At Yale, academics and politicians unite to improve the state's Medicaid program

Recently, Connecticut Medicaid administrators visited the Yales Tobin Center for Economic Policy for a brainstorming session.

In conversation with social scientists from across the Yales campus and beyond, they examined how the latest evidence-based research could strengthen the state’s public health system and improve health outcomes for the approximately 1 million Connecticut residents who rely on on it.

Specifically, they explored the potential to enhance and improve the Medicaid program through randomized controlled trials (RCTs), which are prospective studies that measure the effectiveness of policy interventions.

The meeting marked the beginning of a unique partnership between the State of Connecticut, the Tobin Center and MIT’s Abdul Latif Jameel Poverty Action Lab (J-PAL) that aims to leverage evidence-based scientific research to improve the public health system.

Part of our mission is to work with people at other universities and state agencies to try to do something right, said Zack Cooper, Tobin Centers associate faculty director, at the beginning of the brainstorming session. The plan today is to bring together a group of researchers with J-PAL North America, which is phenomenal at implementing RCTs, and state policy makers to allow everyone to tease ideas and shift the conversation away from what would be interesting if to launch some projects.

Collaboration like this is at the heart of the Tobin Centers’ mission, said Cooper, an associate professor of health policy at the Yale School of Public Health and of economics at the Yales Faculty of Arts and Sciences. That mission, he says, is to facilitate rigorous, policy-relevant social science research that improves people’s lives and engage with policymakers in a way that reduces time between studies and real-world impact.

During a visit to the Tobin Center earlier this spring, Connecticut Governor Ned Lamont agreed to a series of policy partnerships between Yale and the state. Among other efforts, the Tobin Center has incorporated a data scientist into the Medicaid program to help inform research and identify areas of need. He also aligned the Governors Fellowship Program, a Yale-backed initiative that connects a diverse set of talented early-career professionals with top state leaders to address pressing policy issues with the state’s Medicaid priorities.

The use of randomized controlled trials, which researchers use to rigorously evaluate the impact of policy interventions, is a key component of the new partnership. Random sorting of a population into two groups one receiving an intervention and one which does not guarantee that at the start of the study the groups will be on average the same. Thus, any differences in outcomes between groups at study completion can be attributed to the intervention rather than to other causes.

RCTs are the best method available for assessing whether policy interventions are achieving their intended goals, Cooper said.

Gui Woolston, a Stanford-trained economist who heads the Connecticut Medicaid program, expressed optimism about working with scholars at Yale and elsewhere to implement RCTs and improve public policy.

This is an incredible opportunity for the partnership to lead evidence-based policymaking, Cooper said. It is extremely rare for the director of a state Medicaid program to have a Ph.D. in economics and is interested in randomized trials.

There is a lot we can accomplish

The brainstorming session included eight Yale faculty members representing the School of Public Health, the School of Management and the Department of Economics, as well as researchers from Boston University, Harvard Medical School and the University of Wisconsin-Madison. Also in attendance were representatives from J-PAL North America, an organization based at the Massachusetts Institute of Technology with extensive experience implementing randomized evaluations of policy interventions around the world.

Early in the discussion, Woolston established three criteria for potential policy interventions: any proposed action, he said, must be important, budget-neutral, and feasible.

Within those three brackets, I think we can accomplish a lot, Woolston said.

In Connecticut, Medicaid and the Children’s Health Insurance Program (CHIP) are combined into HUSKY Health, the state’s public health coverage program. With an annual budget of $9.2 billion, HUSKY Health provides coverage to more than 1 in 4, or 30 percent, of Connecticut’s 3.5 million residents, including 1 in 6 adults, 1 in 3 children, 4 out of 10 births and 2 out of 3 nurses live at home, according to state data.

One of the nontraditional health care programs the group discussed was a proposed intervention that would help people eat healthier. Medicaid programs in other states have implemented similar initiatives that provide members with nutrition counseling and education, tailor meals to their medical needs, and produce prescriptions for access to fresh fruits and vegetables.

Yale has created a dataset that links information about state Medicaid beneficiaries and residents enrolled in the federal Supplemental Nutrition Assistance (SNAP) program, said Chima Ndumele, associate professor of public health (health policies) at the Yale School of public health.

We already have substantial data on the overlap between these two programs, Ndumele said. Infrastructure is in place to support RCTs in this area, which is ripe for study and could be a catalyst for interventions that improve nutrition and long-term health outcomes for individuals and families in our state.

Participants also contemplated interventions to help people incarcerated in state prisons enroll in Medicaid within 90 days of their release, which could allow them to have a primary care provider, behavioral health doctor, and drug coverage from prescription once released.

Medicaid administrators were eager to gauge how well their public awareness campaigns were influencing people’s behavior. They expressed a need to better understand which message types and delivery methods are most effective in motivating people to schedule medical appointments and engage in preventative care, including dental checkups and flu shots. Helping people access dental care is especially challenging, they said, noting that 70 percent of adult Medicaid recipients did not visit a dentist in 2022.

The researchers suggested potential outreach interventions aimed at helping members with appointment scheduling, reminders, and transportation.

In a conversation about long-term care, experts discussed interventions designed to give Medicaid recipients more autonomy over the type of long-term services and support they receive. A key focus of such initiatives, the trustees said, is to help those who want to live at home (as opposed to moving to a nursing home) do so, which would reduce costs. The state Medicaid program pays about 70 percent of nursing home residents, for a total of $1.12 billion in spending in 2020.

Researchers have suggested interventions to help people plan for their long-term care before they need it, so choices are made before their health conditions become urgent.

Hopefully you all have a better idea of ​​our priorities and resource constraints, Woolston said at the end of the session. I hope that in the coming days we can move forward with a subset of these ideas.

Participants agreed to follow up with each other on research ideas.

This isn’t the last of those conversations, Cooper said. Hopefully this created some connective tissue.

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