Given politics and tight state budgets, how much can Medicaid actually do to address social determinants of health? Is it the responsibility of health care to pay for someone’s social needs, or that of another sector?
“That’s a tough question,” says William Golden, Medical Director for Arkansas Medicaid. Commercial managed care could theoretically buy a refrigerator for someone who can’t store their insulin, for example, but it would be difficult for a state-based program to justify that purchase to its legislature.
“On the other hand, there are lots of opportunities evolving where the division of Health and Human Services in a state starts to collaborate with the corrections institute or starts collaborating with the Department of Education,” says Golden. “There are opportunities across state agencies that can make a difference, which have not been exploited.”
Sachin Jain, CareMore Health System’s President and CEO, agrees, offering the Nurse-Family Partnership as an example. The program, which pairs nurses with first-time single mothers, has shown reduced use of special education, yet it is nationally underfunded because its benefits don’t necessarily accrue to the same buckets — savings accrue to the education system, while costs accrue to health care. “If you view it purely as a health care intervention it’s wildly expensive,” says Jain, “but when you view it as a social intervention that bridges sectors, it’s actually potentially cost-saving for states.”
“Sometimes we take too narrow a view of what health care is and too narrow a view of what education is, or housing,” Jain adds. “We need to start looking at these things more holistically.”
The same dynamic occurs across Medicaid and Medicare, says Anya Rader Wallack, Rhode Island’s former Medicaid Director. If Medicaid tries to save money on acute care, such as reduced hospitalizations, that benefit largely accrues to Medicare. “The flip side is, if Medicare doesn’t take care of somebody, and they end up eventually in a nursing home and spend down to Medicaid level, that’s my problem,” she says.
From the NEJM Catalyst event New Risk, New Business Models held in Boston, October 6, 2016.