Hawai’i Advances Medicaid Innovation with Proposed Section 1115 Demonstration

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AUTHOR – ATI Advisory

“There is a saying that ‘change occurs at the speed of trust.’ If Hawaiʻi wants to be innovative or do things differently, it is important that we do so with the engagement of the community.”

– Judy Mohr Peterson

An interview with the Medicaid Director for the State of Hawai’i Department of Human Services

ATI sat down with Hawaii’s Medicaid Director, Judy Mohr Peterson, to discuss the ins and outs of their recently submitted Section 1115 Demonstration renewal application. Hawaiʻi is proposing a series of new initiatives, with a focus on addressing health-related social needs (HRSN), promoting access to and continuity of coverage, and supporting populations with complex care needs, including individuals involved in the justice system and those with substance use disorders (SUDs). Hawaii’s renewal submission can be accessed here.

ATI: How does this renewal fit into the longer-term strategy for Hawaii’s Medicaid program?  

Judy: We are super excited about this renewal because it builds on and renews the values of our work from the past 5-8 years – focusing on investments in whole person care, including primary care and serving individuals with complex health and social needs. Our longer-term vision is called the HOPE initiative, which stands for the Hawaiʻi ʻOhana Nui Project Expansion. ʻOhana takes a multi-generational approach to providing whole person and whole family care. This renewal builds on that and starts to lay the foundation for financial alignment in care delivery. For example, in thinking about providing care to individuals with complex health needs, we have already started to think about how to pay for these services differently and what providers can be brought into the care team. So, we are using our 1115 demonstration renewal to strengthen relationships with our health systems, primary care providers, community health centers, and other community-based organizations.

ATI: From where did Hawaiʻi draw inspiration for the Section 1115 Demonstration? Are there any other states, guidance, or programs you can point to?

Judy: For sure. We consider ourselves in a leadership role amongst states in implementing innovative programs. But we draw a lot of inspiration from our partner states. For example, California was the first state to get approval for pre-release and housing services – we really appreciate their approach to providing community-based and whole-person care. We also drew inspiration from Oregon and Washington, especially for their continuity of coverage models for kids. Another state is Arizona – we really admire what they have been able to do when it comes to funding for rental assistance and behavioral health integration. And, while we did not include it in our renewal, Arizona and a few other states have sought approval to cover indigenous or tribal healing practices. This aligned with requests from within our own community to take a look at the role of Native Hawaiian healing and cultural practices in our system.

ATI: How has Hawaiʻi engaged with the community and stakeholders on this renewal work?

Judy: There is a saying that “change occurs at the speed of trust.” If Hawaiʻi wants to be innovative or do things differently, it is important that we do so with the engagement of the community. We have been working for several years to develop relationships with a broad group of stakeholders. Additionally, it’s key to incorporate lived experiences – whether it is the individuals who are receiving the services or those providing the services, we seek input from them. As we were thinking about which direction we wanted to move when it came to the new innovations in the renewal, we executed on what the community told us they were interested in. In addition to that, as we defined policy details, we reached out to community groups to learn more about what they wanted to see in these initiatives. Since the early development of this renewal, it was important for us to focus on and engage with the community – if you are only getting feedback during public comment period, for example, it does not really allow you to do the kind of engagement that takes root and gets the community excited.

ATI: How might this renewal impact Hawaii’s most under-resourced or highest-risk communities?

Judy: I would probably narrow that down more, particularly those struggling with severe mental health challenges, addiction, and houselessness – many of whom are from Pacific Islander or Native Hawaiian communities subject to a long history of colonialism and systemic oppression. To help these individuals be healthier and create more stability in their lives, it often takes a lot of resources from a lot of different groups coming together. From my perspective, it’s about us partnering with these entities and bringing Medicaid to the table as an engaged, complementary resource. So, work will by no means right historic and systemic wrongs, but it does help increase resources that can contribute to the overall health and wellbeing of the community. We believe that this is an essential part of Medicaid’s role.

ATI: Last year was a challenging year, in particular with the COVID-19 unwinding and fires that devastated Maui amid this renewal work. How did your team balance these ongoing priorities?

Judy: First, it is important to recognize our fantastic team – we have intentionally built a great team over the years and invested in leadership development. We have tried to create a culture that appreciates and values individuals as whole people, essentially, recognizing their humanity… they do not have to stop being a parent, for example, when they when they walk in the door. We recognize that work is a major part – but not the only part—of people’s lives. When the wildfires hit, it is not a surprise that people dropped everything and simply asked, “what needs to be done?” We had people whose family members had passed or lost everything in the fires; it had a dramatic impact on us… Additionally, our community partners that we were engaging with on the renewal are the same organizations that were responding to needs like housing after the fire. Because we already had these relationships in place, it helped us work together and make connections. Despite everything, our small but mighty team keeps on working and has its eye on a common vision and mission – the health and well-being of our community. It is not just about Medicaid; it is about the well-being of everyone who is here.

ATI: How are you thinking about implementation planning following CMS approval? If approved, what initiatives do you anticipate being implemented first? What challenges do you anticipate? 

Judy: During this negotiation phase with CMS, our team is talking about how to sequence the implementation of initiatives. The expansion of the existing Community Integration Services work, which focuses on housing, will probably be one of the first things we get started on, but likely not the first initiative to be implemented. Another initiative that, again, will not necessarily be implemented early on, but that we will start working on, is the pre-release services – in part this is because of the new federal law that mandates certain in-reach work for children and youth. For continuous eligibility, we are already thinking about what systems changes would be required – this work will build on the eligibility and enrollment work that occurred coming out of COVID-19. I think the one area that is brand new to us is nutrition supports, and so that will likely be the last initiative to be worked on and implemented. We also have not seen as much on nutrition supports from CMS, so we will be working with our community partners and reaching out to other states who have implemented similar initiatives.

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