPAC’s interaction with Medicare and the health care system generally. The statute requires the MACPAC to submit reports—based on its public meetings and regular consults with state officials, congressional and executive branch staff, beneficiaries, health care providers, researchers, and policy experts—to Congress by March 15 and June 15 every year.

DSRIP supplemental payments

DSRIPs are a new type of Medicaid supplemental payment that support the efforts of providers to change the delivery of care, improve quality of care, and promote population health. The report states that California, Texas, Massachusetts, New Jersey, Kansas, and New York have implemented DSRIP programs, and in fiscal year 2015, a total of $3.6 billion in federal funding is available for implementing DSRIP programs in these states. The funding can go toward projects including the expansion of primary care clinics, building IT capacity, creating patient navigator programs, and placing behavioral and primary health care providers in the same location. However, states have reported that finding additional non-federal funding to finance DSRIPs presents a challenge, and data does not yet demonstrate improved health outcomes and cost savings. The MACPAC recommended that the federal government provide clear and consistent guidance and promote more effective oversight.

Dental health

The report states that poor oral health affects adults with incomes below 100 percent of the federal poverty level disproportionately. These individuals are more than three times as likely to have untreated dental issues compared to adults with incomes above 400 percent of the federal poverty level. Dental coverage is often decreased by states in lean times and increased again when the budget improves, making it difficult for beneficiaries and providers to know what services are covered. Even when coverage is available, the report states that Medicaid enrollees use these services less than other health services, possibly because of difficulty in finding a provider who accepts Medicaid. The report cites federal and state initiatives that aim to improve access to dental services.

Children and youth on welfare

Children currently or formerly served by the child welfare system—usually who have either been removed from their homes for abuse or neglect or who receive in-home child welfare services because of allegations of maltreatment—are among the vulnerable populations covered by Medicaid who are likely to become uninsured when they age out of the child welfare system. Roadblocks in the implementation new Medicaid eligibility pathways for former foster youth under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) may produce lower than expected gains in coverage. The MACPAC encouraged states to evaluate how policy changes in Medicaid can improve the health of children involved in welfare.

Behavioral health and psychotropic medications

The report states that Medicaid is the single largest payer in the U.S. for behavioral health services, with 9 million Medicaid enrollees under age 65 having a behavioral health diagnosis. In 2011, this accounted for 20 percent of enrollees and about half of the total Medicaid expenditures (more than $131 billion total spent). These services are provided to a diverse group with different treatment needs. The MACPAC stated that it will continue to focus on the specific needs of each of these groups to shed light on the policies and interventions that could help improve care and contain costs. Given the substantial spending on psychotropic medications, the MACPAC will also continue to explore issues related to whether such drugs are being prescribed appropriately.