Can virtual health trigger a more equitable Medicaid climate?

By David Betts, principal, Public Health Transformation, Deloitte Consulting LLP

Over the holidays, I took part in the experience of a lifetime…a National Geographic expedition cruise to Antarctica! We didn’t encounter many people, but we did see lots and lots of penguins. I learned there are seven species native to Antarctica. These flightless birds exist in the harshest environment on the planet. In the water, they are hunted by killer whales and leopard seals.¹ On land, they face ever-changing living conditions, an uncertain food supply, and a shifting landscape that appears impossible to navigate.

I was recently describing the trip to my colleague (and penguin enthusiast) Alison Muckle Egizi, health policy research lead at the Deloitte Center for Government Insights. We started to see some strong parallels between what I experienced in Antarctica and the harsh conditions and stress that many people in the US endure every day. Financial insecurity, unstable housing conditions, exposure to violence, polluted air and water, unpredictable access to healthy food, and other drivers of health can be detrimental to both physical and mental health (see Addressing the drivers of health). And when health needs arise, Medicaid enrollees sometimes must traverse a health care landscape that can seem impossible to navigate. Our latest research explores how virtual health within a value-based care (VBC) framework could help make high-quality care more accessible and equitable for all Medicaid enrollees (see Leveraging virtual health within a VBC framework).

About 83.9 million people across the United States are covered by Medicaid—roughly 25% of the population.² States and Medicaid managed care plans are well positioned to help enrollees navigate the health care system and use technology and alternative sites of care to improve access (see Advancing health through alternative sites of care). VBC models are becoming more common among commercial health plans and large, self-insured employers. (see Aligning on value-based care). In addition, several states have adopted VBC models for their Medicaid programs.

Four barriers that can contribute to health inequities

Uncertain and limited access to resources, combined with impaired decision-making, can lead to poor health outcomes—for both penguins and people. Here is a look at some of the barriers that can contribute to health inequities among Medicaid enrollees and how virtual health and a VBC model could address some of those challenges:

• Rural environments: You could say that Antarctica is the most rural of all rural environments in the world. But one thing I did not see during my visit was a penguin entirely by itself. Penguins, like humans, are social creatures and typically spend their lives as part of a colony. Nearly a quarter of individuals under age 65 who live in rural areas are covered by Medicaid.³ Overall, rural residents in the United States tend to be older, poorer, sicker and have worse health outcomes than those who live in urban areas.⁴ However, people who live in rural communities often have a strong sense of community. Community engagement and support networks can encourage people to take an active role in their own health.⁵ A Medicaid-first VBC model relies on a symbiotic relationship between the community, the Medicaid program, and the health system. Embedding communal support (such as community health workers) into the health care ecosystem, and connecting people to adequate resources, can be important for the success of a Medicaid program. 
• Transportation: Emperor penguins might walk more than 70 miles—over ice floes and other obstacles—to reach their breeding grounds.⁶ Medicaid enrollees, particularly those who live in rural environments and medically underserved communities, might have to travel long distances to access care. This might be due to a limited number of providers, particularly specialists, who tend to practice in urban/academic settings. Virtual health tools (e.g., audio, phone, remote patient monitoring, chat, and app-based self-management tools) could help improve access to specialists and other providers, which could help make care more equitable. However, rural communities might lag when it comes to broadband access. And while virtual tools have the potential to improve access and equity, there have been concerns that they could exacerbate disparities, particularly if local in-person options are reduced due to the availability of virtual health.⁷ A majority of surveyed Medicaid enrollees (74%) said they would consider a virtual mental health visit, according to the results of Deloitte’s 2022 survey of health care consumers. By contrast, 71% of privately insured consumers surveyed, and just 49% of Medicare recipients, said they would consider a virtual mental health visit (see Tapping virtual health’s potential).
• Trust: A waddle of penguins (yes, that’s actually the term for a group of penguins on land) often huddles closely together on the edge of an ice floe. Once one of them falls in, they all take the plunge. They trust their neighbors that the water is safe. Individuals who trust the health care system are more likely to seek care when needed and follow a clinician’s advice (see Redefining how care is delivered). Trust is also important when establishing virtual health tools to support Medicaid enrollees. People who have limited experience with technology might not trust the privacy, security, and quality of virtual health tools. Building trust in the providers behind the technology, as well as the technology itself, could help support success. One mechanism for building trust is to actively engage Medicaid enrollees in the co-design of solutions. Using this human-centered, person-first approach can help create buy-in. It can also build confidence that the systems are actively engaging for the common good.
• Access to healthy food: Global warming is causing sea ice to melt more quickly in Antarctica, which is having a negative impact on algae, krill, and fish that penguins need to survive.⁸ The US Fish and Wildlife Service recently placed the emperor penguin on the endangered species list.⁹ A growing number of states have introduced food-as-medicine initiatives in response to the White House Conference on Hunger, Health, and Nutrition (see Fresh food as medicine for the heartburn of high prices). The administration is working with Congress to pilot coverage of medically tailored meals in Medicare and testing Medicaid coverage of nutrition education, and other nutrition supports using Medicaid section 1115 demonstration projects. The White House has also advocated updated nutrition criteria for the “healthy” claim on food packages and an expansion of incentives for fruits and vegetables available through the Supplemental Nutrition Assistance Program (SNAP).¹⁰

A penguin’s health is closely tied to its environment just as the drivers of health influence the well-being of Medicaid enrollees. Penguins demonstrate that even in conditions of extreme unpredictability and scarcity, they can overcome seemingly insurmountable obstacles and survive…maybe even thrive. Virtual health within a VBC framework could help make high-quality health care more accessible and equitable for Medicaid enrollees. Providing enrollees with virtual tools that meet their needs—and helping them stay more connected to community-support networks—could help them to take a more active role in their health and stay connected to health care providers.

Acknowledgements: Alison Muckle Egizi, Leslie Korenda, James Howgate

Endnotes:

¹ Penguins – Australian Antarctic Program

² September 2022 Medicaid enrollment data, Medicaid.gov, September 2022

³ Medicaid and Rural Health, The Medicaid and CHIP Payment and Access Commission (MACPAC), April 2021

⁴ About Rural Health, Centers for Disease Control and Prevention, August 2, 2017

⁵ Health in Rural America, National Institutes of Health, March 2022

⁶ Emperor Penguins in Antarctica, coolantarctica.com

⁷ An evaluation of telehealth use by Medicare beneficiaries, Institute for Healthcare Policy & Innovation, University of Michigan

⁸ Scientists Report a Dramatic Drop in the Extent of Antarctic Sea Ice, Inside Climate News, January 6, 2023

⁹ Emperor Penguin Gets Endangered Species Act Protections, US Fish & Wildlife Services, October 25, 2022

¹⁰ FACT SHEET: The Biden-Harris Administration Announces More Than $8 Billion in White House Conference on Hunger, Nutrition, and Health, September 28, 2022

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