In the United States, it’s not the federal government but states that lead the fight against covid-19. That’s not just because the Trump administration hasn’t taken the lead. The U.S. government has no real public health-care system and can act only by coordinating with public health systems in all 50 states.
As a result, Americans depend on the safety net programs — especially Medicaid — that support many of the agencies, working groups and experts that states need to fight the virus. Some states have used Medicaid to build up a vigorous public health system; others have used it just to insure the minimum number of people possible, delegating daily administration of that insurance to a private business. Each state’s public health response to covid-19 may be only as good as its Medicaid program.
I research how states implement federal policies like Medicaid. That includes analyzing national trends in expenditures, and I have interviewed officials or reviewed agency documents in three states — Rhode Island, New Hampshire and Kansas — to determine what Medicaid agencies look like on the ground.
A nation of 50 public health-care systems
The U.S.’s social welfare benefits are administered not by federal agencies but by intermediaries such as private hospitals, insurance companies, nonprofit groups, states and local governments.
As a result, many federal agencies advise rather than implement policy. The Centers for Disease Control and Prevention (CDC) employs just 10,000 people. It can issue directives. But unless the states send it good data, the CDC is flying blind. And CDC directives are only as effective as the state agencies that implement them — or not.
Contrast that with Britain’s National Health Service (NHS), which employs 1.5 million people, including epidemiologists, administrators who control medical equipment, and district nurses and support workers who can conduct community-based surveillance that identifies the spread of the virus before people seek medical treatment.
That’s why governors are making independent decisions about social distancing measures, coronavirus testing and how to deploy scarce resources. Each governor relies on the advice of an alphabet soup of state health agencies. And each one’s capacities depend on how the state structures its Medicaid program.
State Medicaid programs differ dramatically
The federal Medicaid program helps states insure their residents by partially reimbursing them for any eligible expenses. But Medicaid programs vary widely, because states can file waivers asking to redefine what count as Medicaid-eligible expenditures.
Medicaid programs vary in part because of the Affordable Care Act (ACA), which mandated that states extend Medicaid coverage to low-income adults. Some states refused to do so and went to court; the Supreme Court struck down the mandate in National Federation of Independent Business v. Sebelius. The 14 states that refused to expand Medicaid now include a majority of the nation’s uninsured population.
Many states, including some that did take the ACA’s Medicaid expansion, also use waivers to narrow who is eligible for benefits, make it harder for residents to enroll or drop coverage for recipients who cannot prove that they are seeking work. By contrast, other states use waivers to further expand eligibility. And they work with community groups to find and enroll the uninsured, using Spanish and other non-English media to let people know they’re eligible. They send staff into hospitals to enroll newborns and their parents.
What services each state covers varies widely as well. Some states maintain “thin” programs that cover little outside of services provided by medical professionals. Elsewhere, Medicaid pays for social services that fall outside traditional definitions of health care, including such things as mental health care, substance abuse or financial literacy counseling; affordable housing supports; transportation services to and from health-care facilities; public health campaigns and educational programs; remediation of lead and other environmental hazards; community health centers and workers who help vulnerable populations navigate the health-care system.
And, finally, states differ in how they administer Medicaid. Some states use Medicaid dollars to upgrade their own information technology systems and administrative capacity, administering the program directly or in consultation with publicly owned or nonprofit managed care organizations. Other states outsource, using Medicaid dollars to buy recipients private insurance or to pay for-profit managed care companies to administer their program.
Those differences shape whether Medicaid can help states fight covid-19 — or not.
So which kinds of states are better positioned to control the spread of the coronavirus?
First, states whose residents are mostly insured and used to dealing with the health-care system — which makes them more willing to respond to public health directives and more likely to seek care when they have symptoms.
Second, states with health agencies that can act to stop the virus’s spread among groups that don’t see public health campaigns or can’t comply if they do. In California, for instance, officials likely kept the outbreak from getting worse by moving some of the unhoused population to motels and hotels — keeping them off the streets, away from crowded encampments, and less likely to get or transmit the virus.
Such proactive steps will be easier where agency officials have knowledge of vulnerable populations, close relationships with community groups and policymakers’ ears.
In Rhode Island, for example, Medicaid either helps fund or is linked to a web of social services. State agencies meet regularly with advocates for various underprivileged populations, working to reduce costly medical interventions like hospitalization or nursing home care. For instance, Medicaid connects seniors who live alone to community centers, supportive housing programs, and mental health services, preventing cascading health issues and allowing seniors to age in place. Through these and similar services, the state’s agencies are already connected to populations vulnerable to covid-19.
All that will be harder where Medicaid programs are less developed. Under Gov. Sam Brownback (R), for example, Kansas spent much of the 2010s trying to “privatize” Medicaid. The state cut agency budgets and staff, turned program administration over to insurance companies and soured relations with social service providers by threatening to defund those that advocated for beneficiaries.
In the covid-19 pandemic, everyone’s health depends on the well-being of society’s least privileged. Even the well-off cannot isolate themselves entirely; they depend on the labor of those who cannot afford to do so. And everyone’s well-being depends on the states’ public health response, which may be only as good as their Medicaid programs.
Josh Pacewicz is an associate professor of sociology and urban studies at Brown University.