Q&A with Dr. Nathan Chomilo, Medicaid medical director

As a kid, Nathan Chomilo watched his parents — a nurse and pharmacist who immigrated from Cameroon to Minnesota — give health advice to people while out at community events.

“They were always wearing their pharmacist or nurse hat,” said Chomilo. “I really respected that and looked for my own way to help folks and also be part of the community.”

Today, Chomilo is a pediatrician at HealthPartners Park Nicollet and the medical director for Minnesota’s Medicaid program — known as Medical Assistance — a role he assumed just before the pandemic in January 2020. A little over a year later, he also served as the state’s COVID-19 vaccine equity director.

In his roles with the state, Chomilo has put addressing health racial disparities front and center. He has long been interested in studying child brain development, prenatal and maternal health disparities, and other social factors, like housing and nutrition, that lead to healthy — or unhealthy lives — for kids. The killing of Philando Castile by a police officer six years ago, however, spurred Chomilo to really consider the role of structural racism in health, as well. 

“Seeing a guy my age with a young child in the back of the car, and then being asked to go into spaces and talk about my experiences as a Black man in medicine, it led to a lot of reflection,” Chomilo said. “What do I, as a physician, and what does health care do that leads to folks losing their life or suffering?”

The following interview has been edited for length and clarity. 

What motivated you to apply to be the medical director for Minnesota’s Medicaid program?

In my five-year plan, I was never aiming to be the Medical Assistance medical director. It aligned with the work I was doing more broadly to address structural racism in health care and bring the conversations I was having in the community and amongst other physicians and health care leaders to the payer side. In our society, a lot of change happens in response to payment and the way the money flows, and so Medicaid as the biggest payer in particular for communities who are historically disadvantaged — especially Black, Indigenous, and other communities of color — I saw a lot of opportunity to help.

Also in my practice as a pediatrician, half of my patients are on either Medicaid or MinnesotaCare. (Editor’s note: That’s public insurance for the working poor.) When we look at how kids get coverage, a larger percentage get their coverage through Medicaid, and so there was a real opportunity to influence children’s access to care. One of my big areas of advocacy prior to this role was in early childhood and talking about the role of early brain development and how it’s really a critical window and sets the trajectory for so many of the disparities we see. They start within those first three to five years. 

What are some of the inequities you see in health care in Minnesota?

It’s no secret that Minnesota has some of the best outcomes when you look at education and health care in particular — when you look at the average and you look at white Minnesotans. But when you desegregate the data and look at Minnesotans who identify as Black or Native American, those who have lower incomes, we have some of the largest gaps. That really speaks to a structural cause and decisions that have been made over generations about who gets access to which resources.

I’m advocating for investments in our data collection, too. We use race, ethnicity, language data to try to identify gaps and outcomes, but diversity is changing, and the data isn’t keeping up. We use the same five broad racial categories that don’t really capture everyone’s experience, and that can give us false beliefs about what the disparities really are. 

As the COVID-19 vaccine equity director, a lot of my conversations with communities were around, how do we identify where there are gaps in COVID-19 vaccination? For example, when you look at the large Asian/Pacific Islander category, which captures so many distinct cultures and communities, it looks like they’re doing pretty well. They had relatively lower numbers of deaths and hospitalizations and higher vaccination rates. But the Coalition of Asian American Leaders last spring did an analysis with the University of Minnesota and actually found that when you looked at just the zip codes where it’s predominantly Hmong and Karen refugees, they actually had some of the highest death rates. In fact, COVID-19 was the leading cause of death in those communities in 2020, and they had some of the lowest vaccination rates early on in the vaccination campaign.

What other policies would you like to see the state adopt to address some of these health inequities?

My job is to put forward proposals that the governor considers and puts in budget proposals each year. I’ve been involved in advocating for things like the expansion of postpartum coverage to 12 months and expansion of funding for a grant program for integrated care for high-risk pregnancies that focuses on American Indian and African-American mothers and families. Also, increasing continuous eligibility for children on Medicaid up to age 21 months. I think all state agencies need to understand which communities are experiencing gaps and how they can be engaging with those to better serve them and fill those needs, so having funding on the Medicaid side to do that, funding for navigators who help folks enroll in health care, is helpful, too.

You mentioned that Minnesota is actually doing well in some areas. What are these? 

Whenever someone asks this, I always lead with the caveat that we’re doing well on a curve that is the U.S. public health system, which is chronically underfunded. But on that curve, I think we do a really good job in our public health surveillance. The work we’ve done around COVID-19, engaging with communities and having COVID community coordinators is good. On the payment side — for my Medicaid hat — we’ve got some innovative models through our integrated health partnerships. Minnesota Medicaid was one of the first — and still one of the few — Medicaid agencies to pay for doula care and for community health workers. 

When you look outside of the state, you have the University of Minnesota School of Public Health Center for Antiracism Research for Health Equity, led by Rachel Hardeman. That’s hopefully going to give us a way to measure and directly address structural racism’s impact on public health and health care. I think there are lots of areas where we’re leading in innovation, but I think there’s also a lot of opportunity to do better. 

What do you see as the biggest public health challenge in Minnesota today?

I think the challenge remains: Are we going to materially and substantially change our system in response to COVID-19 and George Floyd’s murder? I saw a lot of statements about commitment to racial equity and commitment to Black lives, but I haven’t seen a whole lot of change, particularly in the private sector. What is the private sector doing? I work for the health care system, but I don’t have paid family leave, even though my health care system loves to talk about the importance of early brain development. It’s really frustrating to see that. 

There’s been a lot of education, a lot of conversations, but payment isn’t really changing. We can’t change payment without the Legislature’s buy-in, so we’re trying to do things we can to incentivize folks in the managed care organizations that we contract with. But what I’m hearing in the community is that nothing has changed significantly yet when it comes to access to care itself. 

It’s also frustrating to see that payers can and do use their levers legislatively to get things passed. I don’t think too many people know that even though we didn’t pass a whole lot this last session, what did pass was an $890 million bill for reinsurance for three years, and that money is going to go to insurers. Where’s that same energy to advocate for things like paid family leave or other policy changes that we know would address some of the disparities and gaps we see, particularly those experienced by Black and Indigenous communities?