The Child and Adult Core Sets were established to measure the quality of care for Medicaid and Children’s Health Insurance Program (CHIP) enrollees, nationally and at the state level, based on a uniform set of measures. The goal of the Core Sets is to monitor performance and improve the quality of healthcare. Starting in fiscal year (FY) 2025, states will be required to report a subset of Child and Adult Core Set measures (see Table 1) by race and ethnicity, sex, and geography.

By requiring data disaggregation for key populations of interest, policymakers, advocates and researchers will have a new tool to measure, monitor and inform policies and practices that focus on health equity.

Table 1: Core Set Measures Subject to Stratification (10 Measures in Total)

*No longer endorsed by NQF.

States will be required to stratify these mandatory measures using the following categories:

• Race and ethnicity: Using the newly released 2024 Revisions to the Office of Management and Budget’s Statistical Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. Minimum categories include:
  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino
  • Middle Eastern or North African
  • Native Hawaiian or Pacific Islander
  • White

• Sex: Defined as biologic sex, using the 2011 HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. Categories include:
  • Male
  • Female

• Geography: Using the core-based statistical area (CBSA), which are county-based statistical areas defined by large population areas, as a minimum standard. Those categories include:
  • Metropolitan statistical area (population core of 50,000 or more)
  • Micropolitan statistical area (population core of 10,000 to 49,999)
  • Outside Core Based statistical area

Background and Context

Every year, the Secretary of the U.S. Department of Health and Human Services is required to review and update the Child and Adult Core Sets. This review is designed to detect measurement gaps and to identify and recommend revisions to improve and strengthen the Core Sets. This review is led by a workgroup that includes input from a variety of stakeholders including states, managed care plans, healthcare providers, and quality experts. In response to the annual review process, state reporting of these measures has evolved and starting in FY 2024, reporting of the Child Core Set and the Core Set of behavioral health measures for adults enrolled in Medicaid became mandatory. 

Over time, the Core Sets have been specifically recognized as a critical tool to monitor health disparities. Increasing stratification of the measures is a priority area for the Centers for Medicare & Medicaid Services (CMS) and in guidance released in 2022, CMS explicitly encouraged states to “use Core Set data to identify disparities in care and to develop targeted quality improvement efforts to advance health equity.”  

During the review of the 2025 Core Set Measures, the Core Set review workgroup discussed using stratified Core Sets data to advance health equity. Workgroup members who represent state and enrollee perspectives both highlighted the importance of disaggregation for assessing member experience and monitoring equity while also acknowledging the challenges inherent to data collection and reporting. In response to this discussion, the following challenges and considerations were highlighted in the final FY 2025 recommendations report:

• Data on enrollee demographics is of variable quality, with missing and unknown data (enrollees who don’t provide data and related hesitancy).
• Administrative burden to collect this information.
• Political considerations for how the data are collected and reported (balancing state legislative agendas compared to CMS requirements).
• Technical challenges, such as having multiple conflicting sources of data.
• Misalignment of reporting stratification categories with other federal and state program requirements.
• Need to engage enrollees in the collection and use of these data.
• Need for technical assistance to states to meet the new reporting requirements.

Despite these challenges, there was consensus among the workgroup about the importance of stratification, which aligned with the new requirement that 10 measures be reported by race and ethnicity, sex, and geography. Specifically, for FY 2025 reporting, states will be required to report stratified data for the seven Child Core Set measures listed above in Table 1 (25% of the 27 measures) and three of the Adult Core Set behavioral health measures (25% of 11 behavioral health measures).

Required stratification of additional measures will increase over time and the intent is that all eligible mandatory Core Set measures will be disaggregated by FY 2028. States have the option of reporting stratified data for all measures starting in FY 2025.  

People’s experience of health inequities based on race and ethnicity, sexual orientation, gender identity, geography, immigration status, and other factors, is a longstanding and pervasive problem that is deeply rooted in discrimination and structural racism. The Medicaid program, through its policy, financial, and programmatic levers, is uniquely situated to address the health inequities experienced by the program’s diverse population of enrollees. Key to these efforts is the availability of comparable state programmatic and performance data to identify and track progress.

For this reason, the move toward disaggregated Core Sets data by race and ethnicity, sex, and geography is an important step to improve the monitoring of health care access and quality for Medicaid enrollees, to further identify where disparities exist and to develop and evaluate quality improvement efforts. However, this is a small step that needs to expand to identify other groups that have been economically and socially marginalized such as those with a disability, individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, or outside the gender binary (LGBTQI+), and those with limited English proficiency.

In addition to expanding data disaggregation to include a broader range of groups, it will also be important to provide states with the necessary resources and technical assistance to analyze and report these data in an accurate and comparable way. As was also noted in comments to the workgroup, enrollee engagement in the collection and use of these data is also key for advancing health equity. Community engagement is a way to establish and build trust and to develop interventions informed by the lived experience of Medicaid enrollees.

Finally, it will be critical to provide states, providers, and community partners with the resources and tools necessary to ensure that timely action is taken to actually address, and not just report on, systemic inequities.

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