In this episode, Josh spoke with Nathan Chomilo, MD, Medical Director for the State of Minnesota’s Medicaid & MinnesotaCare programs. This is the first of two condensed parts of the conversation between Dr. Liao and Dr. Chomilo, and has been edited for clarity and length.
Joshua Liao: Can you tell us a little bit about your path and how you became the Medicaid Medical Director of Minnesota?
Nathan Chomilo: I often share that five years ago, I wasn’t planning on or aiming to become Medicaid Medical Director in Minnesota. It really was an opportunity that aligned with my broader goals of addressing structural racism and health equity in our health care systems. That stemmed from the roots of why I wanted to become a doctor, to not only serve patients in clinics and in hospitals, but also in community.
So early on in my career, I found ways to engage in community-based organizations. Prior to coming to Medicaid, I also was the medical director for a non-profit called Reach Out and Read in Minnesota which promotes early literacy and pediatric clinic’s well-child
Nathan Chomilo, MD
Minnesota Medicaid & MinnesotaCare
checks, and that really gave me an idea of both how to integrate addressing social drivers of health, as well as how to move an idea through systems. Because a lot of that role involved talking to not only to my colleagues in pediatrics, but also health care systems, payers, and other community organizations working in early childhood. So that really gave me some of the skills that I thought would translate well to the role of Medicaid Medical Director.
And as I evolved in my goals from addressing the social drivers of health to also addressing the racial equity aspects of health care, and addressing structural racism more head on, Medicaid really is one of the key places to do that, given the populations that Medicaid serves. And the fact that in our capitalistic driven health care system, payment is what drives so much of changes, you really need to have an understanding of what are the levers that payers have to really influence and drive toward health equity, toward racial equity.
So when the state of Minnesota was looking for a new Medicaid Medical Director, they were open to conversations about structural racism and its impact, and really focusing on the racial inequities that we see in Minnesota along the lines of health and in the Medicaid program. I was able to step into that role in January of 2020.
JL: You were the lead author of a report called, “Building Racial Equity into the Walls of Minnesota Medicaid – A Focus on U.S.-born Black Minnesotans”. For those who may be less familiar, can you share a little bit about, one, your motivation behind the report and, two, what’s the change you hope that report will help achieve going forward?
NC: Thanks for noting the report, and giving me a chance to talk more about it because it really is the work I came to this role to do. Really figuring out ways to first analyze, in addressing racial equity and health equity across the board, what is Medicaid’s role. And how has it contributed to some of the inequities that we see. And then what are the levers that Medicaid has.
And then how do we engage communities who are most impacted by racial inequities and health disparities in figuring out what are the places we should prioritize as first steps to address health inequity and racial inequity. We really sought to do that specifically with the U.S.-born Black Minnesota community because the data has shown both across the state, and specifically within our Medicaid program, that community experiences some of the most health disparities because of structural racism.
So we laid the report out saying, we know in Minnesota there are many racial inequities – health inequities being amongst them – that are linked to structural racism. And when we look at health inequities in particular, black Minnesotans experience some of the worst racial inequities.
When we looked in Medicaid, specifically, we saw that that was the case and not only amongst Black Minnesotans, but specifically amongst U.S.-born Black Minnesotans. With that understanding and that frame, here’s where we feel like the levers of Medicaid has to address it. It’s eligibility and enrollment. How do you first get Medicaid insurance in the first place, and what policies do to contribute to the racial inequities that we see in just that eligibility?
Access in general. So once you have your insurance card, how do you actually get to the provider that you see and the care that you need, whether it be establishing a primary care provider or getting things like dental care or behavioral health care, or other specialty care? Is there geographic barriers or other barriers that contribute to you being able to access the care that you need, and how does that differ along the lines of race?
The third was quality. So when we look at our quality metrics – and we have pretty robust reporting of quality metrics in Minnesota across not only our Medicaid enrollees but across all payers in Minnesota, public or private – we have seen for a long time that there is a gap between Minnesotans who get their coverage through public or private payers. As well as within our public programs, there’s a racial inequity gap with Black Minnesotans and American Indians having lower quality metric scores. So, what are we doing to address that gap, do our quality metrics even capture what those communities experience as quality care? And how could we better have metrics that capture what they would consider quality care. Then use that in metrics, like how we structure contracts and reimburse medical care.
And then the last one being early opportunities, and looking at the fact that Medicaid covers a large number of birthing persons and children. And specific amongst our U.S.-born Black Minnesota community, 8 out of 10 mothers in Minnesota who identify as black, give birth on Medicaid. And we know that 64% of children in Minnesota who identify as black get their coverage through Medicaid. Medicaid has a huge role to address the disparities in particular in our Black Minnesota communities.
So we brought that and presented to community leaders in the black Minnesota community, and talked about the different levers to get ideas of where we could start to act. We took that feedback and worked with our policy staff within DHS and within Minnesota Medicaid to really come up with a list of calls to action where we could start to really move the needle to address racial equity in our programs.
Then we brought that back to our community in a series of community conversations that were open to everyone who was either from the Black community or interested in helping advance racial equity in health in the Black community. Then we incorporated all that into the report.
We really tried to marry some of the ideas and reflections that we heard from the community where there was actually evidence of disparities in things like churn, disparities in things like access to culturally responsive care and how that impacted the inequities we saw. The hope was to (a) have some calls to action that we could concretely work on and work towards and help prioritize – as you note – the many different ways you can go to address health equity; and then (b) to then actually put this out there for other Medicaid agencies, for other payers, for other health care systems, to look at as a way that they could really engage communities most impacted by inequities in their work, and really bring that co-created lens to the work that I think has really been missing thus far.
JL: Tell me a little bit about getting ideas and bringing them back, and trying to do what I consider the tough work of marrying that with evidence, and what’s feasible. Were there things that you wanted to do that the community did not feel was a priority, so you had to cut it away? Or things that, you didn’t quite know how to do but wanted to make happen because it was important to the community?
NC: I’ll be honest that we’re still in the process, right? It doesn’t stop with the publication of this report. In fact, in April and in May we went back and had two other follow-up community conversations where we shared the report and continued to get feedback. We’re hoping to launch action groups with community members who are looking to continue to push forward the calls to action and other learnings.
But I think you’re right on in that, you have your ideas – and being someone who is from the Black community in Minnesota, having been in community advocacy spaces, I had a little bit more familiarity than other folks who might enter this work with what some of the concerns have been and areas of improvement that could be. But even I really thought that the quality piece (as far as really finding metrics that better captured the experience of quality care from the community’s lens) would resonate more. But there wasn’t as much, at least in the community members that we worked with, there wasn’t as must interest in starting there.
Most of the interest was around enrollment and eligibility, and then access to culturally responsive care, care that really respects folks’ lived experience. So having to put a pin in [identifying metrics in quality of care from the community’s lens], and maybe its more about how to prepare our systems for when they are open, and that’s more of a priority – and being responsive to that.
So that’s some of the work that we’ve done: to start to think of how would we capture a more community focused quality metric? It’s not necessarily going to be something you can capture form claims, maybe it’s more from patient experience surveys and things like that. So starting to think about those different levers that we have.
As far as some of the things that the community is really, really interested in, how do we improve the workforce of folks providing care to Medicaid enrollees so they reflect the communities that they’re serving in? And that’s one that we have less of a lever over. We can certainly continue to bring that feedback to medical schools and residency programs. We are a part of a human services agency, so we can talk about how when we give access to things like housing and nutrition and childcare to families, that actually improves a child’s opportunity to grow and learn and reach their full potential. A lot of gaps that we see in folks in these spaces is because the pipeline is so slow and narrow right now. So how we can actually improve opportunity and equity across the board, and how that has a direct impact to what a community says.
I think those would be two examples of some of the learnings that we’ve had in this ongoing conversation. That’s what we hope too, that it’s the start of an ongoing conversation and we can continue to find ways to incorporate community input into all of our processes.