Medicaid and Social Determinants of Health: ASTHO and HHS Engage State and Local Leaders in Dialogue

January 17, 2017|5:08 p.m.| Karen DeSalvo and Michael Fraser

Social determinants of health are the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. By some estimates, 60% of premature deaths were rooted in modifiable behavioral patterns, environmental exposure, and social circumstances that are part of these social determinants of health. Yet in spite of the impact of these non-medical factors, nearly 95% of U.S. healthcare dollars were spent on providing medical care with limited attention to addressing the broader determinants of health. Delivery system reform and the rising implementation of value-based and population health payment models is increasing driving payers, the health care system and providers to address all the determinants of health to achieve the best outcomes at the lowest cost.

As part of this trend, public and private payers, including Medicaid and Medicare, are using financial incentives to encourage providers to address the social needs of their patients as well as the social conditions in the communities in which they serve. According to the most recent Kaiser Family Foundation 50-state Medicaid budget survey, states are using managed care and alternative payment models to improve quality and to help screening for social factors impacting health outcomes. In FY 2016, twenty-six states reported requiring or encouraging managed care organizations to screen for social needs and provide referrals to services, and four states intend to do so in FY 2017.

On January 6, 2017, ASTHO gathered state health officials, state Medicaid directors, and HHS and non-profit stakeholders from the New England and Empire regions to learn from one another and identify new ways to collaborate to achieve better health for their communities. Already the Medicaid program offers certain flexibilities to enable public health and state Medicaid directors to coordinate with one another to address the social determinants of health, making a marked impact on beneficiaries’ quality of life, from housing assistance to food and nutrition services to direct support in care coordination.  Indeed many states take advantage of these legal and regulatory authorities, such as state plan amendments, waivers, and Medicaid Managed Care.

In addition to sharing best practices, we also used the convening as an opportunity to share resources that describe the policy options available to state Medicaid and public health leaders in this work. These reports also include examples of models that have already been explored and are in some cases showing results. We include them here to more broadly share them with others interested in better understanding Medicaid’s role in addressing social determinants of health in the Public Health 3.0 era.

1.   Health Policy Brief: Medicaid and Permanent Supportive Housing. Health Affairs. October 2016. by Amanda Cassidy.

This policy brief discussed new opportunities and flexibility offered by Medicaid expansion under the Affordable Care Act to improve access to housing and the services needed to maintain supportive housing.

2.   Medicaid Coverage of Social Interventions – by Deborah Bachrach, Jocelyn Guyer, Ariel Levin at Manatt Health/Milbank/NYS Health. July 2016.

This report summarizes existing mechanisms, including but not limited to waivers, which support four categories of social interventions: (1) Linkages to social services programs; (2) Stable housing (3) Employment and job security; (4) Peer and community support.  

3.   (Re) defining the healthcare delivery system: The role of social services – by KPMG Government Institute & Columbia University Mailman School of Public Health. May 2016. 

This white paper examines the effort by public officials to include “social” interventions into health delivery systems. Drawing on insights from the academic literature and lessons from two key New York DSRIP case studies, the authors highlight the opportunities and successes as well as the tactical and policy challenges that states face in creating effective integrated health systems.

4.   Accountable Health Communities—Addressing Social Needs Through Medicare and Medicaid. New England Journal of Medicine – by Dawn Alley, Chisara Asomugha, Patrick Conway, and Darshak Sanghavi. January 2016.

This paper describes CMS’s 5-year, $157 million program to test the Accountable Health Communities, a delivery model for addressing health-related social needs among community-dwelling Medicaid and Medicare beneficiaries, on its impact on cost and health outcomes.

5.   Beyond Healthcare: The Role of Social Determinants in Promoting Health and Health Equity – by Harry Heiman and Samantha Artiga at Kaiser Family Foundation. November 2015.

This brief overviews the rationales and emerging efforts that address social determinants of health within the context of healthcare delivery system, including initiatives within Medicaid.

6.   Supportive Housing for Chronically Homeless Medicaid Enrollees: State Strategies – by Kathy Moses, Allison Hamblin, Stephen Somers at the Center for Health Care Strategies. July 2015

This report highlights opportunities and considerations for Medicaid to address housing needs of chronically homeless population.

7.   Supporting Social Service Delivery through Medicaid Accountable Care Organizations: Early State Efforts – by Roopa Mahadevan, Rob Houston at the Center for Health Care Strategies and the Commonwealth Fund. February 2015.

This report describes early efforts by state Medicaid agencies to incorporate social services, including housing, nutrition assistance, employment counseling, transportation, language and literacy training, and legal and financial services ACO models, including key themes and considerations for other states.

Looking ahead, ASTHO will continue to engage stakeholders in other regions around the country and will expand the conversation to include state human services commissioners who are another integral piece of the puzzle along with their counterparts in public health and Medicaid. Both ASTHO and HHS believe that this Public Health 3.0 approach can – particularly through strategic cross-sector collaboration and increased flexibility and ingenuity in funding – improve health and health equity for the whole person and for whole communities.  We expect that rigorous evaluation coupled with innovation at the federal, state, and local level will bring evidence to the policy debate and provide tangible, scalable and sustainable health financing models that can spread to touch the lives of millions.

Karen B. DeSalvo, MD, MPH, MSc, is the acting assistant secretary for health in the U.S. Department of Health and Human Services.

Michael Fraser, PhD, CAE, FCPP, is the executive director of ASTHO.