Tag: Medicaid Reform

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[MM Curator Summary]: A KY legislator has introduced a block grant approach for Medicaid.

 
 

 
 

Clipped from: https://hoptownchronicle.org/state-senator-wants-new-health-care-system-with-medicaid-block-grants-to-local-governments/

 
 

It’s time to invent a new health care delivery system in Kentucky, and it should be driven by health-care providers, state Sen. Stephen Meredith, of Leitchfield, said in the keynote address at the Foundation for a Healthy Kentucky’s 2023 Howard L Bost Memorial Health Policy Forum, held Oct. 11 in Lexington. 

Before making this assertion, Meredith pointed to a quote attributed to Abraham Lincoln and Peter Drucker: “The best way to predict the future is to create it.” Then he said, “Let’s do that. Let’s create a new health-care delivery system.” 

The address was titled “How Do You Fix an Irretrievably Broken Health-Care System?”

Meredith spent decades as a leader in health-care administration before being elected to the Senate in 2016. When he retired as boss of Twin Lakes Regional Medical Center, now a subsidiary of Owensboro Health, it was one of the four financially strongest hospitals with under 100 beds in Kentucky. He was also CEO of the Grayson County Hospital Foundation, which employed most of the local medical practitioners and managed their practices.

Meredith, a Republican, is chair of the Senate’s Health Services Committee, co-chair of the Government Contract Review Committee, and a member of other committees, including the recently formed Family and Children Committee.

“He knows the challenges facing our health-care delivery system, because he’s seen them firsthand,” Ben Chandler, CEO president of the foundation, said in introducing him. 

Meredith opened his address by listing several known challenges with the existing health-care system, including the “astronomical” cost of care that has resulted in the average person no longer being able to afford it. 

He also called the “mass” of health-care professionals who are leaving the system “alarming” and called one of the largest insurance companies in the U.S. making a profit of $86.4 billion in the last year one of the “most damning indictments of our current health-care delivery system. “

He noted that the U.S. is spending $1.2 trillion on health care, but has some of the worst health outcomes. 

“The problem is, we know what the issues are; we don’t act on the issues,” Meredith said. 

He went on to point out that the state’s move to a managed-care program for Medicaid has been in place since 2012, “and we have not improved the health of our population.” Further, he said the state Medicaid budget was $10 billion to serve 1.3 million people, and that is as large as it should ever be. 

“In inventing a new health-care delivery system in the future, we all have to agree and acknowledge,  there’s enough money already in the health-care delivery system to take care of every man, woman and child in this country if we spend it the right way,” he said.  

Further, he said, “If we’re truly improving the health of the population and we are getting people back to gainful employment, we should have enough money to take care of everyone.” 

To do this, he said we must have a clear mission and vision for how to fix the system. 

“If we’re all united in this, it’s quite simple,” he said. “We’re here to cure the sick, to help relieve pain and suffering, to give comfort to the dying and improve the quality of life for the people we serve. If we’re all united in that, doesn’t that move us in one direction.

“And one thing I haven’t mentioned is, it doesn’t say anywhere in there to make a profit. Now, I’m a capitalist to the nth degree, and I believe in making a profit. But it’s when you bring value to the system. You increase efficiencies, and you do it a better way. And we’re not doing that.” 

He said changes should be made on the local level by moving to a Medicaid block grant program, which would allow local governments to determine how Medicaid dollars are spent, with an incentive to save money for other local purposes.

“If you improve the health of population, whatever savings you achieve, you get to keep to improve your community,” he said. “If you want to invest in your school system, you want to invest in the infrastructure, you want to invest in broadband, it’s yours to keep.” 

Meredith said the main reason we don’t do such things is fear: “People don’t like risk. Fear keeps us from doing what we need to do.”

Melissa Patrick

Author at Kentucky Health News

Melissa Patrick is a reporter for Kentucky Health News, an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky. She has received several competitive fellowships, including the 2016-17 Nursing and Health Care Workforce Media Fellow of the Center for Health, Media & Policy, which allowed her to focus on and write about nursing workforce issues in Kentucky; and the year-long Association of Health Care Journalists 2017-18 Regional Health Journalism Program fellowship. She is a former registered nurse and holds degrees in journalism and community leadership and development from UK.

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[MM Curator Summary]: CMS approved new billing codes for “street medicine” for states wanting to deliver more care to homeless Medicaid members.

 
 

 
 

Clipped from: https://californiahealthline.org/news/article/street-medicine-cms-new-reimbursement-code/

 
 

Nurse Anna Cummings prepares an injection while Keri Weinstock, a psychiatric nurse practitioner, speaks with patient Linda Wood, who is homeless. Earlier this month, the federal government began allowing insurers to pay for care delivered outside hospitals and clinics, expanding funding for street medicine teams that treat homeless patients. (Angela Hart/KFF Health News)

The Biden administration is making it easier for doctors and nurses to treat homeless people wherever they find them, from creekside encampments to freeway underpasses, marking a fundamental shift in how — and where — health care is delivered.

Starting Oct. 1, the Centers for Medicare & Medicaid Services began allowing public and private insurers to pay “street medicine” providers for medical services they deliver anyplace homeless people might be staying.

Previously, these providers weren’t getting paid by most Medicaid programs, which serve low-income people, because the services weren’t delivered in traditional medical facilities, such as hospitals and clinics.

The change comes in response to the swelling number of homeless people across the country, and the skyrocketing number of people who need intensive addiction and mental health treatment — in addition to medical care for wounds, pregnancy, and chronic diseases like diabetes.

“It’s a game-changer. Before, this was really all done on a volunteer basis,” said Valerie Arkoosh, secretary of Pennsylvania’s Department of Human Services, which spearheaded a similar state-based billing change in July. “We are so excited. Instead of a doctor’s office, routine medical treatments and preventive care can now be done wherever unhoused people are.”

California led the nation when its state Medicaid director in late 2021 approved a new statewide billing mechanism for treating homeless people in the field, whether outdoors or indoors in a shelter or hotel. “Street medicine providers are our trusted partners on the ground, so their services should be paid for,” Jacey Cooper told California Healthline.

Hawaii and Pennsylvania followed. And while street medicine teams already operate in cities like Boston and Fort Worth, Texas, the new government reimbursement rule will allow more health care providers and states to provide the services.

“It’s a bombshell,” said Dave Lettrich, executive director of the Pittsburgh-based nonprofit Bridge to the Mountains, which provides outreach services to street medicine teams in Pennsylvania. “Before, you could provide extensive primary care and even some specialty care under a bridge, but you couldn’t bill for it.”

Under the new rule, doctors, nurses, and other providers can get reimbursed to care for patients in a “non-permanent location on the street or found environment,” making it the first time the federal government has recognized the streets as a legitimate place to provide health care. This will primarily affect low-income, disabled, and older people on Medicaid and Medicare.

“The Biden-Harris Administration has been focused on expanding access to health care across the country,” said CMS spokesperson Sara Lonardo, explaining that federal officials created a new reimbursement code at the request of street medicine providers who weren’t consistently getting reimbursed.

The White House unveiled an ambitious strategy earlier this year to reduce homelessness in America 25% by 2025, in part by plowing health care money into better care for those living on the streets.

Legislation pending in Congress would further expand reimbursement for street medicine, taking aim at the mental health and addiction crisis on the streets. The bipartisan bill, introduced earlier this year, has not yet had a committee hearing.

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Nearly 600,000 people are homeless in America, based on federal estimates from 2022, and on average they die younger than those who have stable housing. The life expectancy for homeless people is 48, compared with the overall life expectancy of 76 years in the U.S.

More than 150 street medicine programs operate across the country, according to street medicine experts. At least 50 are in California, up from 25 in 2022, said Brett Feldman, director of street medicine at the University of Southern California’s Keck School of Medicine.

Feldman spearheaded the state and national efforts to help street medicine providers get paid, alongside the Street Medicine Institute. They submitted a formal request to the Biden administration in January 2022 to ask for a new street medicine billing code.

In the letter, they argued that street medicine saves lives — and money.

“This is done via walking rounds with backpacks, usually working out of a pick-up truck or car, but is also done via horseback, kayak, or any other means to reach hard-to-reach people,” they wrote. “The balance of power is shifted to the patient, with them as the lead of their medical team.”

Street medicine experts argue that by dramatically expanding primary and specialty care on the streets, they can interrupt the cycle of homelessness and reduce costly ambulance rides, hospitalizations, and repeated trips to the emergency room. Street medicine could help California save 300,000 ER trips annually, Feldman projected, based on Medicaid data. Some street medicine teams are even placing people into permanent housing.

Arkoosh said there’s already interest bubbling up across Pennsylvania to expand street medicine because of the federal change. In Hawaii, teams are plotting to go into remote encampments, some in rainforests, to expand primary and behavioral health care.

“We’re seeing a lot of substance abuse and mental health issues and a lot of chronic diseases like HIV,” said Heather Lusk, executive director of the Hawai’i Health & Harm Reduction Center, which provides street medicine services. “We’re hoping this can help people transition from the streets into permanent housing.”

But the federal change, undertaken quietly by the Biden administration, needs a major public messaging campaign to get other states on board and to entice more providers to participate, said Jim Withers, a longtime street medicine provider in Pittsburgh who founded the Street Medicine Institute.

“This is just the beginning, and it’s a wake-up call because so many people are left out of health care,” he said.

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[MM Curator Summary]: VT’s submission of its “Global Commitment to Health” waiver adds it to the list of 14 states trying to get federal funding to turn Medicaid on before inmates re-enter society.

 
 

 
 

Clipped from: https://vtdigger.org/2023/10/13/vermont-officials-seek-medicaid-benefits-for-incarcerated-people-but-federal-approval-could-be-a-long-time-coming/

 
 

A hospital bed in the infirmary unit of Southern State Correctional Facility in December 2016. File photo by Phoebe Sheehan/VTDigger

Incarcerated people have long been ineligible for Medicaid. When the federally funded health care program began in 1965, it expressly excluded “inmate(s) of a public institution” from coverage.

In Vermont and other states, officials are now embarking on a potentially arduous, yearslong process to change that — by seeking a waiver from the federal government that would allow Medicaid coverage to kick in for people in their final 90 days of incarceration. 

Prison officials and reform advocates alike say the Medicaid exclusion sometimes leads to a gap in health care coverage when people are released from prison — a vulnerable period during which they are anywhere from 10 to more than 100 times more likely than their peers to die of a drug overdose. 

“We’re very much living today with the policy decision made in the mid-1960s,” said Isaac Dayno, policy director for Vermont’s Department of Corrections. “It’s an issue that really doesn’t get enough attention.”

There’s also a potentially sizable financial benefit for the state. Vermont currently pays about $33 million per year to a private prison health contractor, Wellpath. According to 2015 data, the most recent year for which national comparisons exist, Vermont spent the second most per capita on prison health care, a Pew study found. 

Allowing Medicaid to cover incarcerated people’s medical expenses would transfer some of the financial burden of prison health care to the federal government, which, according to Dayno, could be a “paradigmatic shift.”

‘Our system is just really clunky’

While states are barred, with few exceptions, from billing Medicaid for prison health care costs, they have the option of suspending, rather than terminating, a person’s Medicaid eligibility when they enter prison. 

In theory, suspension eliminates a mountain of paperwork for people exiting prison by allowing them to access Medicaid coverage with the push of a button.

Vermont, however, lacks the IT infrastructure needed to simply suspend Medicaid eligibility.

And in practice, how — or whether — someone loses eligibility in the state is haphazard. 

More than 30% of Vermont’s prison population are people who have been detained as their cases move through the courts, rather than convicted and sentenced, state data shows. Those individuals can have their Medicaid benefits terminated even if they enter the prison system for a short time and are quickly released while awaiting trial. 

Termination may occur when a person or their family member reports they are incarcerated or when a regular check of Medicaid eligibility determines that a person is incarcerated. The corrections department, according to its health team, does not notify the Department of Vermont Health Access — the state agency responsible for Medicaid enrollment —  to “turn off” a person’s Medicaid.

When an incarcerated person approaches their release date, the Department of Corrections contacts the Department of Vermont Health Access to prepare for Medicaid enrollment, officials said.

But with unpredictable release dates, a decades-old computer system and the inevitable mistakes of a human-powered bureaucracy, eligible people sometimes exit incarceration without being enrolled in Medicaid. 

“We are not blind to a lot of the issues people face as they exit incarceration,” Dayno said. He said the process is “more seamless” in states that suspend, rather than terminate, enrollment. 

Ashley Berliner, who leads Vermont’s Medicaid policy development within the Agency of Human Services, said the state works hard to ensure people exiting state custody have coverage, using an expedited enrollment process once someone is scheduled for release.

“Our system is just really clunky,” she said, adding that enrollment is a “pretty manual process.”

Berliner called eligibility suspension the “gold standard” but said Vermont’s system “is just not capable of that functionality.”

The state is in the process of working to procure a new system. It has hired a technical advisory group and plans to release a request for proposals “for federal partner review” before the end of the year. 

‘Historically very little help’

Tim Burgess, who was previously incarcerated in Vermont and now leads the state’s chapter of Citizens United for the Rehabilitation of Errants, said he’s seen many people eligible for Medicaid leave prison without being enrolled.

“There has been historically very little help for people to transition out of the system so they do have medical coverage,” he said.

Because incarcerated people receive health care in prison, they often wrongly expect a continuity of coverage upon release, Burgess said. 

Without health coverage, recently released people may accumulate medical debt or be unable to access care, including medically assisted opioid treatment, he said, adding that Medicaid can act as a safety net and even prevent recidivism.

Burgess said he supports the variety of efforts underway to enroll incarcerated people in Medicaid, whether that means allowing coverage in the months leading up to release or ensuring reenrollment when a person returns to the community.

Will Hunter, a Windsor County advocate who rents apartments to recently incarcerated people, said their experiences with Medicaid have varied widely. 

“It does not happen automatically that the (corrections) caseworker gets a (Medicaid) application in before the person walks out the door,” he said.

Sometimes people he works with have left prison with Medicaid, Hunter said. In one instance, a former tenant on Medicaid who became incarcerated continued to have prescriptions sent to one of Hunter’s properties even while in custody. 

For people who are released without health care coverage, Hunter said he’s had good luck getting people enrolled in Medicaid over the phone, a process that can take as little as 10 to 20 minutes. That contrasts his experience with mailed applications, which he said have sometimes disappeared into a bureaucratic “black hole.”

As for Vermont’s IT struggles, Hunter felt the state shouldn’t so quickly explain away its own dysfunction.

“There’s an old saying,” he said. “A poor workman blames his tools.”

‘Back to the drawing board’  

Corrections departments nationwide support efforts to bring Medicaid into the prison system, according to Dayno — at least in part because of the potential for financial savings.

And in Congress, a bipartisan group of federal lawmakers, including U.S. Sen. Peter Welch, D-Vt., and U.S. Rep. Becca Balint, D-Vt., have thrown their support behind legislation known as the Reentry Act, which proposes restarting Medicaid benefits 30 days prior to release for people who are otherwise eligible. This would help create “uninterrupted and comprehensive coverage” upon release, according to a white paper on the bill. 

Welch called the Reentry Act a common sense way to strengthen communities, particularly amid the rise of overdose deaths. 

“This bill is designed to limit gaps in health care coverage for eligible people about to reenter society and has broad, bipartisan support,” he said in a statement. 

Introduced in both the House and Senate this year, the bill currently sits in committee. Rather than wait for Congress to act, some states are pursuing a different route to ensure people leave prison with health insurance. 

The federal government allows states to pursue experimental and innovative projects that would not typically be covered by Medicaid through a waiver process. Vermont’s approved waiver is the 279-page “Global Commitment to Health.”

In January, California became the first state to receive federal approval to use its waiver to cover some health expenses for incarcerated people up to 90 days prior to their scheduled release. 

Vermont is among 14 states currently seeking similar approval, according to the Kaiser Family Foundation. 

According to Berliner, the Centers for Medicare and Medicaid Services — the federal organization that administers both programs — wanted to first negotiate California’s waiver before turning to the other states seeking similar coverage of incarcerated individuals. 

Based on the Centers for Medicare and Medicaid Services’ approval of California’s waiver, Vermont officials realized “we would have to come back to the drawing board and really do some planning and design work before we went to have conversations with CMS,” Berliner said.

Vermont could receive waiver approval in 2025, according to Berliner. The state has its work cut out in the meantime, such as updating its IT system to accommodate some of the federal requirements placed on California and conforming its proposal to the strictures the Centers for Medicare and Medicaid Services have already approved elsewhere.

“Right now is a really interesting time in the Medicaid space,” Berliner said. “This is the first time that states are really able to start thinking about how Medicaid can be leveraged inside the walls of a correctional facility.”

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[MM Curator Summary]: About 500,000 Medicaid members who needed meds to help with their substance use disorder did not get it.

 
 

 
 

Clipped from: https://www.hmpgloballearningnetwork.com/site/ap/news/report-shows-discrepancies-moud-utilization-among-medicaid-enrollees

About one-third of the 1.5 million Medicaid enrollees with opioid use disorder (OUD) in 2021 did not receive medication for opioid use disorder treatment (commonly known as MOUD), and certain demographic groups were even less likely to receive MOUD, according to a recent report from the Department of Health and Human Services (HHS) Office of Inspector General.

“Access to MOUD is crucial to reduce overdose mortality and improve the quality of life of people with opioid use disorder,” the report’s authors wrote. “Medicaid is uniquely positioned to achieve these goals given that the program is estimated to cover almost 40% of nonelderly adults with opioid use disorder.

“Although CMS (Centers for Medicare and Medicaid Services) and states have taken several steps in recent years to increase MOUD access in Medicaid, our findings demonstrate that a significant number of enrollees with opioid use disorder may not be receiving this life-saving treatment.”

The findings were based on Medicaid and Medicare claims data to determine the extent to which Medicaid enrollees with OUD received MOUD in 2021. Medicaid enrollment and eligibility data were also examined to determine variances in treatment rates among demographic groups.

In 2021, about two-thirds of Medicaid enrollees with opioid use disorder received MOUD that year, either through Medicaid or, for some dually eligible enrollees, through Medicare. Buprenorphine was the most commonly administered medication (647,832 enrollees), followed by methadone (355,024), and naltrexone (69,001).

Meanwhile, more than 510,000 eligible enrollees with OUD did not receive MOUD through Medicaid or Medicare. Researchers noted that it is possible some of the enrollees in this group may have received medication treatment through self-pay or other sources or it was determined that MOUD was not an appropriate treatment for their circumstances. Still, the authors noted, their findings suggest that more effort is needed to improve access to treatment through Medicaid for all those who are eligible and in need of services.

Demographic Discrepancies

The OIG report showed that people of color and those with a disability and/or blindness were less likely to receive MOUD. Based on data from 15 states with reliable race/ethnicity data, just 53% of Black or African American enrollees with OUD received medication treatment. Other groups, including Asians, Native Hawaiian or other Pacific Islanders, and American Indians or Alaska Natives, also had lower-than-average utilization rates.

Meanwhile, 56% of enrollees with a disability and/or blindness received MOUD compared to 67% of those without.

Utilization rates also varied widely by state. For example, while just 37% of Medicaid enrollees with OUD in Illinois received MOUD, the rate was 89% for enrollees in Rhode Island. Ten states were found to have utilization rates below 50%.

Action Items

OIG concluded its report by recommending that CMS should help states—especially those with low rates of MOUD use— identify and reduce barriers to treatment by providing technical assistance, collaborative learning opportunities, webinars, toolkits, and other resources. Efforts should also be made to increase the number of states with valid and complete race and ethnicity data.

The authors also recommended that states and federal partners dedicate resources to educating Medicaid and Children’s Health Insurance Program (CHIP) enrollees about access to MOUD, including in office-based settings.

 
 

Reference

Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities Present Concerns. Department of Health and Human Services Office of Inspector General; 2023.

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[MM Curator Summary]: There are very few limits on the wealth you can have and still get on Medicaid in CA if you are over 65.

 
 

Clipped from: https://thehill.com/opinion/healthcare/4138033-this-is-reform-california-wants-to-let-its-billionaires-go-on-medicaid/

Politicians and investigative journalists have long complained about the billionaires that have no taxable income and pay no taxes despite their wealth. In response, politicians have advanced many constitutionally dubious proposals to tax wealth on grounds of equity and fairness.

It is odd, then, that there has been so little attention paid or protest given to the pending proposal in California — phase II of its 2021 reform — to strike all asset testing for those above age 65 in determining eligibility for long-term care benefits from Medicaid.

Lest anyone dismiss this as another crazy California idea that will never be enacted, like universal state government health insurance and racial reparations, this Medicaid expansion proposal is well on its way to approval, part of a series of incremental steps over the last several years that have already loosened Medicaid eligibility standards.

And this one offers a dangerous precedent for other states. Because Medicaid is jointly financed by the federal government, at fifty cents on the dollar or more, non-California taxpayers, including many middle-income workers living in states with stricter Medicaid rules, will actually end up paying a huge chunk of this costly California policy’s billion-dollar annual price tag.

Medicaid was designed as a jointly financed federal-state program to provide health care for the poor. It also pays for nursing-home care and increasingly for home healthcare for individuals, especially the disabled and elderly who spend down their assets before becoming eligible. Eligibility for various types of long-term care benefits is determined by medical need and a set of income and asset tests, which differ by state and have changed over time, but are within a federal framework.

California has long played loose with eligibility, benefits and other rules, even beyond the allowable leniencies in federal law. For example, under “Phase I” of the state’s 2021 reform legislation, its asset-test maximum for Medicaid eligibility is $130,000 (compared to just $2,000 in most states) for individuals and $195,000 (compared to $3,000) for couples.

Also, the “look-back” period to identify and disallow strategic transfers of assets to gain Medicaid eligibility is only 30 months, whereas federal law calls for 60 months. California’s look-back also does not apply if the applicant is not in a nursing home at the time of application. Federal law penalizes such strategic transfers, regardless of whether the person is institutionalized. California also turns a blind eye to as much as $12,000 in daily transfers of wealth to relatives per day, meaning that the wealthy can strategically shift as much as $4.4 million per year in order to pass the asset test.

California also completely disregards applicants’ net housing equity, which most states start to count as an asset after exempting the first $688,000 to $1,033,000. Retirement assets, including spousal retirement assets, are also disregarded, unlike in most other states.

Estate recovery from deceased recipients only applies to assets going through probate, thus bypassing retirement and insurance assets entirely. Unlike in some states, no liens are placed on housing. Despite the great wealth held in California, with home values averaging $750,000, the Medicaid program’s estate recovery efforts have lagged over the years, falling from $72 million collected in 2015 to $17 million in 2020.

Many of these leniencies directly contradict federal law, yet they were somehow approved by federal regulators at the Center for Medicare and Medicaid Services (CMS), without request for public comments, through a series of state plan amendments. Today, Phase II of California’s pending proposal — the total elimination of asset testing — is before CMS.

California officials told CMS that the total disregard of assets would annually cost the federal government only $115 million. Their own budget showed an increase of 37,000 newly eligible individuals and a $400 million total cost.

This is low compared to the approximately $35 billion that California spends on long-term care benefits through Medicaid. My own rough calculation, based on data from the Health and Retirement Study on asset holdings and another survey on long-term care needs, is that the annual additional cost to Medicaid from California’s disregard of assets will actually be at least $1.2 billion, with over 100,000 newly-eligible individuals.

Roughly half of this bill will be picked up by the federal government, not just by California taxpayers.

Even more concerning than the bad policy — which is contrary to the financial self-reliance of those who can afford it — is the poor precedent this circumvention of federal law would set for other states in designing their own Medicaid programs. Also, the complete lack of democratic process and bureaucratic transparency at a time of massive federal budget deficits is profoundly disturbing.

It is not too late for CMS and Congress to call these harmful actions into question and stop them.

Mark J. Warshawsky is a senior fellow at the American Enterprise Institute. He served as Vice-Chair on the federal Commission on Long-Term Care in 2013.

Tags California Medicaid

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[MM Curator Summary]: Sending a nurse in the home didn’t help.

 
 

 
 

Clipped from: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2022.01517?journalCode=hlthaff

Abstract

There is an urgent need to improve maternal and neonatal health outcomes and decrease their racial disparities in the US. Prenatal nurse home visiting programs could help achieve this by increasing the use and quality of prenatal care and facilitating healthy behaviors during pregnancy. We conducted a randomized controlled trial of 5,670 Medicaid-eligible pregnant people in South Carolina to evaluate how a nurse home visiting program affected prenatal health care and health outcomes. We compared outcomes between the treatment and control groups and found little evidence of statistically significant differences in the intensity of prenatal care use, receipt of guideline-based prenatal care services, other health care use, or gestational weight gain. Nor did we find treatment effects in subgroup analyses of socially vulnerable participants (46.9 percent of the sample) or non-Hispanic Black participants (52.0 percent of the sample). Compared with the broader Medicaid population, our trial participants had more health and social risk factors, more engagement with prenatal care, and similar pregnancy outcomes. Delivering intensive nurse home visiting programs to the general Medicaid population might not be an efficient method to improve prenatal care for those who need the most support during pregnancy.

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