The debate about if and how to amend, repeal, or replace the Affordable Care Act has drawn attention to the central role that the Medicaid program plays in providing coverage and access to health care for millions of Americans. This central role positions Medicaid as an ideal platform on which to build an integrated system that simultaneously addresses health care and social needs.
Evidence has been building that social determinants of health have a bigger impact even than health care services on people’s health, functioning, and quality of life. But the United States, while arguably developing some of the world’s most powerful health care technologies, has been slower to systematically address social determinants of health. We spend more than any other country on health care, per capita, but achieve worse health outcomes, Betsy Bradley and Lauren Taylor document in their book The American Health Care Paradox. But when health care and social spending are examined together, the United States ranks 13 in total spending.
“Ignoring the economic and social circumstances that result in poor health makes treating the resulting health problems much more expensive,” one review of that book summarized. Bradley and Taylor have gone on to argue that a shift towards social services could improve health outcomes and reduce costs for the system overall.
The Medicaid program provides a plausible platform upon which to build a health infrastructure that incorporates the social determinants of health. Medicaid could provide a common entry point that links individuals and families not just to health care services, but also to social services that affect their health. Indeed, state Medicaid leaders have long embraced this concept and are experienced in building bridges that link health and social programs to meet the comprehensive needs of their citizens.
Where Medicaid Leads In Addressing Social Determinants
Medicaid programs have long been leaders in addressing social determinants of health. A range of innovations for incorporating social determinants of health have been tested in Medicaid programs across the country. State Medicaid programs make referrals to social services, directly connect individuals to needed services, align systems to share goals, and invest future savings to the health care system into social services programs. For example:
- In Pennsylvania, the online health and human services programs eligibility system known as COMPASS allows individuals and families to simultaneously apply for Medicaid, the Children’s Health Insurance Program (CHIP), and the health insurance marketplace, together with programs that administer food stamps, school lunches, child care assistance, and other benefits. There is evidence from a range of social programs that transaction costs—the difficulty of applying—significantly influence take-up rates. Single applications can facilitate access.
- Colorado’s Medicaid program divides the state into seven Regional Care Collaborative Organizations, each of which connects beneficiaries to health care providers as well as social and community services. The goal is to link every beneficiary with a primary care provider who not only serves as a central point of contact for medical care, but also assesses a person’s nonmedical needs.
- Louisiana, meanwhile, has embedded permanent supportive housing into Medicaid home- and community-based services, allowing for better integrated care for individuals who are homeless or at risk of homelessness.
- Recognizing the mutually reinforcing roles of health and education—health status influences a child’s ability to learn, for instance—Oregon began aligning its health care and early education systems around 2011. The Medicaid program and early learning systems share goals, staffing, and funding.
Additionally, Massachusetts, New York, Oregon, Utah, and Vermont are all testing strategies not only to link Medicaid and social services, but also to use Medicaid funds to actually deliver supportive services that affect social determinants of health. These value-based delivery system reforms include the creation of accountable care organizations, health homes, community health teams, and accountable communities for health.
Most recently, the Centers for Medicare and Medicaid Services (CMS) launched an initiative called Accountable Health Communities to better manage the health-related social needs of Medicare and Medicaid enrollees. The initiative will test whether systematically identifying and addressing the social determinants of health through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Over the next five years, the model will provide support to community organizations that link enrollees to services that address housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs. As CMS begins to test this model, there is reason for optimism, given Medicaid’s track record of integrating health care and social services.
Why Medicaid?
Why is Medicaid best suited to integrate health care and social services? To begin, Medicaid programs are up and running in all 50 states. Rather than starting from scratch to design an integrated social services platform, Medicaid can serve as a foundation upon which to build integrated health and social services systems. Building on Medicaid’s infrastructure by further integrating social services with health care may even result in health care savings down the road.
Second, Medicaid, as a federal-state partnership, can be tailored to the needs of each state’s populations and the unique circumstances that determine health outcomes in our vast and varied country. Though federal rules establish a baseline for Medicaid services, state Medicaid programs have been designed to fit into each state’s governmental ecosystem, facilitating linkages to other government-run programs.
Third, Medicaid is big. The program has enrolled more than 74 million people who thus are already connected to a system that can determine eligibility based on income and other factors and has the systems in place to conduct program enrollment. Furthermore, the federal requirement to enroll in health insurance continuously brings people into contact with the Medicaid program, which can then connect them to social services.
Finally, state Medicaid programs already have experience serving diverse populations who may benefit from a range of social services — the young and the old, families and individuals, and those with complex health care and related social needs. As leading states have been among the first to recognize, addressing social needs may result in positive health care outcomes for the populations Medicaid serves.
Rather than emphasizing personal responsibility for health care expenditures, the social determinants of health model recognizes that social conditions affect health care utilization, costs, and outcomes. The current health care system invisibly factors in social costs dependent on variables beyond an individual’s health choices. A social determinants model makes these factors visible and actionable. Health care costs will continue to rise until we address the underlying social conditions that affect health and wellbeing for everyone. As a national conversation continues about the role of health care in our society, there is a real opportunity to support and build on the Medicaid platform to address the social determinants that can improve health for all Americans.