PROVIDENCE – A large health iceberg has been sighted. The icy peak is fully visible – not just here in Rhode Island but across the United States. The question is: Can a major collision be avoided in the turbulent waters of health care delivery?

Beginning on April 1, the federal government is requiring that all states must begin to recertify the eligibility all residents who are now receiving health insurance through Medicaid.

The annual culling exercise around Medicaid eligibility, which is based upon low-income guidelines, had been placed on hiatus for three years, ever since the COVID 19 pandemic swept the nation beginning in March of 2020. In response, the state of Rhode Island is launching a yearlong process to recertify more than one-third of the entire population of the state who rely on Medicaid for their health insurance coverage.

In what one prominent health leader called a “dog-and-pony show” – a performance put on for the benefit of news media coverage, with Gov. Dan McKee leading the cheers, the state announced the launch of its “Stay Covered” campaign at a news conference held on Thursday morning, March 16.

It was an all-hands-on-deck performance, as many of the government agency directors were featured speakers at the news conference – including Acting Director Kimberly Merolla-Brito of the R.I. Department of Human Services, Director Lindsay Lang of Health SourceRI, and Medicaid Program Director Kristin Sousa. Each detailed their respective roles in a comprehensive outreach program to contact all of the Rhode Islanders currently receiving Medicaid –as well as plans to enroll all those who were no longer eligible for Medicaid in health plans offered by HealthSource RI on the exchange, with promises to pay premiums for the first two months to ease the transition.

“We will be taking many of the lessons we learned from COVID 19 when it comes to outreach, communication, partnerships with the community, and meeting people where they live,” Gov. McKee said, speaking in a halting manner, sometimes stumbling over the scripted words. “You can find all of our resources on our new website, StayCovered.RI.gov.”

[Editor’s Note: The larger, as yet unanswered question is: What did the state actually learn about the need to invest in the delivery of primary care, rather than in paying millions to deploy private consulting firms, such as Boston Consulting Group?]

The backdrop for the show-and-tell was the new Providence Community Health Centers facility at 31 Atwood St. in Olneyville, which opened its doors just last year, built on the former site of a Boys & Girls Club.

Lori Whittemore, the director of Patient Access Services at Providence Community Health Centers, who introduced Gov. McKee, said: “Our state’s largest health center network, Providence Community Health Centers, provides care to approximately 85,000 Rhode Islanders. Almost 60,000 of those rely on Medicaid insurance products for their families. Our patients generally live in areas that are underserved when it comes to access to care. If they lose their insurance, they risk [missing] out of primary preventative and specialty care that keeps them healthy.”

“People with Medicaid often have very complex lives,” said Dr. Andrew Saal, chief medical officer at Providence Community Health Centers. “Whether it’s a family with small children or an elder who lives alone, people need to watch for these letters and take action to stay enrolled.” Saal urged everyone to “do your part to help spread the message” to help make Rhode Island a healthier community for everyone.

One-third of all Rhode Islanders
By the numbers, there are currently about 365,000 Rhode Islanders on Medicaid, more than one-third of all the state’s 1.1 million residents, according to state officials. That is an increase of nearly 20,000 Medicaid members in the last year – growing from 347,977 Medicaid members recorded as of March 31, 2022.

Translated, the size of the state’s middle class continues to shrink, as more and more Rhode Islanders are struggling economically. Further, the re-certification of Medicaid members in Rhode Island could be seen as a massive economic development program, given the fact that the Medicaid budget represents more than a third of the entire state budget.

The number of current Medicaid recipients who would be found to be ineligible to continue as Medicaid members was estimated to be between 25,000 and 30,000 Rhode Islanders, in response to a reporter’s question – but the actual number may prove to much higher than that.

The message delivered by Gov. Dan McKee and his heath and human services agency directors was “stay covered” – which was indeed the name of the new website created, staycovered.ri.gov.

Rhode Island Health Center Association President and CEO Elena Nicolella also spoke, saying that community health centers would always treat patients, regardless of their insurance coverage or their ability to pay.

“At one of the very first meetings that I attended on this effort, the state sent a very clear message: that their primary goal in doing this was to ensure that as many people as possible maintained insurance coverage,” Nicolella said. “The significance of that message was not lost on me. It means that the state is not interested in clearing the Medicaid roles; the state is interested in keeping our uninsured rate as low as possible.” Not every state, she continued, is pursuing that approach.

[Editor's Note: The question raised by Attorney General Peter Neronha in a recent interview with ConvergenceRI, seemed relevant: "It's all well and good to be insured, but if you can't find a doctor, what good is it to have insurance?]

In addition, Brenda Taylor, a dually eligible Medicare and Medicaid patient, who described herself as a mother, a grandmother, and a great grandmother, spoke about the importance that health insurance had made in her life and lives of her family, including her being able to receive treatment for breast cancer that had been recently diagnosed.

Tame questions?
The news media was, for the most part, quiescent if not tame in its questioning at the press conference, it seemed.

No one inquired about the 2024 budget question: How much will the General Assembly raise Medicaid rates for providers? The opening salvo being pushed in new legislation is $200 million. [See link below to ConvergenceRI story, “As the world turns for Medicaid budget.”]

Will the General Assembly or the McKee administration have the gumption to conduct a rigorous audit of the Managed Care Organizations – currently UnitedHealthcare, Neighborhood Health Plan of RI, and Tufts Health Plan – before a new contract procurement RFP is issued, a contract said to be worth $7 billion over five years?

Staffing needs
There were also no questions asked about the additional staffing needs for the agencies involved in the “Stay Covered” campaign.

Following the news conference, ConvergenceRi reached out to Department of Human Services Acting Director Merolla-Brito to ask about staffing needs at her agency. James Beardsworth, chief public affairs officer at DHS, sent the following responses.

ConvergenceRI: Do you at DHS currently have all the staffing and resources that you need to manage your part in this process? Are any additional resources been given to you?
BEARDSWORTH: We are currently staffed to provide the necessary support for the Medicaid recertification. However, given the scope of the work ahead, DHS has the flexibility to retain up to 48 additional staff for the duration of this effort and is in the process of retaining these resources.

ConvergenceRI: How does the flow of information between you and HealthSource RI work?
BEARDSWORTH: DHS and HSRI share an eligibility system and work very closely together to ensure the exchange of information, data, and benefits eligibility to maintain the network of support both agencies provide.

As discussed in our press conference Thursday, as we go through the recertification process, including the scheduled notifications outlined, individuals who ultimately receive a Decision Benefits Notice from DHS that they are no longer eligible for Medicaid, will be informed in the same notice about eligibility for HSRI coverage and both federal and state financial assistance available to them.

DHS and HSRI also collectively work to provide online services via the HealthyRhode Mobile App and the Customer Portal [healthyrhode.ri.gov] for beneficiaries.

ConvergenceRI: What role, if any, is Deloitte playing in the integration of data for Medicaid members?
BEARDSWORTH: Deloitte supports DHS in the management of the data associated with the Medicaid recertification. As you can imagine, with approximately 350,000 individuals currently covered, the sheer volume of data is extremely large. Deloitte provides important resources that enable DHS to actively service, communicate with, and manage benefits for nearly a third of Rhode Islanders.

Accountable entities
Another topic not addressed at the “Stay Covered” news conference was the ongoing progress in efforts to develop accountable entities to foster better population health management in Rhode Island.

In a separate, unrelated development, Care New England and its Integra Community Care Network announced a new initiative targeting health equity issues in the communities it serves.

“The Integra Social Partnerships Initiative for Community Engagement & Equity (I-SPICEE) will support the planning, piloting, and evaluation of community-based projects that help ensure all Rhode Islanders have a fair and just opportunity to be healthy,” according to the news release.

ConvergenceRI was curious how the work in developing the Integra’s network might be affected in the context of the state’s effort to recertify Medicaid eligibility beginning April 1. Matthew Harvey, Senior Director of Government Programs at Care New England, responded to the questions below.

ConvergenceRI: How many clients/Medicaid patients are members of the Integra Accountable Entity? How is that projected to change with recertification? The figure given in the news release is more than 150,000 members, which would be nearly half of the current 350,000 state residents who are Medicaid members.
HARVEY: Integra’s Accountable Entity includes slightly more than 50,000 members, making us the second-largest AE in the state. The 150,000 figure refers to all of Integra’s members, not just the AE, including those insured through Medicaid, Medicare, and commercial health plans.

ConvergenceRI: How will the new equity investments announced today factor into the coming shift in Medicaid members? Given the decision by the Governor to disband the equity council established during COVID, how will this focus on health equity issues deal with continuing problems related to COVID?
HARVEY: We are very concerned about the possibility of many of our members losing eligibility as Medicaid renewals are restarted, and about the potential of these eligibility changes to exacerbate health disparities. We strongly encourage potential partners to look closely at the ways in which COVID exacerbated inequalities in health outcomes.

ConvergenceRI: How are you defining “community engagement” as part of this effort?
HARVEY: For the purposes of this program, “community engagement” means collaborating with organizations and people impacted by health equity issues to share knowledge, plan strategy, and take action to improve health.

Integra needs to engage with the community in order to be effective in our programs, to be equitable in our approach, and to contribute to an ecosystem of conditions that drive health in Rhode Island. [This program] is an opportunity to deepen our community engagement and to make concrete changes together that advance health equity.

ConvergenceRI: How will these investments focus on the ongoing unmet needs for behavioral health care?
HARVEY: We’ve designed I-SPICEE to be a process by which we learn from our community stakeholders what issues are most important to them, and use that information to decide how to most effectively invest in our programs and communities. As a result, we do not have preconceived notions about where these investments will focus.

That said, we are intensely focused on the behavioral health needs of our members, and on the extent to which health equity impacts access to needed services. We hope to see project proposals that focus on this area.

ConvergenceRI: How does the current effort to increase Medicaid rates factor into this work?
HARVEY: Because this set of investments is targeted at community-based organizations, rather than health care providers, it is not directly impacted by changes in Medicaid rates.