How to make Medicaid racially equitable

The term "Minnesota paradox," coined by Samuel Myers at the University of Minnesota, describes how Minnesota can have one of the highest qualities of life for white residents, while Black residents fare worse in nearly every measurable category than in virtually every other state. For Black Minnesotans, the consistent denial of equal opportunities in housing, education, nutrition, healthy neighborhoods and justice under the law makes the racial health disparities here less surprising.

A new state report, "Building Racial Equity into the Walls of Minnesota Medicaid: A focus on U.S.-born Black Minnesotans," aims to address these gaps. Medicaid plays a key role in addressing these health disparities, with approximately 41.5% of Black Minnesotans and 64% of Black Minnesotan children relying on Medicaid for health care coverage. Given the distinct current and historical contexts that have contributed to the health of U.S.-born Black communities in the U.S., the Minnesota Department of Human Services (DHS) focused the report on this community.

The path toward racial equity requires intentional community involvement in policy design within DHS. The report incorporates recommendations from conversations with members of the Black community born in this country, leaders of community organizations and those working to advance racial equity in health care for Black Minnesotans. It highlights three areas for action:

• Simplifying enrollment and re-enrollment: Despite being eligible, many people who would benefit from Medicaid aren't enrolled or experience gaps in coverage due to administrative barriers. Challenges in enrollment are well known, but they have a disproportionate effect on Black Minnesotans born in the U.S. Being off Medicaid for more than six months makes a person less likely to have regular care and more likely to forgo care for financial reasons and report problems paying medical bills. Continuous eligibility policies can improve racial equity, allowing people to maintain Medicaid coverage uninterrupted for up to a year, eliminating the often-cumbersome paperwork required to maintain coverage. The report recommends that the state explore six years of continuous Medicaid eligibility for children up to age 6, and two years for everyone else.

Multiple sources also underlined the value of having navigators help people apply and maintain their coverage. Navigators are trusted community resources, and the report recommends robust support of their work.

• Improving access to culturally relevant care: Access is a significant barrier for Black community members, with one community conversation participant reflecting that medical practitioners "don't listen to us when we explain our problems; Black patients do not receive the same treatment as white patients." Community leaders stressed the importance of culture — the fabric that links an individual to their community through shared beliefs, knowledge, practices and protections — in the health and well-being of community members. Loss of culture in the healing space contributes to illness by separating an individual from one of their strengths. The report recommends a dedicated internal structure at DHS to provide a direct connection to U.S.-born Black Medicaid enrollees, community-based organizations and other institutions to inform and co-create policies that elevate strengths and address inequities.

• Engaging the communities Medicaid serves: Top-down policy solutions have been tried, yet disparities continue to grow. All our conversations highlighted a shared desire for meaningful policy engagement and co-creation. Community members noted that the pandemic has clearly demonstrated the impact of a fractured trust between state agencies and the U.S.-born Black community. A repair of this trust requires relationships be built over years and gives that community the opportunity to "start a journey of trusting larger agencies that provide resources and services," as one participant in our conversations put it. The report calls on DHS to integrate not just community engagement in general, but longitudinal, culturally specific engagement of enrollees and their families into routine policy, budget and administrative activities.

Gov. Tim Walz's current budget proposal would support these priorities with simplified enrollment and renewal processes, 12-month continuous eligibility for children to age 21, more community engagement conversations, easier access to culturally relevant care, and resources for navigators.

More than 100 years ago, W.E.B. Du Bois pointed out the impact of structural racism and how social drivers of health affected the opportunity of Black Americans. To meet this moment, it's time to heed his words: "Now is the accepted time, not tomorrow, not some more convenient season. It is today that our best work can be done and not some future day or future year."

Dr. Nathan Chomilo is medical director of Minnesota's Medicaid program and lead author of the report "Building Racial Equity into the Walls of Minnesota Medicaid: A Focus on U.S.-born Black Minnesotans."