A Roadmap of Medicaid Prevention Pathways – White Paper: Realizing the Promise of Medicaid Prevention and Population Health

Chang DI, Bonney J, Steinberg A, Gilmore L
Publication Year: 2017
Patient Need Addressed: Chronic Conditions
Population Focus: Medicaid beneficiaries
Demographic Group: Child
Type of Literature: Grey

The Robert Wood Johnson Foundation awarded Nemours a one-year grant to explore and promote the use of existing Medicaid authority to support prevention. The initiatives described here are intended to sustain approaches that link clinic to community prevention to address chronic disease, including childhood obesity. With 40 examples, this Roadmap is part of a practical resource that includes three case studies and a white paper. Together, these resources bring to light how states have successfully created sustainable financing through Medicaid and the Children’s Health Insurance Program (CHIP) for preventing chronic diseases at both the individual and population levels. The toolkit can help states get started or continue their prevention efforts. These documents can be found at: http://movinghealthcareupstream.org/innovations/pathways-through-medicaid-to-prevention.
The Roadmap illustrates how state Medicaid agencies and their partners can maximize the authority that exists under federal Medicaid and CHIP law to deliver a range of preventive services and strategies at both the individual and population levels. The intent is to promote the use of existing federal Medicaid authority so a state may exercise the options that best align with its unique needs and conditions.

The Roadmap is applicable to a broad array of prevention activities that a state may opt to cover under Medicaid. More specifically, the Roadmap focuses a lens on childhood obesity, a challenge for which prevention is particularly relevant. The American Academy of Pediatrics (AAP) states, “because intervention programs are few, and program costs are high, the most successful intervention for promoting a healthy weight is prevention.” The AAP’s Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents notes that healthy weight has special significance not only because of its importance to childhood and future adult health but also because of “its interrelationships with lifestyle, behavior, the environment, and family life.” 

Since its passage half a century ago, Medicaid has played an essential role in promoting the health and wellbeing of America’s children. Today, 40 % of children—over 35.5 million—are enrolled in Medicaid or CHIP. Medicaid and CHIP are essential to low income children, and particularly children of color. 
The health policy landscape changed dramatically in recent years with the passage and implementation of the Affordable Care Act (ACA). Federal and state level health policy will continue to evolve in the coming years. This Roadmap will continue to be important to promoting the health and wellbeing of children by showing states how they can accelerate the innovative efforts already underway to strengthen prevention.

Insights Results

Overview of article

  • This study aims to highlight that community-based prevention efforts can decrease the incidence of preventable diseases at the population level including childhood obesity


  • Facilitators identified that affect the successful implementation of prevention strategies financed through Medicaid: 1) A champion within state government; 2) An integrator that works across sectors to achieve improvements in health and wellbeing; 3) An entity that brings key players together to develop shared priorities; 4) An alignment of Medicaid and public health goals; 5) A system that encourages collaboration across agencies; 6) A comprehensive data system; 7) Incentives in Medicaid managed care contracts to promote non-traditional providers and non-traditional preventive services; 8) Learning collaboratives for exchanging information; and 9) An educational program for providers to achieve practice transformation
  • Barriers identified include: 1) Difficulty in establishing a return on investment for obesity and other types of prevention; 2) Medicaid’s historical focus on clinical care, not population-level services; 3) Concern about medical loss ratio; 4) Challenges for a state wanting to shift from a clinical focus to a population-level focus; 5) Conflicting sets of priorities across agencies and community partners; 6) Lack of established working relationships across agencies; 7) Credentialing of non-traditional providers; 8) Enrollee churning in Medicaid; and 9) Lack of provider training about community linkages

Key takeaways/implications

  • There are several critical elements a state must have in place when transforming its healthcare delivery system to include a population health focus: 1) Leadership from a high-ranking state official who can make prevention a priority across the state or department; 2) A state planning process that begins by focusing on the state’s unique goals; 3) Collaboration across state and community partners to address population health; and 4) Recognition that state Medicaid agencies are one piece of the population health puzzle
  • It is worth reiterating that Nemours expected to find many more examples of Medicaid-funded clinic to community prevention linkages to address childhood obesity. This lack of childhood obesity prevention examples funded by Medicaid led Nemours to broaden the scope of the project to include prevention strategies generally