Day 38 – Medicaid at 50: State Highlight: Maryland

Over the coming weeks this blog will highlight a key feature of Medicaid and the individual states that administer Medicaid and CHIP leading up to the program’s 50th anniversary (July 30th). Hopefully, you’ll learn some interesting facts about Medicaid and each of the 51 state programs.

Basics: Maryland Medicaid covers 1,121,256 lives

Maryland is a unique state when it comes to health care financing. For decades it has done all-payer rate setting for hospitals, and as part of this program, the state has had both Medicare and Medicaid waivers since 1977. But, 2014 brought big changes: in January of that year, Maryland began a new five-year waiver period that moves hospitals into global budgeting  – Global Budget Revenue, or GBR, as it is known. This is a massive shift away from volume-driven payment and really galvanizes hospitals to think outside of their walls. (Of note, physician payment is still fee-for-service based.)

Bon Secours Baltimore Health System is a couple of blocks away from the corner that inspired “The Wire”. Founded by nuns, the hospital has a deep commitment to service, and it has seized the new payment model as an opportunity to invest in the community it serves. Bon Secours is involved in many fascinating activities, for example, revitalizing the neighborhood by working on rehabilitating abandoned housing. Bon Secours Community Works does everything from benefits enrollment, to GED class, to child care, to financial literacy, to workforce development, to home visitation. On the clinical side, they are staffing up their primary care practices. While such a seismic shift in payment carries many risks for a hospital like Bon Secours that doesn’t have much of a financial cushion, it also brings potential rewards, like the ability to build a business model around mission-driven population health priorities.

While the Maryland waiver isn’t 100% Medicaid focused, it is still really important for Medicaid. One, global budgeting enables/forces hospitals to think about patients’ health needs more broadly, and Medicaid covers some of the people (children, poor, disabled) most affected by social and environmental determinants of health. Second, the Affordable Care Act created Section 1332 waivers, which will enable states to apply for waivers that include Medicare, Medicaid, and CHIP. This means Maryland may be a harbinger of things to come…


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