Voices from the Field: Madeline Steward on Oral Health Equity for Medicaid Populations

There’s obviously no one solution, no silver bullet, to creating an equitable oral health system. But for Madeline Steward, MPH, a program officer at the Center for Health Care Strategies (CHCS), there’s one element that’s critical to the effort: trust.

“A key ingredient raised by community-based organizations to establishing an equitable oral health care system is strengthening trust between patients and the health care system,” says Steward, a co-author of a new brief, “Advancing Oral Health Equity for Medicaid Populations,” which was released today. “While the information itself isn’t novel, I was surprised how often this was raised by our key informant interviews. And one way to start building this foundation is to create a culturally competent experience for individuals from all backgrounds.”

That’s just one finding from the research and subsequent brief Steward produced with CHCS colleagues Greg Howe, senior fellow, and Shilpa Patel, PhD, associate director of health equity. CareQuest Institute supported the work that focused on understanding how oral health equity does and does not exist in Medicaid populations, as well as what opportunities exist for advancing it.

Steward, who started her career advocating for children with special needs, took some time out of her schedule to highlight key findings from the brief, discuss misconceptions many people have about Medicaid, and share a health care podcast recommendation.

How did you first get interested in working on oral health projects?

Early on, I was asked to support our State Oral Health Leadership Institute (SOHLI). In most states, Medicaid programs and public health departments share responsibility for addressing the oral health needs of individuals with low incomes, yet each entity typically has its own dental director — often operating in silos. SOHLI, supported by CareQuest Institute (DentaQuest Foundation at the time), was created to bring together state Medicaid dental program directors and state oral health program directors to advance shared goals.

Although the SOHLI program has since wrapped, I chose to remain working in the oral health space. Not only is it an area that I find incredibly interesting, but I am humbled every day by the passion of the oral health stakeholders that I’ve met and worked with along the way.

Why did you and your co-authors develop the “Advancing Oral Health Equity for Medicaid Populations” brief? What was the goal?

In 2020, CHCS conducted interviews with oral health stakeholders across the country — representing oral health providers, Medicaid agencies, professional and consumer organizations, and health plans — to learn more about the state of value-based payment (VBP) in oral health care. As we conducted that research, two points pertaining to equity stuck with us: (1) there are long-standing inequities in oral health, particularly in Medicaid; and (2) there are opportunities for partnerships within communities to make a meaningful difference. We know that Medicaid offers critical opportunities to improve systemic oral health inequities, but there’s limited information available about state efforts to improve oral health equity among Medicaid-enrolled populations.

Through this publication, we hoped to learn more about: (1) specific barriers that contribute to and perpetuate oral health inequities, such as consumer-level and system-level barriers (e.g., provider enrollment, state resource constraints); (2) emerging opportunities to reduce oral health-related disparities; and (3) resources to improve oral health equity.

In three bullet points, what were the key takeaways from the paper?

• Medicaid — given its size and diversity of enrollees — offers critical opportunities to dismantle systemic inequities related to oral health access, reduce long-standing disparities, and advance oral health equity. There is limited information, however, about state efforts to improve oral health equity among Medicaid-enrolled populations.
• There are common barriers for addressing oral health equity, and we highlight recommendations within four key areas: (1) coverage and access; (2) workforce capacity building; (3) partnerships; and (4) payment.
• Lastly, the brief highlights specific opportunities to partner with community-based stakeholders (e.g., community-based organizations, individuals with Medicaid) as part of efforts to reduce oral health disparities and advance oral health equity for individuals with Medicaid.

What’s one misconception many people have about Medicaid populations?

There is a misconception that Medicaid discourages individuals from working — and that those on Medicaid do not want to work in order to continue receiving coverage. That is entirely untrue. Nationally, more than 6 in 10 nonelderly adults in Medicaid who do not receive federal disability or Medicare coverage are already working full- or part-time. Individuals can still qualify for Medicaid coverage, especially in expansion states, because they work low-wage jobs and still meet the eligibility criteria. Low-wage jobs are less likely to offer employer-covered insurance, and for those that do, workers may not be able to afford coverage.

Research also shows that access to affordable health insurance has a positive effect on the ability to secure and maintain employment. Medicaid coverage can facilitate care to keep folks healthy enough to work. Additionally, many states, either through managed care plans or another mechanism, take steps to connect their members with job services and employment.

The importance of engaging community voices came through loud and clear in the brief. Why is that so critical?

I am a firm believer in “nothing about us, without us,” a mantra which signals that no policy should be decided by any representative without the full and direct participation of members of the group(s) affected by that policy. Considerations for advancing oral health equity would not be complete without the perspective of impacted communities to address health priorities and co-develop solutions. Meaningful and trusting partnerships with community members require substantial time, effort, and a genuine commitment for long-term engagement and change.

Of the recommendations you provided in the brief, are there one or two you think would have the biggest impact?

The recommendations in this publication can help states advance toward increased oral health equity for their beneficiaries, whether they are just beginning to develop an oral health equity agenda or if they are further along in pursuing oral health equity. However, foundational to state-level efforts to advance oral health equity is partnering with the individuals and communities most affected by oral health inequities. Without their expertise in identifying oral health inequities and the root causes that drive them, solutions to address identified inequities may have less impact or even potentially exacerbate disparities.

What actions do you hope readers take after exploring the brief?

There is much work to be done to increase equity in oral health for Medicaid populations, but forging authentic stakeholder relationships, particularly those with the community, is a fundamental first step to advancing equity in oral health. Ultimately, states should look to build and maintain partnerships that include regular opportunities for direct and meaningful engagement with consumers.

Health care organizations, such as health systems and Medicaid agencies, may consider leveraging the influence of trusted community figures, such as leaders of community-based organizations, religious leaders, community organizers, or community volunteers, to serve as a launching point for understanding community needs. These leaders may be able to broker relationships with the community more broadly. Health care organizations can hire and meaningfully compensate community liaisons to act as go-betweens, translators, or engagement champions to participate in partnership activities. Medicaid agencies could also leverage existing means of engagement (e.g., Medicaid advisory committees) to solicit input on oral health policy and facilitate connections to other state agencies that impact beneficiaries.

Additionally, Medicaid could explore program levers to strengthen community-based organizations (CBOs), including direct funding and incentives for providers and plans to actively engage with CBOs. For example, Medicaid programs can encourage, incentivize, or require health plans to contract with CBOs for the purpose of: (1) care coordination; (2) community needs assessments; and (3) addressing health-related social needs, and more.

Lastly, we know you’re a big podcast fan. Any health care-related shows you’d recommend?

I recently started listening to “Where It Hurts,” a podcast produced in partnership by Kaiser Health News and St. Louis Public Radio. The series examines overlooked parts of the United States where cracks in the health system leave people frustrated and without the care they need. The first season covers the fallout in rural Fort Scott, Kansas, after Mercy Hospital closes. More than 500 rural hospitals in the U.S. are at immediate risk of closing because of financial losses and lack of financial reserves to sustain operations. This podcast does a wonderful job painting a picture of how Mercy’s closure impacts its workers, patients, and the overall Fort Scott area.