Addressing social determinants of health through Medicaid expansion 

Until her last year of undergrad, Hannah Shadowen had no intention of enrolling in a dual-degree program. Now an M.D.-Ph.D. candidate, Shadowen has received the Ruth L. Kirschstein National Research Service F30 Award for her dissertation on the relationship between Medicaid expansion and how it reduces financial burdens for underserved families in Virginia. The award will fund the continuation of her research and the remainder of her M.D.-Ph.D. program. 

Named after the first female director of an NIH institute, this award supports the integrated research and clinical training of promising predoctoral students in M.D.-Ph.D. and other dual-doctoral degree programs.  

As a third-year M.D.-Ph.D. candidate in the Department of Health Behavior and Policy, Shadowen focuses on how Medicaid can function not only as a health insurance tool, but as a resource to address social determinants of health. 

“Having the NIH fund my research was really exciting,” Shadowen said. “I think it also speaks to science moving in the direction of recognizing that structural racism does impact people’s health. I find that important from a science, public health and policy perspective.” 

Realizing a love for research 

Before coming to VCU School of Medicine, Shadowen volunteered for the Charlottesville-Albemarle Rescue Squad, where she assessed patient complaints, provided care and transported patients to the hospital. Her experience as a squad member were foundational to her understanding of medicine and societal inequities, and it altered her career path. 

“It showed me how different environments can affect people’s health, which made me want to get my master’s in public health,” Shadowen said. “I fell in love with the research during my M.P.H., but since I didn’t have enough time to develop those skills, I thought the M.D.-Ph.D. route complemented my love of research and medicine.”   

Shadowen now works with Department of Health Behavior and Policy professors Andrew Barnes, Ph.D., and Peter Cunningham, Ph.D., as third-party evaluators of Medicaid expansion programs contracted by the Virginia Department of Medical Assistance Services (DMAS), a state agency that administers all Medicaid health insurance benefit programs in Virginia.  

“Shadowen is a force of nature and I am so proud of her,” Barnes said. “She is gifted in her ability to be an extender on a team as someone who can push ideas to new places and follow through on them.” 

As evaluators, their aim is to determine whether the programs improve health insurance coverage and health conditions for Medicaid members. Shadowen also views the programs as potential tools to alleviate poverty in relation to patient care. 

“Individuals constrained by budget, housing or food insecurity can’t make the same choices they would otherwise make,” Shadowen said.  

Shadowen recalled providing primary care to a patient with a history of depression and anxiety during her ambulatory rotation at the Hayes E. Williams Health Center. The patient was facing eviction, which increased their anxiety to the point that they felt neither medicine nor any medical treatment could help. 

“When someone is living in a hotel or bouncing around homes, their primary concern is finding a place to live rather than health care advice,” Shadowen said. 

Investigating Medicaid benefits 

According to a report by DMAS, more than 500,000 low-income Virginians became eligible for Medicaid due to its expansion in 2019. The expansion gave Shadowen the opportunity to investigate the financial support Medicaid provided for new Virginia enrollees and who benefitted the most. To do so, Shadowen surveyed newly enrolled Medicaid members, inquiring about their health and financial status before and after enrollment.  

Shadowen explained that although improving the overall financial well-being of a household was not Medicaid's purpose, it does increase the financial ability of members to avoid bankruptcy, food and housing insecurity and pay off medical debts. 

“Prior to Medicaid expansion, health care providers wrote off about 70% of uninsured individual care, meaning the payment for care was not tied to a specific plan and providers were often left with a significant amount of unpaid care,” Shadowen said. “Since many who enrolled were either uninsured or in high-cost plans and Medicaid doesn’t have any premiums and offers little to no cost for care, we think these reductions in cost improve a household’s disposable income.” 

In 2022, Shadowen co-authored an article in the peer-reviewed Health Affairs journal on her research on Virginia’s Medicaid expansion, which revealed that newly enrolled Medicaid members who are Black, African American or live in rural areas experienced larger reductions in overall financial burdens after enrolling. 

Her findings supported her hypothesis that Medicaid can be a useful tool to improve the financial well-being of individuals in underserved communities, which became the basis of her dissertation. 

“I really want my work to not only showcase that Medicaid expansion is good in general, but is particularly beneficial for those who faced disadvantages in the past,” Shadowen said.  

Access through policy 

As an aspiring family medicine physician, Shadowen wants to provide patient care at a clinic, while also holding a position at a federal or state agency to develop health policies to help patients at the system level. 

Shadowen intends to condense her findings into research papers with hopes that it will result in legislative changes and Medicaid expansion in other states to increase access to patient care among marginalized communities. 

“My primary belief is that policies can help people, especially those who suffered the most due to structural racism, sexism and any kind of historical power and marginalization structures in America,” Shadowen said.