Addressing nonclinical, social needs, or social determinants of health (SDOH), is a hot topic in health policy and practice discussions. Virtually every health conference has many sessions devoted to the subject. Many of the most-read pieces on Health Affairs Blog in 2019 concerned accurately defining terms and categorizing social interventions.
The topic takes on added urgency given the tsunami of social needs that is taking shape as a result of the COVID-19 pandemic and pre-existing system failures and gaps. Some of these issues have immediate, evident connections to health such as increases in domestic violence, food insecurity, depression and anxiety brought on by social isolation, and pre-existing and new barriers to mental health and substance use services. Other issues such as housing instability and economic insecurity will take an enormous toll on health over upcoming years. The social impacts of the pandemic are likely to follow the same racial and socioeconomic contours as the disparate medical effects and to be shaped by the same structural and historic factors.
Medicaid health plans have an important perspective and set of interests in this topic. Medicaid enrollees have historically had more challenging economic, behavioral, and social circumstances than populations insured through their employers or the individual market have had. Medicaid plans in many states have been part of implementing innovative 1115 waiver programs focused on expanding services to better address behavioral health and social needs. Moreover, many Medicaid plans serve defined geographic areas and have an explicit mission to improve community health and well-being. In spite of this, the perspective of Medicaid plans on social determinants of health has not been investigated extensively.
Given the important role of Medicaid health plans in California and Texas in addressing the health and social needs of large Medicaid populations and the plans’ interest in advancing the SDOH agenda in both states, Blue Shield of California Foundation (BSCF) and the Episcopal Health Foundation (EHF) (in Texas) sought to better understand health plan investment in SDOH strategies, facilitating factors and challenges for plans, technical assistance needs, and policy recommendations.
Both funders have also invested in related SDOH efforts serving safety-net populations, such as supporting the pilot implementation of Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) screening tools at community health centers. BSCF is supporting partnerships between health care and community-based organizations in California to work collaboratively on social issues such as housing and domestic violence. EHF has supported partnership efforts between payers, providers, and community groups to develop a sustainable financing strategy to address the SDOH needs of low-income populations in Texas.
In late 2018, with support from BSCF, JSI Research & Training Institute, Inc. (JSI) set out to survey and interview the majority of California’s Medi-Cal (Medicaid) managed care plans (MCPs). At around the same time, EHF research staff collaborated with the Texas Association of Health Plans and Texas Association of Community Health Plans to undertake a similar effort in Texas. After JSI and EHF provided input on each other’s survey design, both processes moved forward and wrapped up in 2019. JSI surveyed 19 Medi-Cal managed care plans, and EHF surveyed 14 plans that serve Medicaid populations in Texas. Comparing results from this data collection in the two most populous states in the country reveals a number of clear findings.
Findings From The Surveys
Implementation of federal policy was cited as a catalyst in both states. Despite significant differences between the health care policy landscapes in California and Texas, virtually all plans surveyed in both states appear to be actively engaging in some strategies related to SDOH. One factor motivating those efforts is the implementation of new federal policies in the states. In California, Medicaid coverage expansion through the Affordable Care Act (ACA) increased enrollment of low-income adults with more complex social needs. Medicaid expansion also resulted in the growth of Medicaid plan reserves, allowing for more flexible plan spending. In Texas, one of the major milestones under the Delivery System Reform Incentive Payment (DSRIP) program’s Transition Plan is to conduct an assessment of social factors of the state’s Medicaid population to inform new program proposals, policy changes, and strategies for quality improvement in Texas Medicaid related to SDOH. In both Texas and California, implementation of 1115 waiver programs, such as the DSRIP program, have created flexibility for plans and providers to invest innovatively to better address patient needs, including nonclinical social needs and to improve outcomes.
Plans reported prioritizing different determinants in each state. Plans in both states indicated that they were making investments in a variety of social issues among their members. The issues of housing instability, food insecurity, and lack of transportation were cited most often in both states but were ranked in a different order.
- All Texas plans surveyed reported addressing food insecurity and transportation, while 71 percent of plans reported addressing housing.
- In California, housing instability was the top issue being addressed (84 percent), followed by lack of transportation (79 percent) and food insecurity (74 percent).
This is not surprising given the crisis of homelessness and unaffordable housing in California and the increase in Medi-Cal enrollment of homeless or housing insecure adults through the ACA. In the Texas survey, cost was cited as a major barrier for health plans to address housing needs of their members. Transportation and food insecurity are both issues that health care institutions have a track record of working on and are a primary focus of screening tools such as the one developed by the Center for Medicare and Medicaid Innovation’s Accountable Health Communities initiative. The great majority of Medicaid plans in both states report screening for social needs (79 percent of Texas plans and 85 percent of California plans).
Self-expressed motivations are very similar. What drives Medicaid managed care plans to invest in social determinant–related efforts? In Texas, plans responded that the top three factors were “Data reflecting member needs” (79 percent), “Mission and values,” and “Quality considerations.” In California the top three factors were “Mission and values” (79 percent), “Quality considerations,” and “Data reflecting needs.”
Interestingly, in both states, reducing costs came in a distant fourth, despite prevalent national and state focus on containing health care–related costs. On another survey question, plans in both states reported concern over the lack of clear evidence around which SDOH investments are the most effective. The lack of emphasis on reducing costs may reflect lack of certainty that social determinants–related investments will actually result in short-term cost savings.
Fundamental concerns about sustainability are universal. In both states, the primary concerns centered on having adequate and stable resources to continue and expand strategies related to social determinants. Plans in both states indicated that the most favorable steps that state government could take would be to support up-front investment (for example, by reimbursing for social determinants–related services and/or allowing social determinants–focused investments to qualify as quality improvements) and to count SDOH investments when setting future health plan rates. (Currently, if SDOH investments lead to reduced health care utilization, future rates likely decline because they are based on the medical spending only—a phenomenon commonly referred to as “premium slide.”). Unsurprisingly, the idea of requiring plans to invest in their local communities did not garner much support in the California survey and interviews.
Additional nuance and details are important. This research was intended to provide a landscape view, not a fine analysis. There are limitations to conducting a self-report survey, and the topic of social determinants is very complex. For example, neither effort got into parsing out the distinctions between responding to social needs (for example, providing transportation vouchers to people) versus working on social determinants at a systems and policy level (for example, working with a local transit agency to ensure that bus lines connect people to necessary services). While we did discover that the majority of plans in both states reported making community investments that benefit populations beyond their members, the precise scale of those investments was not captured, and there is a wide gulf between, for instance, a multimillion-dollar investment in family resource centers and sponsoring a health fair! As this field develops, it will be important to get clearer about the various types of SDOH investments and depth of activity.
Next Steps After The Two Research Projects
These investigations were undertaken with the intent of understanding and elevating the perspectives of plan leaders so as to expand SDOH activity supported by health care payers and institutions. (Health care institutions, in carrying out their services, tend to follow the contract guidance language of their payers.) JSI and EHF have each made their results available and conducted numerous presentations to raise awareness among a variety of health care and public health audiences.
To continue building momentum and to consider policy solutions, EHF, in partnership with the Robert Wood Johnson Foundation, Texas Association of Health Plans, Texas Association of Community Health Plans, and Texas Medicaid office, has engaged the Center for Health Care Strategies to begin convening payers, providers, government agencies, and other key stakeholders in Texas via a SDOH learning collaborative for managed care organizations.
And JSI has engaged with numerous health plan participants and advocates to align the findings from the research with policy recommendations on, for instance, California’s Advancing Innovation in Medi-Cal (CalAIM) initiative.
In both states, philanthropic dollars were used to support research that helps us better understand the facilitating factors and challenges for health plans to engage in SDOH work, as well as the potential policy opportunities to advance the SDOH agenda at the state level.
As SDOH continue to rise to the forefront of health reform conversations, particularly in light of the social inequities laid bare during the COVID-19 pandemic, state Medicaid plans have an outsized role to play in addressing these vexing issues.
