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Improving Credit Health After A Claim: Kansas Attorney Recommendations – Extensive research and the pandemic have increased the importance of addressing social determinants of health (SDOH) to improve health and reduce chronic health and health care disparities.1 Social determinants of health include factors such as socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, such as access to health care. Prior to the pandemic, both health and non-health sectors have been engaged in initiatives to address social determinants of health. Additionally, in response to the pandemic, legislation has been enacted to provide significant new funding to address the health and economic impacts of the pandemic, including direct support to address food and housing insecurity, such as stimulus payments to individuals, federal unemployment insurance payments, and extended child tax credit payments. While measures like these have a direct impact in helping to address SDOH, health programs like Medicaid can also play a supporting role. Although federal Medicaid rules prohibit spending for most non-medical services, state Medicaid programs have developed strategies to identify and address social needs of enrollees both within and outside of managed care. CMS published guidance for states on opportunities to use Medicaid and CHIP to address SDOH in January 2021.
This brief describes options federal Medicaid authorities and states can use to address the social determinants of enrollee health (Figure 1) and provides state examples, including initiatives launched in response to the COVID-19 pandemic. The focus of this brief is on state-driven Medicaid efforts to address social determinants for nonelderly enrollees who do not meet functional status or health needs criteria for home and community-based services (HCBS) programs.
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Social determinants of health are the conditions in which people are born, grow, live, work and age.2 They include factors such as socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, such as access to health care (Figure 2).
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Although health care is essential to health, research shows that health outcomes are driven by an array of factors, including underlying genetics, health behaviors, social, economic, and environmental factors. While there is currently no consensus in research on the extent of the relative contributions of each of these factors to health, studies suggest that health behaviors and social and economic factors are primary drivers of health outcomes, and social and economic factors can individuals form ‘ health behaviour. There is extensive research that concludes that addressing social determinants of health is important for improving health outcomes and reducing health disparities.3
The COVID-19 pandemic exacerbated already existing health disparities for a wide range of populations, but specifically for people of color. Data from the Census Bureau’s Household Pulse Survey show that black and Hispanic adults are worse off than white adults in nearly every measure of economic and food security over the past year. For example, in April 2021, nearly two-thirds of Black adults and seven in ten Hispanic adults (64% and 70%, respectively) reported difficulty paying household expenses compared to 42% of White adults; 7% of black adults and 12% of Hispanic adults reported no confidence in their ability to pay for housing next month compared to 4% of white adults, and 14% of black adults and 16% of Hispanic adults reported lack to food in the household compared to 5% of White adults. Although these disparities in social determinants of health existed prior to the pandemic, the high current levels among certain groups highlight the disproportionate burden of the pandemic on people of color.
Prior to the pandemic, there were a variety of initiatives to address social determinants of health, both in health and non-health sectors. Outside the health care system, non-health sector initiatives seek to shape policies and practices in ways that promote health and equity. Within the health care industry, a wide range of initiatives have been launched at the federal, state, and local levels and by plans and providers to address social determinants of health, including efforts within Medicaid. These efforts stem from increasing rates of coverage under the Affordable Care Act (ACA), new financing and demonstration authorities provided by the ACA, and an increasing shift across the health system toward value- or outcome-based payments and “whole person” care. The Centers for Medicare & Medicaid Services Innovation Center (“CMMI”) was authorized under the ACA and is charged with designing, implementing and testing new health care payment and service delivery models that aim to improve patient care, reduce costs lowering, and better align payment systems to promote patient-centered practices. In April 2017, CMMI launched the “Accountable Health Communities” (AHC) Model to test different approaches to support local communities in addressing the health-related social needs of Medicare and Medicaid beneficiaries. The model aims to bridge the gap between clinical and social service providers and was the first CMS innovation model with a primary focus on social determinants of health.
State Medicaid programs can add certain non-clinical services to home and community-based services (HCBS) programs to support seniors and people with disabilities. In general, states have not been able to use federal Medicaid funds to pay the direct costs of nonmedical services such as housing and food.4 However, within Medicaid, states can use a variety of state plans and waiver authorities (e.g., 1905 (a) ), 1915(i), 1915(c), or section 1115) to add certain nonclinical services to the Medicaid benefit package including case management, housing support, employment support, and peer support services. Historically, non-medical services have been included as part of Medicaid programs for home and community-based services (HCBS) for people who need help with self-care or household activities as a result of disability or chronic illness.
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Outside of Medicaid HCBS authorities, state Medicaid programs have more limited flexibility to address social determinants of health. Certain options exist under Medicaid state plan authority, such as Section 1115 authority to add non-clinical benefits. Additionally, under federal Medicaid managed care rules, managed care plans have some limited flexibility to pay for non-medical services. Other Medicaid payment and delivery system reforms, such as the formation of Accountable Care Organizations (ACOs), may provide flexibility or opportunities to cover non-medical services that also support health.
To encourage the adoption of strategies that address the social determinants of health in Medicaid and CHIP, CMS published guidance for states in January 2021. The remaining sections outline the primary Medicaid authorities and flexibilities that can be used to provide benefits and add design programs to address the social determinants of health for nonelderly enrollees who do not meet functional status or health criteria required for Medicaid home and community-based services (HCBS) programs. Some efforts may address a single problem (eg.
States may choose to include optional benefits that address social determinants under Section 1905(a) State Plan authority. For example, states may include rehabilitative services, including peer support and/or case management (or “direct” case management5) services, under their Medicaid state plan. States that choose to offer these services often focus on services based on health or functional need criteria. Peer support can help individuals coordinate care and social support and services, facilitating connections to housing, transportation, employment, food services and other community-based supports. Case management services can also help individuals gain access to medical, social, educational, and other services. Case management services are often an important part of HCBS programs, but can also be used to address a broader range of enrollment needs.
States can provide broader services to support health through the optional option for home health benefit plan established by the ACA (Figure 3). Under this option (section 1945), states can establish health homes to coordinate care for people who have chronic conditions. Home health services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, as well as referrals to community and social support services (such as housing, transportation, employment, or nutrition services). States receive a 90% federal matching rate for qualified health home service expenditures for the first eight quarters under each health home SPA.6
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7 A federally funded evaluation of the health home model found that most providers reported significant growth in their ability to connect patients to nonclinical social services and supports under the model, but that lack of stable housing and transportation were common issues for a many enrollees who were difficult for providers to address with insufficient affordable housing and rental support resources.8
Through Section 1115 authority, states may test approaches to addressing SDOH, including requesting federal matching funds to test and support SDOH-related services in ways that promote Medicaid program goals. States may receive approval for Section 1115 demonstration waivers that test broad changes in Medicaid eligibility, benefits and cost sharing, and payment and delivery systems, as long as the Secretary determines that the demonstration advances the objectives of the Medicaid program. Although not required by statute, longstanding policy requires that Section 1115 waivers be budget neutral for the federal government. States must conduct independent evaluations of Section 1115 demonstrations to determine their impact and effectiveness. States may apply for federal matching funds through section 1115 to test the effectiveness of providing services such as one-time community transition services (to supportive housing) for
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