One of the many ripple effects of the Affordable Care Act was pushing Medicaid into the national spotlight. Historically overshadowed by Medicare, the public insurance program for low-income people now dominates political conversations, especially in statehouses where lawmakers try to balance the desire to provide coverage with the drain on state coffers. For Tracy Carter, vice president of government relations at Cleveland-based MetroHealth System, protecting Medicaid is intertwined with the public health system's overall mission. In recent budget battles, her team fought off cuts that would have cost MetroHealth nearly $25 million. Carter, one of Modern Healthcare's Top 25 Minority Executives in 2018, recently spoke with Managing Editor Matthew Weinstock. They were joined by Michael Dalton, MetroHealth's director of state government relations. Dalton was named to Modern Healthcare's 2018 class of Up & Comers. The following is an edited transcript.
MH: You've been very involved in Medicaid throughout your career. What led you to that trajectory? Why has that program been so important for you to focus on?
Carter: I grew up in a mixed-income community. There were a lot of people who were living in poverty. I was always raised to believe that everyone, independent of their income, is equal. Some people in life need additional help and that additional help came through the Medicaid program. As I evolved in my education and training, and even my employment pathway, whatever I can do to better advocate and champion for people to access that support, maintain that support, that's what I am excited about.
Being at a public hospital, we have close to 40% of our patient base tied to that program. It's an alignment of purpose and passion for me in terms of government relations to advance those policies to help people maintain their coverage.
MH: Your payer mix is predominately Medicaid and Medicare, correct?
Carter: We are roughly 40% Medicaid, about 30% Medicare, and another 5% uninsured.
MH: One of the things you took on when you arrived at MetroHealth in 2015 was aligning government relations with the system's strategic plan. Can you talk about that?
Carter: Government relations is designed to support the strategy of an organization. We sit down with our clinical and administrative leadership to have a conversation about where we are and where we want to go and how public policy, funding and partnerships can help facilitate that. It's an active dialogue and requires us to be really focused on what we ask from government. For example, when we're talking about population health, how can we better deliver care to certain groups from a better cost and quality position.
On the government relations side, we would say that one tool that always needs to be in play is making sure people have coverage so that there are no barriers for them to accessing care when they need it.
MH: How engaged are your clinicians?
Carter: A lot of the clinicians here are politically aware and active. They're very effective with advocacy around patient interests and needs. For example, in our market there is an opioid crisis. Government, the private sector, the community—all of those different sectors—want to work together to try and come up with solutions. Mike has been partnering with the workforce to try to activate political and legislative solutions.
Dalton: Dr. Joan Papp is director of MetroHealth's office of opioid safety and has been instrumental in going down to Columbus and being seen as a champion and a leader on this issue through the creation of a program we call Project Dawn, which is about getting naloxone into the hands of first responders, and also patients and their family members.
We make sure she's connecting with the right legislators to hear her message and then also working with departments in the regulatory bodies to make sure we have the right rules in place. That's more than half the battle. They need to hear the clinician's perspective.
MH: You were successful last year in staving off Medicaid cuts, too. Can you walk me through what you were able to do on that front?
Carter: Whenever there are proposals that could impact our mission, our ability to provide care to patients, we always partner with our finance team to get a sense of the impact. If this moves forward, how would we operate or function differently, what's the real impact from a patient-care perspective, a health service perspective, a jobs perspective?
What we find to be effective is not only having a conversation with legislators, but also the administration, about what's being proposed and what the impact is on the ground level, from a community level, that they probably did not anticipate.
Once you come to them with facts, with human impact stories, a lot of times there's a way for them to reconsider their policy plan. There's active dialogue (with legislators). “If your goal is X, could we consider a different pathway or solution to reach the same destination?”
That's how we were able to, at that point in time, avoid multimillion-dollar cuts. We told our story.
MH: What kind of collaboration do you have with University Hospitals and the Cleveland Clinic, which have different patient populations than you do?
Carter: The good news about our market is that all of our government relations offices know each other. We have a history of working together. We all know and understand that there are times, there are places where we have to protect our own institution's interest. That's OK, but there are also times when we have to work together for a bigger agenda that supports a broader industry, and I think we do that well in this region.
MH: Ohio expanded Medicaid, but it is back on the agenda in the gubernatorial campaign, this time around work requirements. What are you doing to prepare for that part of the campaign?
Carter: When the proposal for work requirements was released, we—along with the Cleveland Clinic, Sisters of Charity Health System and University Hospitals—got in a room and said, “We could work together on this, because we understand the implications toward our lower-income populations if they lose coverage.”
We partnered with a group called Medworks, an organization that provides free healthcare clinics throughout the community. As part of that, they now want to better educate patients and enroll people into Medicaid.
Their interests are aligned with the hospitals' interest. We've been meeting for the past three to four months about what the likely impact is for Medicaid recipients in northeast Ohio if the work proposal moves forward. We have been talking about the need to be prepared if this moves forward to do X, Y and Z, to better educate and engage people about what just happened, and how they could keep their coverage. It's a great example of community benefit, community collaboration.
Dalton: As a public hospital, we are unable to engage in the political process that's going on right now, but we are working and planning for what could come about both at the end of this year and then also as we prepare for the budget next year.
There's an ongoing race for speaker in the Ohio House of Representatives, and it's not about Democrat versus Republican and how things turn out there, it's Republican and Republican and there's two different factions. One is considered to be a more moderate Republican, the other is more conservative and ran against Medicaid expansion.
There's this dynamic of: if that person—Larry Householder—prevails, how do we maintain current eligibility for Medicaid expansion, because there's another dynamic hanging over our heads, which is in the last budget Gov. John Kasich vetoed an enrollment freeze.
If there's a Democratic governor, how do we make sure that there's an alignment with their agenda and what will be a Republican House and Senate. Then if there's a Republican governor, how do we make sure that the expansion is maintained as a priority, but also that these work requirements that have been proposed, and if they go forward and are deemed legal, that they are not overly onerous.
MH: How closely are you following what's happening with the Kentucky work-requirement litigation?
Carter: We're monitoring it a great deal because we believe that's why Ohio's proposal is delayed. But because of our relationship with legislators, we understand their values, we understand their priorities and that they want some changes to the program to better incentivize people to have skin in the game, or demonstrate skin in the game with their coverage.
The hospitals are all thinking that at some point change is coming. We're preparing for the change so that the least amount of people will be impacted, fewer people will lose coverage, and, at the same time, providers can continue to do what we do best in terms of providing them with the best care possible when they need it.
MH: Anything else you want to add, Tracy?
Carter: In my 15-plus years of experience in this world, what I find to be true is everyone—Democrat and Republican—comes to the office with a heart and mind ready to serve, to do the best job they can. I have to look at what's on my agenda that intersects or aligns with their agenda and to the extent I can, figure that out and go to them with data and the impact on our community.
For me and my system, it's the patients. That's what I focus on when I come here.
