Why Medicaid Is The Platform Best Suited For Addressing Both Health Care And Social Needs

The following excerpt comes from the article by Katharine Witgert published September 7, 2017 on the Health Affairs Blog.


...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.

Read the full article.

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Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

The following excerpt comes from the Issue Brief written by Susan L. Hayes, Pamela Riley, David Radley, and Douglas McCarthy.  It was originally posted to the Commonwealth Fund website on August 24, 2017.


Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.

Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA, but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.

We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:

  • the share of uninsured working-age adults ages 19 to 64
  • the share of adults age 18 and older who went without care because of costs in the past year
  • the share of adults age 18 and older without a usual source of care.

These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.

As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.

Findings include:

  • Racial and Ethnic Disparities in Adult Uninsured Rates Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Who Went Without Care Because of Costs Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Without a Usual Source of Care Narrowed After the ACA’s Major Coverage Expansions
  • Disparities Between Hispanic and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Without a Usual Source of Care in Medicaid Expansion States vs. Nonexpansion States, 2013–2015

Download the full issue brief.

The Interplay of Community Trauma, Diet, and Physical Activity

The following excerpt comes from the Discussion Paper by Howard Pinderhughes* posted August 7. 2017 on the National Academy of Medicine website.


Diet- and activity-related illnesses—such as heart disease, stroke, cancer, and type 2 diabetes—can shorten life spans and adversely impact quality of life. Over the past 15 years, the public health field has made important progress in addressing these illnesses by shifting the focus from individual behavior to the broader social and economic forces that shape health. There is now widespread agreement among experts in the field that in order to improve health outcomes and reduce the impact of these illnesses, we must pursue strategies, practices, and policies that are multifaceted, comprehensive, and focused on community- and institutional-level change.

There is a growing understanding that community conditions—the places where we live, work, and play—have a significant impact on our health and that adverse community experiences (community trauma) affect our food and activity behaviors. Advances in understanding the connection between adverse childhood experiences and health have revolutionized the field of trauma-informed care, which has now become an important standard practice in communities across the country. But we must also seek to illuminate how adverse community experiences impact healthy eating and activity, and to develop integrated solutions. Adverse community experiences are destructive factors—such as racial, residential, and economic segregation; violence; structural racism and discrimination; intergenerational poverty; and public and private disinvestment—that traumatize entire communities. For example, experiencing and witnessing community violence can negatively impact the ability to eat healthfully and be active. Violence and fear of violence reduce social interactions that would otherwise contribute to community cohesion, thus reducing support for healthy eating and active living. The pervasive presence of community trauma can become a significant barrier to efforts to improve population health and health equity, including those that address eating- and activity-related diseases. When people don’t feel safe in their communities, they are less likely to walk to the grocery store, use local parks, access public transportation, and let their children play outside. Healthy food retailers and recreation businesses are less likely to invest in communities perceived as unsafe.

An analysis of the production of health inequities across multiple determinants of health revealed that adverse community factors—which decrease opportunities for healthy eating and activity—are rooted in structural violence in the form of government policies and business practices. These policies and practices have led, for example, to the over concentration of unhealthy food outlets in communities of color and communities with low to average household incomes. In the case of food retail, public policies such as those of the Federal Housing Administration incentivized suburban home ownership, which resulted in white middle-class flight to the suburbs and a concentration of poverty in the inner cities. Supermarkets, grocery stores, and many other businesses followed the white middle-class population in migrating to the suburbs. This flight (along with financial policies and practices, including redlining) left a void for unhealthful food outlets to fill. The high cost and scarce availability of land in dense urban areas contributed to the migration of businesses out of the cities and resulted in loss of jobs and tax revenues, and has influenced decisions about the siting of grocery stores and supermarkets. Additionally, there has been limited availability of loans for local residents in underserved neighborhoods so that they might open businesses that sell and promote healthy food options. These adverse community experiences have resulted in limited economic opportunities for residents and a poor food system in which chain restaurants and stores fill the gap with less healthy or unhealthful food options.

Read the full Discussion Paper.

*References have been removed from the excerpt. Please visit the full paper for more details.

Useful Resource: “Health Equity Change Makers” Toolkit

The Office of Minority Health’s web port “Health Equity Change Makers” using stories to highlight the impact of health disparities and ways in which individuals and groups can make changes. The portal includes a toolkit “designed to provide ideas and resources for activities that you can do — at home, at work, and in the community– to help end health disparities and accelerate health equity.” The toolkit topics cover:

Visit the Health Equity Change Makers web portal to see the full toolkit.

 

Annual Report on Healthcare Quality and Disparities

In July, the Agency for Healthcare Research and Quality (AHRQ) posted the 2016 National Healthcare Quality and Disparities Report on its website. Mandated by Congress, this annual report “provides a comprehensive overview of the quality of healthcare received by the general US population and disparities in care experienced by different racial and socioeconomic groups.”  Based on over 250 quality measures, the report covers a wide range of healthcare services and settings. The key findings from the report were:

Access: While most access measures (65%) tracked in this report did not demonstrate significant improvement (2000-2014), uninsurance rates (measured as uninsured at the time of interview) decreased from 2010 to 2016.

Quality: Quality of health care improved overall from 2000 through 2014-2015 but the pace of improvement varied by priority area:

  • Person-Centered Care: About 80% of person-centered care measures improved overall.
  • Patient Safety: Almost two-thirds of patient safety measures improved overall.
  • Healthy Living: About 60% of healthy living measures improved overall.
  • Effective Treatment: More than half of effective treatment measures improved overall.
  • Care Coordination: About half of care coordination measures improved overall.
  • Care Affordability: About 70% of care affordability measures did not change overall.  

Disparities: Overall, some disparities were getting smaller from 2000 through 2014-2015, but disparities persist, especially for poor and uninsured populations in all priority areas:

  • While 20% of measures show disparities getting smaller for Blacks and Hispanics, most disparities have not changed significantly for any racial and ethnic groups.
  • More than half of measures show that poor and low-income households have worse care than high-income households; for middle-income households, more than 40% of measures show worse care than high-income households.
  • Nearly two-thirds of measures show that uninsured people had worse care than privately insured people.

See the table of contents and description of the report.

Download the full report.

What are the Top Common Social Determinants of Health?

The following excerpt comes from an August 9, 2017, article by Sara Heath on Patient Engagement HIT.


The social determinants of health are the factors that affect health outside of the four walls of the hospital. Housing, social services, geographical location, and education are some of the most common social determinants of health.

These factors have a significant impact on the current healthcare landscape. As more healthcare organizations deliver value-based healthcare, they are developing strategies to drive wellness care.

Organizations are catering to patient needs outside of the hospital with the goal of keeping patients healthy in the long-run. Patients who have better health support in their daily lives may be less likely to fall ill and require an expensive medical intervention.

But what are the specific social determinants of health? Which examples are most common? And how can healthcare organizations and community partners act on these determinants?

Socioeconomic factors can encompass several different social determinants of health. Poverty can limit access to healthy food, safe neighborhoods, and good schools, among other things. Most prominently, poverty affects housing.

Although individuals can lose reliable housing for a number of reasons – trauma, violence, mental illness, addiction, or another chronic health issue – poverty remains a notable factor driving homelessness.

Hospitals treating a large homeless patient population can forge partnerships with housing departments to help drive housing in the community. Housing development partners can help place individuals who are homeless in houses and offer support that will help individuals maintain that housing.

“Access to safe, quality, affordable housing – and the supports necessary to maintain that housing – constitute one of the most basic and powerful social determinants of health,” wrote the Corporation for Supportive Housing (CSH) in a 2014 white paper.

“Supportive Housing, an evidence-based practice that combines permanent affordable housing with comprehensive and flexible support services, is increasingly recognized as a cost-effective health intervention for homeless and other extremely vulnerable populations,” CSH wrote.

Expanding housing development can also help ensure that living conditions are safe, free of asbestos, lead paint, or other environmental factors that can impair health.

Housing support can also account for other poverty-driven determinants of health, CSH said.

“Furthermore, supportive housing developments often attract or directly bring critical services to resource-barren neighborhoods,” wrote CSH. “Many supportive housing developments are increasingly featuring on-site or direct linkages to gym facilities, after-school programs, recreational spaces, food pantries, recovery support groups and full-service health clinics that benefit the larger community.”

There are countless different social support and public service gaps that are significant social determinants of health, according to Healthy People 2020, a public health organization developed as a part of the Affordable Care Act.

Issues such as race disparities, lack of social support groups, weak culture of health equity, and limited public services are all drivers of adverse health events.

Populations rely on community partners that will advocate for health equity. Examples of partners include the housing department working with homeless patients or health navigators helping a population’s surplus of single mothers.

Social support also includes efforts toward desegregation, which in turn may ensure certain races are not targeted disproportionately for the social determinants of health. One example is black patients living in poverty-ridden areas at a higher rate than their white patient counterparts.

Support for the public good means ensuring public services meet all patient needs. For instance, neighborhoods that are filled with trash need more support from public sanitation departments.

Public safety is also integral and requires the partnership of safety officers, such as fire departments and police. Police specifically can work to reduce drug issues, crime, and incidents of violence. Public safety officers can also help funnel patients out of negative lifestyles by reducing safety issues.
To learn more, read the full article.

Useful Resource: Behavioral Health Equity

The Office of Behavioral Health Equity of the Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources to address disparities related to mental health and/or substance use disorders in various populations. Available resources include: Data, Reports and Issue Briefs; SAMHSA Programs and Initiatives; SAMHSA Behavioral Health and In-Language Resources; and  Federal Initiatives and Resources. Items are organized by minority group:

Visit the Office of Behavioral Health Equity website to learn more.

The Health Care System Is Leaving The Southern Black Belt Behind

The following excerpt comes from an article by Anna Maria Barry-Jester on FiveThrityEight.

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Sitting outside of a Starbucks on the corner of a strip mall in Tuscaloosa late last year, Dr. Remona Peterson described her hometown of Thomaston, Alabama, population 400. “Everybody loves our grocery store. That’s, like, our pride,” she said with a laugh. She was in Tuscaloosa, Alabama’s fifth-largest city, finishing her medical residency when Dave’s Market opened in an old Thomaston high school gym last year. Peterson said it became the only place to buy groceries for miles in any direction, and it was one of the few changes to the town she can remember from the last three decades.

Peterson wants to be a part of positive change in the region, which is why she’s back after a circuitous journey through medical school. She was valedictorian of her 29-person high school class and graduated summa cum laude from Tuskegee University, where she earned a full scholarship and the university’s distinguished scholars award. She went on to medical school and got the residency in Tuscaloosa. It was her first choice; she felt that the University of Alabama would best prepare her for her long-term goal: to add her name to the short list of African-American doctors working in the Alabama Black Belt who were also born and raised there.

The Black Belt refers to a stretch of land in the U.S. South whose fertile soil drew white colonists and plantation owners centuries ago. After hundreds of thousands of people were forced there as slaves, the region became the center of rural, black America. Today, the name describes predominantly rural counties where a large share of the population is African-American. The area is one of the most persistently poor in the country, and residents have some of the most limited economic prospects. Life expectancies are among the shortest in the U.S., and poor health outcomes are common. This article is part of a series examining these disparities.

The disparities partly stem from a lack of access to care — but access is a complicated notion. Early in the Republican efforts to repeal and replace the Affordable Care Act, the GOP homed in on the idea, saying the party wanted to guarantee “access to health care” for everyone. But the ongoing national policy conversation has hinged on insurance coverage, the main issue tackled by both the Affordable Care Act and the current GOP efforts. Yes, measuring who’s insured illuminates one way by which people have access to the health care system, but it’s only part of the picture. The term “access to health care” has a standardized federal definition that’s much broader: “the timely use of personal health services to achieve the best health outcomes.” And there’s a list of metrics to measure it. Researchers consider structural barriers, such as distance to a hospital or how many health professionals work in an area, to be important. As are metrics that gauge whether a patient can find a health care provider that she trusts and can communicate with well enough to get the services she needs.

Southern states have health outcomes that are among the worst in the U.S. overall, and they have some of the largest in-state health disparities, according to County Health Rankings, an annual report from the Robert Wood Johnson Foundation and the University of Wisconsin. Transportation options are limited, and health care worker shortages are routine. In Alabama, Black Belt counties have fewer primary care physicians, dentists and mental health providers per resident than other counties. They also tend to have the highest rates of uninsured people. Poverty rates, which are associated with limited access to care, are also high.

Read the full article.

Defining Health Equity

In May 2017, the Robert Wood Johnson Foundation released a report titled “What is Health Equity? And What Difference Does a Definition Make?” with the purpose “stimulate discussion and promote greater consensus about the meaning of health equity and the implications for action within the Culture of Health Action Framework.” In doing so, the authors identify crucial elements to guide effective action. The way we define health equity is important as it reveals the values and beliefs that are used to make decisions, justify actions, and promote policies.

The document provides a general definition of health equity:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.

In pointing out the importance of measurement for accountability, the authors added the following:

For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.

With those definitions as a starting point the report offers :

  • Series of definitions for different audiences
  • Explanation of key concepts
  • Criteria for defining health equity
  • Discussion of steps to advancing health equity
  • Guiding principles
  • Glossary of terms often arising in health equity discussions

See a summary of the report.

Download the report, Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

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Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults

The following comes from a Commonwealth Fund summary of research first published in Health Affairs Web.


Synopsis
Low-income adults in Arkansas and Kentucky who obtained coverage under the Affordable Care Act’s Medicaid expansion had better access to primary care and preventive health services, lower out-of-pocket costs, improved medication compliance, and improved self-reported health status than did low-income adults in Texas, which did not expand Medicaid. Among adults with chronic conditions, ACA coverage was associated with better disease management and medication compliance and a significant increase in self-reported health status.

The Issue
Congress is currently weighing the future of the Affordable Care Act. Since becoming law, the ACA has helped more than 20 million Americans enroll in health insurance coverage, and national studies have noted improvements in coverage, consumer satisfaction, and access to care. In this Commonwealth Fund–supported study, researchers compared Kentucky, which expanded Medicaid as prescribed by the ACA; Arkansas, which obtained a waiver to use federal Medicaid funds available through the ACA to purchase private marketplace insurance for low-income adults; and Texas, which did not expand Medicaid coverage. Looking at these three states, the authors assessed ongoing changes in health care use and self-reported health among low-income adults, including those with chronic conditions, after three full years of the ACA’s coverage expansions.

Key Findings

  • By the end of 2016, the uninsured rate in Arkansas and Kentucky—the two expansion states—had dropped by more than 20 percentage points compared to Texas, the nonexpansion state. In 2016, the uninsured rate was 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.
  • Low-income adults in Kentucky and Arkansas who gained coverage experienced a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket costs, and a 23-point increase in the share of those who reported they were in “excellent” health.
  • Results were similarly positive for people with chronic illnesses who gained coverage because of the ACA. Low-income patients with diabetes, heart disease, hypertension, and stroke who gained coverage were 56 points more likely to report having regular care for their condition than were chronically ill adults in Texas, 51 points less likely than those in Texas to skip medications because of the cost, and 20 points more likely to report being in excellent health.

See the full summary.
See the original article.