Kate McEvoy: How Medicaid Is Driving Healthcare Innovation

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We are physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome Kate McEvoy to the podcast today. But first, we like to check in on current or hot topics in health and healthcare. Usually, Harlan gives me some preparatory information about this, but today he told me he’s going to truly surprise me. So here I am, waiting for the surprise.

Harlan Krumholz: Well, look, Howie, we talk about health here. It’s called Health & Veritas. That’s the topic here. We’re often talking about things that have to do with politics. Of course, healthcare is very tied in with policy, and I feel like we try to be fair. We recognize that there are different points of view to things. We have our own points of view, but we try to be respectful of other points of view.

There’s some times though where actually I don’t think there are two sides to this. I want to tell you, Howie, I woke up this morning and I saw the Wall Street Journal poll. Look, Biden’s losing in the states that matter in the U.S., and we’re on the precipice of an election that could put someone into office who denies the fact that he lost the last election. You and I have decided on this podcast that we really don’t want to make this a political podcast. This is about healthcare. But you know, health is tightly tied to the kind of government that you have.

Let me just say, this isn’t about differences of opinion about how we should do something in healthcare or whether or not you like Viktor Orbán, the dictator in Hungary. Or whether or not you’re a Putin apologist. I mean, let’s just say we may feel strongly about whether that’s right for America, but we also may recognize that other people may feel differently about that. That’s not what it’s about. When we’re talking about health—and this is why I’m bringing it into the politics—facts matter. There are facts that are indisputable, and we now have a situation where someone’s running for president who denies certain facts. I mean, that have been adjudicated in the courts, that have been seen by so many different angles. At some point, we just have to move on from it, and I’m concerned.

The other reason I’m concerned, and I’m just saying this as an alert for people who are listening, because I also have been just watching—you’re very much more involved than I am in talking about these things. But there was a new book out by the historian Timothy Ryback. I don’t know if you’ve...

Howard Forman: I heard about it. I haven’t read it.

Harlan Krumholz: Takeover: Hitler’s Final Rise to Power. Now people may think, “Oh, God, you’re invoking Hitler. How can you do that?” There was an article by Adam Gopnik in The New Yorker, which sort of does a review of this book, and it’s a very interesting analysis of what Ryback explains to how this happened. And I just want to read two parts from this article that I found chilling. It talks about the 1930s and it says, “The Germans were voting, in the absent-minded ways of democratic voters everywhere, for easy reassurances, for stability, with classes siding against their historic enemies. They weren’t wild-eyed nationalists voting for a millennial authoritarian regime that would rule forever and restore Germany to glory, and, certainly, they weren’t voting for an apocalyptic nightmare that would leave tens of millions of people dead and the cities of Germany destroyed. They were voting for specific programs that they thought would benefit them, and for a year’s insurance against the people they feared.”

But the point was that on the cusp of that election, the election that ended up bringing Hitler power.... By the way, he didn’t win a majority—he was named chancellor by Hindenburg because of political machinations that are well—I think—described in this book. But the world changed as a result of people not, I think, paying close enough attention to what was happening. There’s another quote from Goebbels, the propaganda master for the Nazis, who said, “The big joke on democracy is that it gives its mortal enemies the tools to its own destruction.” Gopnik in this article says, that sounds apocryphal, but it was a true quote.

I only say that I think we as Americans need to pay attention and that the stakes are extremely high. Again, I’m not arguing about differences in policy, but when there’s a difference in what reality is, when in fact there’s a clarity around what that reality is, I think we’re in trouble. Just like in healthcare when misinformation rules and people can’t agree on simple facts that are clear and crisp and indisputable. Now I’m not saying there’s not a lot of gray areas in medicine, in health, just like there’s a lot of gray areas in policy, but this is one that’s not. So I had to take this time to at least express the concern.

Howard Forman: No, I think it’s good that you bring it up. We have purposely avoided a lot of things that are just inherently political, even as we talk about very direct healthcare things like abortion and in vitro fertilization, which have political parts to them.

But I am concerned as you are about this. I would just say I remain a little more optimistic at this moment that we have seven more months and a lot can change. But I do think we will come back to this on the podcast, not so much specifically about the candidate but about what the candidate’s populism and platform mean for healthcare. Because it’s not just about women’s reproductive rights and health, and it’s not just about expansion of healthcare coverage and holding costs down. It’s not just about thinking about underresourced populations and how do we make sure that they receive health so that we don’t have further problems. It’s not just about vaccination rates and whether people may shun or adopt vaccinations earlier or later than they should.

So I agree with you. I’m worried about it, and I’m happy that you brought it up.

Harlan Krumholz: Thank you. Thank you. Anyway, I just wanted to get a chance to say, facts matter and when we have people in these positions who dispute facts, we have a problem. All right, I don’t mean to start on such a somber note, I just felt the need—

Howard Forman: That’s good. Yeah.

Harlan Krumholz: …to bring it out. Let’s go to our guest, and we have a great guest today, Kate McEvoy. Let’s go.

Howard Forman: Kate McEvoy is the executive director of the National Association of Medicaid Directors, which advocates for the needs of state Medicaid programs at the federal level. Prior to this position, she worked at the Connecticut Department of Social Services for almost a decade, running our HUSKY and Medicaid and CHIP programs and during the key years of the Affordable Care Act, or Obamacare, implementation, including major systemic transformation. In this position, she administered a budget of $7.3 billion and oversaw a staff of 145 individuals serving over 850,000 Connecticut beneficiaries. She has also worked at the Milbank Memorial Fund and the Connecticut Association of Area Agencies on Aging. She holds a bachelor’s degree in English and economics from Oberlin College and received her JD degree from the University of Connecticut School of Law.

So first of all, I want to welcome you to the podcast. We’re very excited to have you. About a year ago, Harlan and I started spending a lot of time explaining to individuals about Medicaid disenrollment and why they should care and what’s going on. I want to get into a little bit of the weeds of Medicaid, but I thought maybe you could just start off using that as a starting point to explain why Medicaid is so important to our country and what is going on with disenrollment now.

Kate McEvoy: Absolutely. It’s such a pleasure to join both of you. Thanks for the invitation. So I do want to say this is a watershed year for the Medicaid program, bridging, as you said, from a very intense period of activity during the pandemic, during which Medicaid directors all across the country and in the territories were very much focused on continuing to enable access for everyone served by the program through adoption of telehealth, flexibilities of kind of site and care teams, adopting the diverse strategies that enabled states to respond to COVID-19 vaccination and testing and the like.

But the emergence from that period is equally important. It’s a bridging year for the program really to evaluate the learning during the pandemic, a very intense but also generative time learning about what we can do to help smooth eligibility pathways to keep people covered, to continue to preserve and promote access to primary, medical, and behavioral health services.

One of the marquee areas of focus, as you said, is the obligation for all states to resume historically typical eligibility processes. During the pandemic, we protected everyone who became eligible for the program by a continuous coverage requirement that was mandated by Congress. All states, during this intense year, have had to conduct eligibility redeterminations for each and every person on the Medicaid program nationwide. That’s a historically unprecedented volume and scope of work, and it has been a very challenging process. It’s also involved innumerable partners who have contributed to the outreach and engagement, and I think there’s a lot of learning from it that is going to promote better eligibility practices ongoing.

Harlan Krumholz: Kate, people hear about Medicaid all the time. We talk about it a lot on this program. I still don’t think most people have a full appreciation for its impact in this country. I mean, it’s almost like a shadow federal healthcare insurance program in the sense that because of being administered by the states, lots of people hear about Medicare all the time. You’ve been in a leadership position for a long time.

Let me just say a few things. As I understand it, four in 10 births nationwide are to women served by Medicaid. Forty percent of all the births in the country. About maybe 35 million children are covered. I mean in Connecticut alone, a quarter of the state or more—I mean, what is it? You would know better than I—is actually receiving their coverage from Medicaid. It’s important for people struggling with addiction; it’s important for low-wage workers.

This is something I think not talked about enough because of its major impact. Can you give people listening, just give us your view on how important is this program? How big is this program, how much should we be paying attention to it because it really is a thing that’s holding together for so many families, the ability to access care?

Kate McEvoy: I can’t tell you how much I appreciate you starting in this vein. Medicaid, as you know, was enacted in 1965, and it is the fulcrum point of healthcare coverage for almost a quarter of our fellow Americans.

As you said, it is a launching point for moms and babies. That one in four figure belies the fact that in many parts of the country, especially in cities, it’s more like seven in eight women who are covered by the program. So it is an incredible fulcrum point for maternal healthcare, for launching children in developmentally appropriate stages, school readiness. So that whole piece around mothers and families and children, that piece of getting kids ready to be good students. It’s also a major engine for improving people’s economic security. It’s a major support for working adults.

Finally and not least significant, it is kind of bucking people’s perception that Medicare is the primary payer. It is the primary payer of services for older adults and people with disabilities around community integration, giving them choice of setting and enabling people to be served at home, where they want to be. This really illustrates the age span that Medicaid serves, and as you said, nearly one in five Americans still remains covered, even as we’re kind of dialing back from that apex point of enrollment during the pandemic.

So it is critically important to so many folks and the touch Medicaid has is really now manifest in public polling data that shows that there’s broad bipartisan support for the program and that there’s much more public literacy about it than there used to be.

Howard Forman: There are 57 Medicaid programs or 58 Medicaid programs, right?

Kate McEvoy: Fifty-six, yes. Hard to narrow that down. Yes.

Harlan Krumholz: Just remind me, Kate, how do you get to 56 if every state—

Howard Forman: Fifty states, D.C., and then our territories, right?

Harlan Krumholz: Is that right?

Kate McEvoy: Yes.

Harlan Krumholz: Yeah. Okay.

Kate McEvoy: Absolutely. Yep.

Howard Forman: The thing is that they are all different. There is no identical Medicaid program out there. They’re all different. You went from having incredible expertise about the Medicaid program in Connecticut to all of a sudden having to be the sheep herder of 50—or the cat herder of 56 Medicaid programs.

Can you talk about how that has been both a learning process but also sort of fascinating for you about how you deal with all these different programs?

Kate McEvoy: Yeah, it’s a great question. First, I’ll say that although there are 56 distinct programs, federal law does establish a floor of protections for all Medicaid beneficiaries. So there are mandatory eligibility groups, there are mandatory parameters around covered benefits and also features around the structure of the funding, which undergird the program no matter where you are.

As you said, though, there is a lot of autonomy for states and territories to tailor the program in locally relevant ways. Some states have really built substantially on that floor protections. Others have more limited investment in the program. So there is a lot of variation. There’s also a lot of variation of the structural model for Medicaid. Some programs using capitated managed care, some self-insured, and then the innovation strategies, and I think that’s really among the most exciting work. So I mean that’s a very true-to-life observation of the range of experiences. For me, I had the good fortune of serving on the NAMD [National Association of Medicaid Directors] board of directors for many years.

Howard Forman: Oh, yes.

Kate McEvoy: While I was a sitting Medicaid director, and that gives you an incredible altitude to kind of examine the range of experiences across the country, kind of looking at the commonalities but also how this is locally applied, how ideology influences state application of the program, different theories of change. Because I think that’s a real phenomenon, but that’s really kind of the central vehicle where I was exposed in that respect and got a lot of opportunity to work directly with the federal agency that manages Medicaid, the Center for Medicare and Medicaid Services. That really kind of boosted my ability to get that bigger worldview.

Howard Forman: Just a quick question that I’ve heard you answer for me before, but I wanted the listeners to know. What is the average tenure of a Medicaid director and what do you learn from that?

Kate McEvoy: Yeah. The average tenure challengingly is only about a year and a half, ultimately, and a lot of factors influence that. Some Medicaid directors are political appointees, so when there are transitions of administration at the state level, there is typically a transition that accompanies a new governor coming in. Also, it’s an incredibly intense job, as you might imagine. I think a lot of trade winds of the various constituencies—obviously, notably, people served by the program, but policymakers, advocates, a lot of folks with an interest in the program, so it is something that we remain very concerned about how to increase that tenure and get more continuity.

With that said, there are senior civil service staff in state Medicaid programs who often have very long tenure. They’re really the kind of bulwark of managing the program, carrying forward innovation and giving, again, that longevity of the investment that often, even in the transition of directors, can kind of move that agenda forward.

Harlan Krumholz: I wanted to surface a question that Ines, our amazing Yale undergrad, surfaced to me because when we ask her to prepare bios for folks, she sometimes puts in questions. So Ines, on your behalf, I want to put forth this question because I thought it was such a good one.

She said, “In one of the question-and-answer sessions that you did, you said, ‘We recently held a session to support Medicaid staff that offered strategies around burnout but also illuminated the premise of moral injury.’ Of course, moral injury results from working environment that might be challenging from the point of consistency with one’s values and a moral compass.”

Ines has been interesting for us. She’s heard us talk about it before on the podcast. It is a central problem where people are in healthcare trying to do one thing, but the policies or structures around them are sort of putting them in a position to do something else. How do you think about this and what were some of the strategies you were thinking to help people to overcome their feelings about this but also to move forward but not asking them to sacrifice their values?

Kate McEvoy: Harlan, I’m so glad you’re touching on this. It was really an epiphany for us at NAMD to work with a consultant named Loree Keeley on this subject. We often heard, especially during the pandemic, about the need for self-care, kind of preserving reserves of energy and about the aspect of resilience, which—I think all of us are very taxed. Anyone who’s involved in direct provision of healthcare and healthcare policy, but this kind of more newly emerging strand around moral injury is very distinct, and it spoke in an incredibly emotional way, especially to folks who entered human services and specifically Medicaid leadership to a person with the goal of supporting people in the program.

I mean, there is absolute congruity across the country around Medicaid leadership. The premise for the program helping to boost access to care and also economic security for people. The reality is Medicaid is just one of any number of state budget priorities. Medicaid on the whole is about 29% of most state general fund budgets, so it’s a very significant amount of spending. Even as Medicaid programs have been very successful in controlling cost growth rates, there’s constant tensions about other needs, like for instance child care education and about that relative level of spending of precious state resources, especially as tax revenues have kind of plummeted this year, and federal pandemic assistance has kind of dried up, that we’ve seen that really sunset, so there’s a lot of tensions about how to invest, what level to invest. That can be extremely difficult for a director who can see a very clear relationship from an evidence base in terms of what and how to cover things, again with that counterpoint of the fiscal accountability and the realities of the political process and different, like I said, theories of social change across the country that may present challenges to directors in terms of what they can see would be beneficial to people.

Howard Forman: I’m curious to hear your views seeing now from your position about how much innovation is going on at the state level and how that is impacting patients, physicians, even hospitals. What is your view of innovation on Medicaid?

Kate McEvoy: My unequivocal view is that Medicaid is the seed of innovation in healthcare right now. It is probably less well known publicly than I would like it to be. This has burgeoned in recent years, even through the pandemic.

When I was the sitting Medicaid director, it was really a small vanguard set of states, the coastal states and a couple of states in the Southwest, that were leading the charge on use of these federal innovation waivers, these research and demonstration waivers that are enabled under federal law that have been used by Medicaid programs to kind of push the envelope on covering benefits and services that are not previously coverable under Medicaid state plans with the federal government. We’ve gone from about five or six leading light states now to have 54 states and one territory with those innovation waivers in the pipeline. So it has absolutely burgeoned across the country.

We have red and blue states, large and small, rural and urban, with lots of different health-related social needs waivers, lots of expansion of various benefit array and also value-based payment. This is something that is so exciting to see taking root and scaling in this way.

Howard Forman: Just one quick follow-up, Harlan, if I can. The healthy opportunities pilot project in North Carolina that Harlan and I spoke about probably a year, year and a half ago now, so we probably should do a follow-up. I’m curious to know your thoughts about how Medicaid is doing in using these pilots to attack social determinants of health.

Kate McEvoy: It’s a wonderful non-exclusive example of a comprehensive approach that looks to build in assessment of holistic needs, you know, nexus with housing supports and with food security, smoothing the continuity of coverage of the program and really connecting with other sources of federal assistance, kind of braiding not only Medicaid but other types of dollars. I think North Carolina’s done a phenomenal job of thinking of that in this very comprehensive way.

I will quickly say that there are numerous other states that are probably not as well known to most folks. Illinois is an example. Illinois is using its research and demonstration waiver in very similar ways, again, kind of tailored to the Illinois landscape but many of the same emphasis points on eliminating homelessness by using Medicaid as a kind of fulcrum point. So when I talk about 54 states having demonstrations either in the pipeline or already implemented, this is now scaling across the country in ways that are not just isolated incidences in a given state.

Harlan Krumholz: What a pleasure to have you on. So great to see you. Thank you for everything you do.

Howard Forman: Thank you.

Kate McEvoy: Reciprocally. Thank you very much.

Harlan Krumholz: Yeah, that was a great interview, Howie. I’m really glad we had her on today. Let’s get to your section.

Howard Forman: Yeah, so this is interesting. It’s obviously very different than your intro segment, so a little bit of science here. Glyoxylic acid, and for our listeners, please note this is not the same as glycolic acid, another chemical. But glyoxylic acid is a recent addition to certain hair-straightening regimens. It seems to be effective for this purpose. I personally wouldn’t know, but I’m told this is true. It’s also a naturally occurring chemical in humans, but at very, very low levels.

But when highly concentrated glyoxylic acid gets on your hair, it also gets on your scalp. Our skin or scalp is an amazing organ for absorption of chemicals, intentionally or unintentionally. So a group of authors, physicians in France this past month reported on an unusual experience of a Tunisian woman who went for hair-straightening treatments three consecutive times in June 2020, April ’21, and July ’22. In each of these three times, she then went to the hospital with signs and symptoms of acute kidney injury. It includes vomiting, fever, back pain, diarrhea, and her lab tests also showed kidney injury each time. Her kidneys did, thankfully, recover fully after each event.

The investigators then took this hypothesis and tested it in mice and showed that you could actually get the mice to also absorb the chemical. That they would form calcium oxalate stones, which is a certain type of renal stone, presumably from the way the mice and probably humans metabolize this chemical.

So why do I bring this up? Number one, this appears to be a pretty dangerous chemical. Even if it’s natural, it’s dangerous and it should be shunned. Anyone who’s listening to us should make sure they are not using a product with glyoxylic acid until we know more and full stop with that. If this is replicated or confirmed elsewhere, and I expect it will be, we can do without a hair-straightening product with such an adverse impact. That’s number one.

Number two, this is a fairly new use of a chemical, and one of the reasons why this came into use is because the FDA is on the cusp of banning the use of formaldehyde in hair-straightening products. Formaldehyde was used for this purpose, and about 12 years ago the FDA was able to make a determination that it’s carcinogenic. So they started to move toward banning it, and I think we’re on the cusp of that happening right now.

The FDA has authority here, and they should rapidly convene experts to suss this out in a reasonable amount of time. Formaldehyde, as I mentioned, has been on the market for 12 years after confirmation that it is a carcinogen. We owe the public to act faster than this in this type of situation.

Just to point out the power of association and good clinical judgment for our listeners, I don’t know, maybe the French clinicians didn’t even make the diagnosis. Maybe the patient did, but connections were made and this has the potential to save lives. The broad publication in The New England Journal of Medicine, where this came from, I think is also a really good thing because it gets the message out really quickly.

So our listeners may think, look, this is one case, full recovery. Why are you making such a big deal with it? There’s almost no doubt that this injures the kidney. It’s just a very small injury each time. But cumulatively over time, almost without a doubt, this could cause renal failure and the loss of kidney function.

Harlan Krumholz: Well, one of the challenges is balancing this idea of rapid response with really getting the evidence in and being able to be clear exactly what are the risks to people.

You raise another aspect of this, which is this someone who sort of had an acute reaction. But the question is, what’s the cumulative impact? If there’s small injuries over time, will this add up so that a decade from now, people who’ve been using this will all of a sudden start be having problems? Again, this sort of falls outside of drug approvals and even device approvals. It’s a consumer product. Do you have any recommendations for what the FDA should be doing to...

Howard Forman: So don’t forget, the FDA’s founding authority is the Food, Drug, and Cosmetic Act. They actually have authority over cosmetics. They don’t exercise that authority in a particularly aggressive way, but they have authority here.

I don’t know. I don’t know enough about the regulatory apparatus of the FDA to know how they can move more swiftly here. In a perfect world, I would love the FDA to quickly commission a randomized controlled trial where—

Harlan Krumholz: I just laugh because it’s hard to imagine. For hair spray?

Howard Forman: I mean, why not? It’s a hair-straightening device. There are people that get hair straightening all the time. This is clearly on the market right now. We have some evidence, but it’s very limited. You can imagine getting ethical approval for this.

So I don’t know the right answer. What I do know is if I knew anybody... I don’t think I have anybody in my family who have hair that gets straightened, but if I knew anybody in my family who went for hair straightening, I would be sending up big bright, red flags.

Harlan Krumholz: Warning signals.

Howard Forman: Yeah, right.

Harlan Krumholz: Yeah. I think this is, again, the aspiration is that we can put together large-scale data that still protects people’s privacy that gives us a line of sight into whether or not there are signals of harm that could come from a whole variety of things. When we see unexpected... it’s sort of like fraud alerts that occur with credit cards when there’s anomalies within healthcare that can start an epidemiologic unit trying to figure out, was there an exposure? Is there a new product that’s causing a problem? We need to be able to be better at this. I think it will be possible one day that we’ll be saying like, “Look, that wasn’t expected” and then trying to link that to something else. Maybe that there are many people who’ve been affected, but just no one thought to link it to the—

Howard Forman: Exactly. Exactly. So we underestimate how much harm may be occurring. A lot of people have renal failure, and we never understand why they get renal failure. Maybe it’s something as simple as this.

Harlan Krumholz: Maybe we can get smarter. Thanks, Howie. That’s a great topic. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how did we do? To give us your feedback or to keep the conversation going, email us at health.veritas@yale.edu or follow us on any social media, LinkedIn, Threads, or Twitter.

Harlan Krumholz: You should know we want to hear your feedback or questions or anything you’ve got on these topics. I did a little bit of a controversial topic in the beginning. I shared some information. I’m curious what people think, and of course, if you like the podcast or if you feel strongly about the podcast, rate us and review us in your favorite podcastapp. We always read them, and it helps others to find us.

Howard Forman: If you have questions about the MBA for Executives program at the Yale School of Management, reach out via email for more information or check out our website at som.yale.edu/EMBA.

Harlan Krumholz: Health & Veritas is produced with Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, two wonderful Yale undergraduates, and our producer, Miranda Shafer, a skilled producer. We appreciate it.

Howard Forman: Very thankful.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.