Leveraging Robust Evaluation Principles to Make Medicaid Better
A core element of all Medicaid Section 1115 “research and demonstration” waivers is an evaluation of the demonstration program and its efficacy in meeting the demonstration’s goals. Historically, however, Section 1115 waiver evaluations have been an afterthought for states and CMS, limiting their ability to inform future Medicaid policy and financing approaches. While CMS has been working to clarify and enhance its requirements for states in hopes of improving the quality of waiver evaluations, more work needs to be done to make these costly and time-consuming studies valuable to the Medicaid program.For example, randomized controlled trials (RCTs) are a powerful research method, used to produce credible estimates of the causal effects of new interventions. While widely used to evaluate drug safety and efficacy, RCTs have less often been used to evaluate health care delivery interventions in Medicaid—with important implications for state and federal policymakers.As discussed in a piece just published in in the New England Journal of Medicine, which I co-authored with Jacob Wallace and Atheendar Venkataramani, professors at the Yale School of Public Health and the Perelman School of Medicine at the University of Pennsylvania, respectively, Medicaid Section 1115 waivers provide an ideal vehicle for the use of RCTs.Section 1115 waivers, which authorize and finance state experimentation in Medicaid policy, include a mandatory evaluation component. With greater use of RCTs, states and the federal government could ensure access to more robust and credible evidence about the impacts of the innovative policies and interventions tested under Section 1115. The article suggests several ways CMS can support the use of RCTs in connection with Section 1115 waiver evaluations. As noted, better evidence provides a basis for better policy, both for Section 1115 waivers and for Medicaid more generally.