The Department of Health and Human Services
(HHS) defines the social determinants of health as 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.” The concept, which comes from the global public health field, is at its best when it is
understood to encompass an individual’s social location—their race, ethnicity,
sex, class, ability, orientation, culture, and how each of these identities
impact them in their community context. It was created to identify and serve
the most vulnerable among the world’s populations and to address the inequities
that disproportionately impact their lives and their health.
In step with the growing popularization of the
term in US health policy, Trump administration health officials have frequently
espoused a commitment to more fully address social determinants of health
within federal health coverage programs. In execution, however, they have done
so inequitably, seeking simultaneously to shrink and weaken health and
safety-net programs that are best positioned to provide social
determinant-related services to the beneficiaries who need them most.
Select Progress On
Social Determinants of Health
Top HHS officials have spoken at length on
efforts to better address beneficiaries’ social determinants of health. And, on
the face of it, the Trump administration has made select progress on advancing
these goals under limited demonstrations and for segments of enrollees under
certain programs, which we outline below.
Demonstration Programs
In November 2018, HHS Secretary Alex Azar
delivered a speech on America’s social determinants of
health, in which he highlighted increased focus on social determinants within
demonstration programs run by the Center for Medicare and Medicaid Innovation
(Innovation Center) created under the Affordable Care Act (ACA). Since that
time, the Innovation Center has rolled out several integrated care models that
include features designed to address the physical, behavioral, and social needs
of at-risk populations (for example, the Integrated Care for Kids model, the Maternal Opioid Misuse model, and the Primary Care First model options, and so forth). Many of these models build on the
progress and momentum achieved under the Innovation Center initiatives of the
previous administration, such as the Accountable Health Communities Model.
Medicare Advantage
Effective 2020, the Centers for Medicare and
Medicaid Services (CMS) is offering new flexibilities for private Medicare Advantage plan
sponsors to provide special supplemental benefits for chronically ill
enrollees, including benefits “that are not primarily health related” and that
may be tailored to enrollees based on individual needs. These new supplemental
benefits can include: plan-sponsored housing or subsidies for rent or assisted
living; subsidies for gas, electric, and other utilities; home meal delivery or
reimbursement for food and fresh produce; transportation for non-medical needs,
such as to the grocery store or the bank; social needs benefits, such as
fitness club memberships, park passes, counseling, and more.
Z Code Data
CMS also recently released a report on the largely untapped potential to
capture standardized data on Medicare beneficiaries’ social determinants of
health through the use of ICD-10 Z codes, which physicians can use to document
non-primarily health-related “factors that influence health status and contact
with health services.” The report finds that such factors are widely
undercounted and recommends that standardized reporting on social determinants
could improve clinicians’ abilities to improve beneficiary outcomes and control
costs.
The Broader Picture:
Backsliding In Medicaid, SNAP, And The Social Safety Net
Given the low-income and vulnerable population
Medicaid serves, the program’s joint state and federal administration, and the
unique flexibilities and authorities granted to states to design their own
program features, the program is exceptionally well-positioned to address the
social determinants of health. Indeed, many—if not all—states have used the
flexible program features over the years in various ways to cover additional
vulnerable populations, add additional benefits and services, or test
innovative delivery reforms in ways that best serve their residents.
The Medicaid program ought to be a primary
focus of the administration’s aims to improve social determinants, but its
Medicaid agenda reveals a distinct disconnect between how such benefits are
being afforded to older Americans enrolled in private Medicare plans, for
example, and what is afforded to low-income and marginalized communities on
Medicaid. Rather than seeking to amplify, facilitate, or accelerate state
innovation around the social determinants of health, the Trump administration
has instead championed—often in ways that stretch the bounds of its legal authority—Medicaid reforms
that increase barriers to care, leave fewer people enrolled, and that will
likely strip billions of dollars from state budgets if fully implemented.
Medicaid Work
Requirements
At the beginning of 2018, CMS issued guidance to states to implement work and
“community engagement” requirements for able-bodied (expansion group) adults.
Under the first-of-its-kind optional model, beneficiaries continually need to
meet and report up to 80 hours of work or community engagement per month, or
lose their health coverage entirely. To date, CMS has approved work requirement waivers in 10 states, three of which have been
halted by legal challenges, while several other waivers are pending approval.
In Arkansas, implementation of these requirements resulted in 18,000 people losing their Medicaid coverage
before implementation was paused.
In her roll-out speech, CMS Administrator Seema Verma invoked the
concept of social determinants of health, citing that employment leads to a
better quality of life and improved health outcomes. However, the lawsuits that have stopped the programs moving
forward rest in part on the grounds that these programs did little to nothing
to actually connect people to required employment; and furthermore, that CMS
had no metrics nor monitoring requirements in place to determine if employment
was acquired or if outcomes improved.
Medicaid Block
Grants
More recently, we saw the unveiling of another
long-sought overhaul to Medicaid. Oft recommended in the president’s
congressional budget requests and under the effort to repeal the ACA in 2017,
CMS has put forward a new waiver pathway for states to seek a block grant for a
portion of their Medicaid population. Under the plan, states could opt to receive
a capped federal contribution for any optional coverage group, including the
Medicaid expansion population, and to waive certain optional and mandatory
benefits and services. Critics of Medicaid block grants point to evidence that they would lead to state budget
shortfalls in the face of economic downturns, growing populations, and rising
health care costs. Such an arrangement would likely require significant budgetary
adjustments that could lead to the scaling back of benefits and services for
all enrollees or falling provider reimbursement rates, which ultimately
threatens access.
Medicaid
Transportation Benefit
Where CMS is freeing private plans in Medicare
to begin paying for both medical and non-medical transportation, the
administration has been “reexamining” Medicaid’s longstanding mandatory program
requirement of states to provide non-emergency medical transportation (NEMT)
when beneficiaries lack means of accessing medical services. The agency has
already permitted several states to waive this requirement
for expansion group adults; however, a pending regulatory proposal suggests that they may seek to erode
NEMT requirements for a broader group of Medicaid-covered lives.
Medicaid Financing And
Access Monitoring
Beneath the headline-grabbing optional waiver
programs, the administration has also advanced complex rules that will have
deep impacts on both expansion and traditional Medicaid eligibility groups in
all states. The proposed Medicaid Fiscal Accountability Rule, or MFAR, would significantly alter the rules
regarding how states can finance their share of supplemental payments, which
typically are paid to hospitals and providers disproportionately serving
vulnerable and low-income populations to make up for low Medicaid reimbursement
rates. CMS estimated in its proposed rule that the changes could lead to $222
million in lost provider supplemental payments nationwide each year; however,
the agency acknowledged that the exact impact of such changes are
unknown. Analysis by Manatt Health pegs the cuts to
program spending between $37 and $49 billion per year, with impacts likely
varying widely from state to state.
The Medicaid and CHIP Payment and Access
Commission (MACPAC) urged CMS not to move forward with the proposed changes before
fully assessing the potential impacts, which commissioners fear could reduce
payments in ways that would jeopardize access to care for Medicaid enrollees.
Of particular note, MACPAC advised that a careful review of the access
implications of MFAR is especially important in light of CMS’s separate and prior proposal to rescind the requirement that states
evaluate beneficiary access to care before reducing or restructuring Medicaid
provider payments.
SNAP Work Requirements
And Other Reforms
While CMS is encouraging spending on fresh
produce and reliable meals for vulnerable beneficiaries in Medicare, the
administration is simultaneously seeking numerous cuts and program changes that
will impact the 44.2 million low-income people who receive benefits under the
Supplemental Nutrition Assistance Program (SNAP), formerly known as food
stamps.
The Department of Agriculture (USDA) has finalized a rule that, if implemented in April
2020, will narrow the criteria by which states may exempt certain SNAP
beneficiaries known as able-bodied adults without dependents (ABAWDs) from
existing program work requirements. Hundreds of thousands of ABAWDs would newly
be exposed to a three-month time limit on their SNAP benefits if they cannot
maintain 80 hours per month of employment.
Another recent proposal seeks to limit the “broad-based categorical eligibility”
pathway, which currently allows households to be automatically eligible for
SNAP benefits based on receipt of other low-income assistance benefits. A
third proposal would regiment how standard utility
allowances (SUAs) are calculated within a household’s SNAP benefit calculation.
Again, where certain beneficiaries in private Medicare plans are newly eligible
for subsidized utility reimbursements to bolster their health, the USDA’s SUA
proposal for SNAP recipients will, in many cases, count their utility spending
against them, resulting in approximately 8,000 households losing SNAP
eligibility all together. Recent analysis by the Urban Institute estimated that
the combined impact of these three rules together, had they been in effect in
program year 2018, would have meant a decrease in benefit allotments of $4.2
billion, and the disenrollment of 3.7 million beneficiaries.
Looking Ahead
The growing attention paid to the social
determinants of health by the nation’s top federal health agency is encouraging.
However, if the concept of the social determinants of health is most
aggressively brought to bear only where it is most likely to yield shared
savings for providers and health systems, profit margins for managed care
plans, or taxpayer savings, then it isn’t of much use to the people it was
designed to describe and serve. Worse, if these more vulnerable groups are
actively and simultaneously seeing their access to health services and social
supports degraded and stripped away, then the department’s professed focus on
the social determinants is disingenuous—mere lip service to the latest buzz
word in health policy.
The good news is that stakeholders across the
health system are awakening to the importance of this mission, investing in community programs to address
affordable housing, hunger, and transportation, and calling for a coordinated strategy to close the gap
between health and social needs. Under the current administration, it will be
up to these states, payers, health systems, and other stakeholders to ensure
that the focus remains on meaningful improvements for all who need them most.
In addition to targeted investments, those hoping to impact the social
determinants must mobilize to protect and strengthen the existing social safety
net and to push this administration and the next to leverage the federal
programs that can make a difference for the largest number of people in need.
https://www.healthaffairs.org/do/10.1377/hblog20200319.952157/full/
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