Research shows that clinical care is only one factor that impacts population health and that a collection of other factors – including the natural and built environment where people live, education economic stability, food, and community and social context – grouped under the term social determinants of health (SDOH), have significantly more influence on care utilization, outcomes, and population health. Together, these factors account for 60% of preventable mortality.
Seventy million people in the U.S. receive health care services through Medicaid managed care plans. Managed Care Organizations (MCO) contract with states and are tasked with providing a mix of required and supplemental Medicaid services to the patients in their networks while receiving a set payment per member. This relationship puts MCOs in a position where implementing policies to address SDOH potentially saves them from paying for clinical and expensive emergency care services later.
A recent report, Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations, published by the Center for Health Care Strategies (CHCS), examines how states are structuring Medicaid Managed Care contracts and using Medicaid § 1115 waivers, which allow states to make operational changes to their Medicaid program, to address the many facets of SDOH. Of particular interest are interventions targeted at improving maternal and child health.
Three examples of states using MCO contract provisions specific to maternal and child health problems are highlighted in the report:
States are also using § 1115 demonstration waivers, which allow states to disregard certain Medicaid requirements to offer experimental or pilot programs to address maternal and child SDOH:
While these examples address just a handful of issues that impact maternal and child health, it is easy to see how other SDOH factors could have an impact as well: for example, an expectant mother lacks access to transportation to get to prenatal care appointments; a child from a low-income family whose parents both leave for work early in the morning goes to a school that does not offer free breakfast; an immigrant child is not vaccinated because her parents have not been educated on vaccine safety. These small examples compound when multiplied at the population level.
The report concludes with policy recommendations on how states and MCOs can overcome barriers in addressing SDOH. A major focus of the recommendations is the extent to which the Centers for Medicare and Medicaid Services (CMS) can implement policy changes to address SDOH through its authority and funding mechanisms. Whether these recommendations become enacted policy is dependent on the current administration’s designs for Medicaid. If MCOs continue to be the dominant form of Medicaid service delivery, this report provides a roadmap for addressing SDOH in the managed care landscape.
This blog post was developed by Daniel Young, MPH., Health Policy Fellow for the Network for Public Health Law–Southeastern Region and National Health Law Program.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.