Healthcare executives should leverage the new CMS Section 1115 waiver flexibilities to pilot programs addressing housing instability and food insecurity.
Organizations must prepare for the expanded scope of allowable services, including nutrition counseling and housing supports, now permitted under federal guidance.
Strategic planning should account for the new federal allowance to spend up to 3% of total Medicaid costs on health-related social needs without requiring offsetting savings.
Leaders should strengthen partnerships with community-based organizations to effectively address the structural inequities highlighted by the COVID-19 pandemic.
Abstract
As a government program designed with the intention of providing health insurance for both adults and children with a limited income, Medicaid has a responsibility to acknowledge the social determinants of health that serve as potential structural barriers for these communities. Public health strategy is integral in creating effective administrative policy and cannot be done without ensuring equitable healthcare. As of November 2023, the Center for Medicare and Medicaid Services acknowledged health-related social needs by integrating Section 1115 waivers to pilot public health programs. This paper critically analyzes not only the effects of the waivers, but the change in healthcare policy seen in a post-COVID-19 United States. By pushing for several public health programs that involve the social determinants in Medicaid managed care organizations, the opportunities for reforming care in an equitable manner are truly vast.
Introduction
Medicaid is a joint federal and state program that covers medical costs and insurance policies for those with limited resources and incomes. It is fully managed through the Centers for Medicare and Medicaid Services. Although federally mandated, each state in the United States runs a different program, meaning that requirements, benefits, and eligibility vary slightly from state to state. The Health and Human Services Department emphasizes that good health is crucial to every individual, and structural barriers must be taken down to receive the proper healthcare necessary. Families with a lower income total, pregnant individuals, children & teenagers, and those with disabilities are considered eligible for Medicaid. Social determinants of health (SDOH) are a significant factor in healthcare overall and are characterized as the non-medical factors that affect health outcomes. The World Health Organization defines SDOH as the conditions in which people are born, grow, work, live, and age (WHO, n.d.). This includes structural factors such as economic policy, socioeconomic status, social norms & policies, education, built environment, and more. Seen in public health as a concept to improve communities by acknowledging the structural differences within different regions and systems, social determinants take a fascinating perspective when discussing public health policy and how to interact with a diverse population. These structural factors must be acknowledged to create impactful health policies, and Medicaid has certainly played a large role in highlighting the structural inequities that plague the healthcare system.This paper seeks to analyze the collaboration between health policy making and the social determinants of health, noting how policy makers can integrate public health information into important administrative policy. Equitable healthcare can only be achieved through the acknowledgment of these different factors in the structure of societal norms. Medicaid, a program directly targeted towards low-income individuals and families that cannot access privatized health insurance, is a great example of how policy and social determinants can collaborate with each other. But is there more that can be done to integrate the determinants with other forms of policy? It is critical to remember that on the other side of healthcare policy are the individuals and families affected by it. By focusing on not only the healthcare providers, but the consumers as well, the social determinants will be acknowledged far more effectively.
New CMS Policy: Section 115 Waivers
In November of 2023, the Center for Medicare and Medicaid Services publicized the necessity to acknowledge health-related social needs (HRSN). As an individual's unmet, adverse social conditions that contribute to poor health outcomes, not acknowledging HRSN leads to disadvantages in underserved communities (CMS, n.d.). Section 1115 waivers specifically give the Secretary of Health and Human Services the authority to approve experimental and demonstration projects to assist in promoting the Medicaid program objectives (About Section 1115 Waivers, n.d.). The Center for Medicaid and Medicare Services, CMS, can perform a review of each project to determine if it meets the needs of those aligned with Medicaid. States are given additional flexibility in improving their programs to better serve Medicaid populations. In the Children’s Health Insurance Program (CHIP) & Medicaid coverage regarding HRSN, it was found that housing environments and nutritional interventions were allowable under the Section 1115 demonstrations, with proposed programs like day habilitation programs, home remediation, home delivered meals that are medically tailored, and nutrition counseling programs (CMS, n.d.). Under the waiver flexibilities granted by the Biden administration in December 2022, different pilot programs can be put into place, covering housing supports, nutrition supports, and HRSN case management (Hinton & Diana, 2024). Community care hubs have been advocated for by the Biden administration, all focusing on aligning social and health care. The U.S. Playbook to Address Social Determinants of Health expands upon the three main pillars: expanding data gathering and sharing; supporting flexible funding to address social needs; and to support backbone organizations, such as community-based organizations, state and local governments, and public health authorities (DOMESTIC POLICY, 2023). CMS has advised that the spending for HRSN must not exceed 3% of total annual Medicaid spending and will not require any offsetting savings. The states in participation must meet the minimum provider payment requirements for healthcare services including behavioral health and primary care (Hinton & Diana, 2024). CMS defines health-related social needs (or “HRSN”) as an individual’s unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health. These conditions emphasize the urgency to acknowledge those determinants, and as of 2023, CMS released professional guidance on what qualifies as an acceptable 1115 HRSN service, including nutrition case management and counseling, home delivered meals, nutrition and grocery ‘prescriptions and provisions (Hinton & Diana, 2024).
How Does This Affect Individuals?
It is integral to understand that although social determinants are acknowledged and Medicaid plans have been altered and constructed, there are certain groups of individuals whose healthcare situations might be exacerbated by higher health costs and poorer health outcomes. In a significant health-reliant situation such as COVID-19, for example, marginalized communities have faced structural disadvantages through different Medicaid policy changes. The following information is critical in understanding the urgency to acknowledge the social determinants of health.At the height of the COVID-19 pandemic in November 2020, the enrollment numbers of Medicaid increased by nearly 8 million individuals from March 2020, due to the severe economic effects of the pandemic (Opoku et. al, 2022). The world is all too familiar with the lockdowns that took place, intended to slow the spread of the virus. Low-income households were found to have an increase in food insecurity, limited healthcare access, employment concerns, and especially economic instability. Medicaid managed care organizations (MMCOs) were seen as a key program in allowing for COVID-19 recovery processes. In a study conducted by Opoku et. al., studying a sample of MMCOs and their key representatives, there was a consensus amongst the participants in emphasizing the significance of food insecurity during the height of the pandemic. One SDOH Programming Director noted that they have collaborated with food banks to safely deliver culturally appropriate foods, due to the ever-decreasing employment rates. In the spirit of collaboration, multiple case managers and programming directors emphasized the lack of resources they were given to help different organizations. The resources they were given were often utilized to create virtual care communities, since many individuals were not using their in-person healthcare benefits due to an ongoing fear of in-person healthcare during the pandemic.As an existing Medicaid managed organization, researchers and managers are already accustomed to work with and assist vulnerable populations, so using social determinants to gauge strategic investments were a common theme amongst the participants in the study. MMCO pandemic efforts went far past economic and medical needs. Through different virtual technologies, members were able to access different healthcare interventions and obtain reviewed resources. As stated before, a significant factor of MMCOs during the pandemic was the concept of collaboration. Different programs were put into place, such as nutrition prescriptions, grab and go breakfast in public schools, youth resource centers, and more. These collaborative measures allowed for directors and programming experts to acknowledge other factors as key social determinants, such as racism, health inequities, assistance in employment searches, and childcare. Having the Internet, for example, quickly became an absolute necessity, something that could easily have been considered a luxury for low-income communities prior to lockdown measures (McClain et. al, 2021). Additionally, some families with parents who were considered essential workers that could not go virtual did not have access to childcare services, something crucial in a time when all schooling was done online. Lastly, it is integral to note that structural inequalities were magnified during the pandemic. COVID-19 exposed the detrimental effects that health inequities had on communities of color, showing severe structural barriers to accessing quality healthcare and higher ates of discrimination on minority groups. As stated by participant #14 in the study, COVID-19 was simply another social determinant, but one that every individual was forced to deal with, at incredibly different levels (Opoku et. al, 2022). Although policy changes made during the peak times of COVID have made their long-lasting impact, Medicaid enrollment in 2024 has gone down 8.6%, compared to 2022. However, state Medicaid spending has increased significantly, going from 2.0% in 2022 to 17.2% in 2024 (Williams et al., 2024). Since Medicaid is a countercyclical program, enrollment and spending will increase when an eventual downturn in the economic cycle occurs, often leading to rising unemployment. State economic conditions did worsen severely in March 2020, but recovered in late 2022 (Williams et al., 2024).
Moving Forward: What to do?
How can Medicaid services take the new social determinants made prominent after COVID-19 into account when creating different services and programs? The first place to start is to create holistic based programming and care models for beneficiaries. MMCOs can not only create virtual care hubs for communities to come to in times of duress like COVID-19 but can strengthen the populations in non-illness-stricken times. Healthcare must be always considered, as well as the underserved communities that should be targeted by different public health campaigns. A campaign that will enhance the benefits of Medicaid and acknowledge integral social determinants of health is one that emphasizes non-emergency transportation to different healthcare providers, grocery stores with nutritious and affordable food, pharmacies, and other areas where access to transportation might be limited for certain rural areas. Although telehealth has been established as a valid option after the pandemic, partnering with rideshare services and local transportations to create free/low-in-price transportation options can create not only a large volunteer network, but a strong community-based program that does not shame individuals for not being able to make it to their appointments or purchase healthy foods. Additionally, creating a medical and legal collaboration by working with integrated community healthcare workers and legal aid organizations would be a supportive program for beneficiaries to utilize. Housing in underserved populations is a significant issue and are often faced by structural inequalities. Legal aid lawyers can be paired with healthcare providers to produce easy access to legal services, something that has the ability to improve mental health by decreasing stress and potential structural violence. The opportunities for Medicaid focused programs are vast and truly have the ability to properly support beneficiaries who are a part of underserved and marginalized communities.
Conclusion
The concept of health equity in administrative policy is one that everyone in the healthcare fields have familiarized themselves with. However, an introduction and critical understanding of the social determinants of health is crucial to an effective public health strategy. Especially in a time post global pandemic, understanding that the conditions that people thrive, grow, work, live, and age in is imperative in creating policy. Through an understanding of implementing cost effective programming that is supported by Medicaid, providers can utilize different strategies to ensure that beneficiaries can profit from their insurance. Ultimately, implementing programs that highlight accessibility to all aspects of safe and healthy living are significant, and truly acknowledge those coveted health-related social needs.
Centers for Medicare and Medicaid Services. (2023). Coverage of health-related social needs (HRSN) Services in Medicaid and the Children’s Health Insurance Program (CHIP). November 2023.
McClain, C., Vogels, E. A., Perrin, A., Sechopoulos, S., & Rainie, L. (2021). The internet and the pandemic. Pew Research Center, 1.
Opoku ST, Apenteng BA, Kimsey L, Peden A, Owens C (2022) COVID-19 and social determinants of health: Medicaid managed care organizations’ experiences with addressing member social needs. PLOS ONE 17(3): e0264940. https://doi.org/10.1371/journal.pone.0264940
