Abstract

The changes to Medicaid funding aren’t coming – they’re here. Drawing from my experience running health plans and talking with leaders across the country, I’m laying out exactly what plans need to do right now. No theoretical frameworks or vague suggestions – just practical steps to protect your members and make the most of your resources in this new reality. If you’re a plan leader trying to figure out what’s next, here’s what actually works.

3 minute read

Author: Trey Sutten

First off, two things.

This isn’t going to be a political piece. I don’t want what could be a valuable resource to turn into an opinion piece when we need real solutions and action. That’s what I want to talk about – what’s actually useful and helpful for plans right now.

The end goal here is to provide practical things that plan executives can start doing today, this week, this month. If you’re reading this and have something that’s worked for your plan, I want to hear about it.

Speaking of, we’re hosting a conversation this February with Medicaid directors, health plan leaders, and community organizations to discuss real-world ways to safeguard these vital programs. I’d love for you to join us.

Why This Matters Now

I didn’t write this because I wanted to – I wrote it because I felt like I needed to. Let me be direct: The changes we’ve been preparing for are here. This isn’t theoretical anymore – it’s happening. As I meet with community health plan leaders and sit on panels, one question keeps coming up: How can and should health plans adapt to these Medicare/Medicaid/Marketplace changes right now?

I’ve been answering this based on my experience as a former Medicaid CFO and health plan CEO. Two things started happening: I got better at giving concrete answers the more I dug into it, and I started talking to a lot more people to get their take.

Some of those conversations were super helpful – you’ll see those thoughts reflected below. Others… not so much. I got a lot of “We’re all going to have to come together and do our best.”

Let me address that last point first. As of yesterday, we are seeing real change happening with significant cuts to programs that impact M/M/M funding and programs our members rely on.

Let’s not use hope as a strategy. These reductions are already impacting real people in real ways. Health plans need to get organized and start moving. Here’s how:

What Plans Need to Do Now

  1. Get Deep Understanding of Your Members – I don’t mean “this zip code has a lot of readmits” or “we have a NICU problem over there.” I mean really deep. Understand every member’s needs – medical, behavioral, Rx, and social needs. Every single one. Then you can thoughtfully group them for targeted support that makes sense.
  2. Know Your Capacity Inside and Out – This isn’t just about internal capacity. Take a hard look at all your CBOs and social needs programs. Where are your food pantries? How broad is your transport program? Who’s handling social connectedness for members and how much can you actually do? Don’t stop at medical, BH, and Rx. When you find holes, either rebuild old relationships or create new ones to fill the gaps.
  3. Match Members to What They Actually Need – This is the hard part, but it’s crucial. You have to figure out how to connect the right member with exactly what they need most. Resources have always been tight, but this is about to become even more critical.

The Data Revolution That Actually Matters

For us at Siftwell, this is exactly the reason we built what we built. We see our clients getting remarkable results when they layer traditional healthcare data with social determinants of health (SDOH) and health-related social needs (HRSN) information. This isn’t just about gathering more data – it’s about making it actionable.

Here’s what our clients have been doing for a while now:

  • Moving beyond basic risk scores to understand the full context of member lives
  • Using predictive analytics to spot high-risk members 6-12 months before crisis
  • Running targeted interventions that work because they know exactly how to reach members – whether they prefer texts over calls, need info in Spanish, or face barriers like lack of transportation
  • Building real partnerships with community organizations that extend their reach

The Bottom Line

The future of Medicaid isn’t about doing more with less – it’s about doing better with what we have. No health plan is an island, especially now. The changes to Medicaid are significant, but they don’t have to be devastating. It’s about how we move forward now that they’ve arrived.