Blueprints for better care: Matt Dean on cleaning up Medicaid and patient-centered reform
Matt Dean is a policy fellow at the Center of the American Experiment, where he focuses on healthcare policy and reform. A former Minnesota legislator, he served seven terms in the House, including as Majority Leader and chair of the Health and Human Services Finance Committee. Dean has also worked with the Heartland Institute on healthcare policy outreach and led bipartisan efforts to cut fraud and expand patient choice. He recently spoke with American Habits Editor Ray Nothstine.
You worked extensively on Medicaid during your time in the Minnesota Legislature. From your experience, what are the biggest weaknesses in Minnesota’s Medicaid system today?
Matt Dean: Minnesota’s problems with Medicaid are like what we see across the country: it’s exploded in size. Enrollment grew dramatically after expansion and then again during the COVID pandemic.
Right now, we have a massive program and more than a million Minnesotans, or over one in five people, are on Medicaid. The program was originally designed for those who are very low income or disabled, but it’s become a middle-class alternative for many families.
Even more troubling, many of the enrollees aren’t eligible. In Minnesota, we contract with managed care organizations (MCO) to administer Medicaid. These companies receive monthly payments for enrollees, including some who no longer qualify. Some recipients have moved out of state, make too much money, are on another program, or have even passed away. Yet the MCOs still get paid.
The biggest issue is eligibility determination and redetermination. People can sign up easily, but if they leave, get a job, or change circumstances, they often stay on the rolls. Utilization is up, but people aren’t necessarily healthier or getting better care.
At the American Experiment, we estimated last year that as many as one in five Medicaid recipients in Minnesota could be “phantom patients.” When people turn 65 and move to Medicare, they’re asked what program they were on before. We found about 20% of those who reported being on Medicaid weren’t showing up in the data, which means they still had a policy, or even multiple ones, without realizing it.
Given your experience work in healthcare in the legislature and still today, what are a few ways Medicaid could be improved in Minnesota? I know there have been some federal changes, including new verification requirements meant to strengthen financial accountability. But what would you do to make the system better?
Dean: We just published a report at the American Experiment on what states can do to strengthen program integrity—what I like to call the “low-hanging fruit.” Actually, it’s more like the fruit that’s already fallen into the basket. The simplest and most immediate fix is to clean up eligibility.
If you can improve eligibility verification, making sure people on the rolls are indeed eligible, that’s the easiest, quickest way to save money and protect resources for those who really need care. Removing people who have died, moved, or are on other programs doesn’t harm anyone. It just saves taxpayer dollars.
Back when I served in the legislature, I introduced a bill called “I’m Not a Robot.” It was very simple. It said to the insurance companies managing Medicaid: “We’re happy to pay for Ray’s Medicaid coverage, but we need to make sure Ray is alive, still lives in Minnesota, and actually wants the coverage.” The company could confirm that by email, phone, or even a home visit. We required some form of verified contact before renewing another year of payments.
Under the bill, if a company verified that information, it would receive the full payment. If not, part of the payment would be withheld until verification happened. It wasn’t about cutting anyone off; it was solely about confirming eligibility.
Oddly enough, that bill faced bipartisan opposition. Still, most people I talk to hear the idea and say, “Why aren’t we already doing that?” It’s such a basic step that could save a lot of money and ensure the funds are going to real patients, not merely padding the operations of insurance companies.
Minnesota is widely known for having some of the best healthcare in the world—the Mayo Clinic immediately comes to mind. But we also hear so much negative news about healthcare in general that it can feel discouraging. I think a lot of Americans have experienced that simply having coverage doesn’t necessarily mean you’re getting good care. Are there lessons or positives we can take from Minnesota today?
Dean: Absolutely. As you mentioned, the Mayo Clinic provides the best care anywhere. When the Mayo brothers founded it, their guiding principle was that “the best interest of the patient is the only interest to be considered.” That philosophy, always asking what’s best for the patient, still defines how they deliver care today. It’s one reason their model remains so innovative and renowned.
Minnesota also benefits from a strong research and medical community through partnerships like the Mayo Clinic and the University of Minnesota. Those institutions continue to produce breakthroughs that alleviate suffering and cure diseases. But it’s become harder to innovate when so much of the system is bogged down by red tape, mandates, and the threat of litigation.
That’s why at the American Experiment; we focus on two big areas: payment reform and care delivery. Mayo isn’t great because the government gave it a lot of money. It’s great because of how it delivers care. Their doctors are all paid the same, regardless of how many patients they see. That means they’re not driven by volume but outcomes. They also work in teams, taking a collaborative approach to each patient, and they constantly look for innovative ways to improve recovery and care.
There’s still so much to be optimistic about. Yes, Washington, D.C. can be frustrating, but many people still go into medicine for the right reasons. I love that the smartest kids in the class still want to be doctors. Even though more of them are drawn to finance or hedge funds now, I think the medical field still attracts people with compassion and purpose.
I can’t relate to that. I had to give blood just to pass biology in college, so I knew a medical career wasn’t in my future. I always thought it would be fascinating to be a surgeon, but if Biology 101 is a struggle, that’s likely a sign.
Dean: [laughs] As a legislator—and especially when I chaired the Health and Human Services Committee—I used to joke that one of my main jobs was to keep legislators from practicing medicine.
As both a healthcare expert and a citizen, are there any advances you’re particularly excited about in medical policy or technology? I know artificial intelligence is getting a lot of attention right now, but what stands out to you personally?
I think there’s a lot to be optimistic about on the delivery side of medicine. One major change is how telemedicine has evolved. The pandemic forced us into remote care almost overnight but it turned out to work far better than many expected.
…many people still go into medicine for the right reasons.
About 70% of people who had virtual visits with their doctors said they wanted to do it again. They liked the convenience, and it made care more accessible, especially for patients who are elderly, disabled, or homebound. That’s a huge opportunity for Medicaid and Medicare patients who often struggle with transportation or mobility.
What’s exciting is how this technology can integrate with other kinds of care. There’s a Minnesota company called HealtheMed, started by Steve Pontius—the same innovator who founded MinuteClinic. HealtheMed takes telehealth a step further. It uses patients’ TVs, something even most elderly people are comfortable with, to deliver care right in the home.
Here’s how it works: the system connects to medical devices that take blood pressure, weight, and other readings in real time while the patient interacts with a clinician via video. There’s even a small robot that dispenses medication, morning and evening doses, so you can see patients take their meds and verify adherence. The clinician can then mark patients as “green, yellow, or red” based on how they’re doing. Keeping more people in the green means fewer hospital visits and lower overall costs.
We’re testing this approach in a small pilot program across four counties in Minnesota. The goal is to prove that better home management can improve outcomes and reduce costs for the state.
You’re an architect by training. Does that background give you any advantages as a legislator? I imagine there might be some parallels between designing a building and shaping healthcare policy—both require vision, structure, and collaboration.
Dean: Definitely. When you build a building, you have to bring together people who may not know each other or agree with each other—contractors, engineers, designers, financiers—and get them all working toward one goal. You have a deadline, a budget, and clear standards to meet. Everyone must stay focused on getting the project done, on time and up to code.
That experience translates well to the legislature. In politics, you also have a budget, a deadline and a bunch of people trying to get their own priorities across the finish line, sometimes while practically strangling each other in the process.
As an architect, you learn to manage those competing interests and keep everyone moving forward toward a finished product. I’ve talked with other architects who’ve served in public office, and they say the same thing. The end result, legislation, isn’t as pretty as a building, but it still requires the same kind of collaboration, structure, and persistence to get it done.
