Does helping people to be healthier, more productive, and less expensive make things worse?
Why do we need any more proof that having basic necessities, access to care, and social support leads to better health in order for poor people live healthier, less expensive and more productive lives?
We all know that poor people can’t afford deductibles and copays, lack food, gas for a car, struggle with rent, and don’t have a social network with the means to help them. Instead of seeing a doctor to get better, they go to the emergency department or straight to the hospital when they can’t go on.
Private payers, the Centers for Medicare and Medicaid Services (CMS), and state and local governments want evidence that providing things like transportation, food, rent, and household health accessories like air filters reduce costs and improve health before they will fund them.
We spoke with Laurie Stradley, Executive Director of Impact Health about the Healthy Opportunities Pilot, which aims to provide that evidence.
Still, are we just adding more administration and complexity to the healthcare system? People with money have already proven that being able to pay for the basic necessities to establish health, plus the healthcare to maintain it, experience lower costs and better health.
Health is about basic necessities, not just doctor, nurses, surgeries, and prescriptions
Most Americans have foundational health — the ability to get food, pay bills, drive to get wherever we need to be, and have a decent place to live. If we can, we pay for our health insurance premium and deductible and prescription drugs. We apply our education and social network to know what to do, navigate the system, and get the support we need in a pinch.
For example, let’s say you need to take your car to the shop. You pay the cost of the repair, maybe work from home, and have a friend or spouse to your kids to school.
As we move down the wealth ladder, people have less money to pay their bills and afford the care they need, and it’s likely their support network is in the same situation and smaller.
Going back to the example of a car that needs work. They can’t get to work if they don’t have someone to take them. The kids don’t go to school. If the car breaks down during the day, they can’t pick them up from school, so they pay a penalty for care/being late, which they can’t afford.
At the level people are eligible for Medicaid, they can’t afford the deductible and copays, lack food, gas for the car, struggle with rent, and don’t have a social network with the means to help them. The don’t see the doctor. They go to the emergency department or straight to the hospital instead. Every day is a trade-off of barely-met needs.
One idea is to provide Medicaid members with the clinical and social support services they need to either get back on their feet or simply live healthier lives.
Private payers, the Centers for Medicare and Medicaid Services (CMS), and state and local governments demand evidence before they will pay for community resources to improve health and reduce costs related to, for example, emergency department visits and hospital readmissions.
The Healthy Opportunities Pilot is a five-year program in North Carolina designed to provide that evidence by improving the living conditions that influence eligible Medicaid members’ health, like access to food, transportation, rent, and other basic needs, along with physical and mental health services.
Food: Healthy food boxes; Fruit and vegetable prescription; Medically tailored, home-delivered meals; Group nutrition classes; Diabetes prevention program
Housing: One-time security deposit and first month’s rent; Inspection for housing safety and quality; Home remediation services; Home accessibility and safety modifications; Short-term post-hospitalization housing; Linkages to legal support services
Transportation: Transportation to support health needs like the grocery store or fitness center; Taxi and ride-sharing credits where public transportation is unavailable; Reimbursement for gas mileage; Vehicle repairs
Toxic Stress: Evidence-based parenting curriculum; Home visiting services; Dyadic therapy (form of therapy in which child and parent are treated together)
The mini-fridge example
A diabetic repeatedly visits the emergency department despite having access to insulin.
During an interview with the patient, a social worker finds out that they don’t have a refrigerator, which is required to keep insulin active.
By paying $300 to get a refrigerator into that person’s apartment, the program can keep them from multiple visits to the ER because they are able to manage diabetes.
Further, the person can put food in the refrigerator.
How Healthy Opportunities works
Members can enter the program through a healthcare provider, whatever social service they need, or self-refer into the program by going to the Impact Health site or calling Impact Health or the number on their Medicaid Managed Care card.
Impact Health coordinates private insurers, physician practices, care management organizations, and local community groups like food banks and housing remediates, which do things like remove moldy carpet so people have better air quality in their homes.
A care manager assesses their need for services and then connects them with community organizations that can help.
Who is eligible?
Members must have at least two chronic conditions or repeat emergency department or hospital visits, and have an additional risk factor like food or housing insecurity.
If one person in the family is eligible, the entire family is eligible, so, for example, HEPA filters can be brought in for one asthmatic child or food boxes can be delivered to serve the entire family.
Challenges: Patients are distrustful, workers are scarce, red tape abounds, and potential sponsors want immediate payback.
We need more care managers and coordinators, who tend to be nurses and social workers.
The jobs don’t pay that well.
They have a hard-earned clinical license, but are responsible for reaching our to members, getting to know them, assessing their needs and helping them navigate care after a diagnosis.
They are not trained nor inclined to play the role of coordinator, especially for Medicaid members — who tend to be more difficult to reach and reluctant to enter the healthcare system.
Distrust and privacy make recruitment difficult.
Many individuals are wary of enrolling because they doubt the system will support them because someone in their family has had a bad experience or they are concerned because they have mixed immigration status, for example.
Outreach must come from someone the member trusts because health information is supposed to be private, e.g. a doctor or representative of an organization they already know.
Privacy rules can make getting eligibility lists for outreach from state enrollee logs or providers difficult.
Building a network of services is uncharted territory.
There is no network of community services in a single database like there is for medical providers. For example, there is no connection from a primary car physician for a referral to a food pantry or feedback loop to tell the physician whether the patient got food.
While urban areas tend to have more social services in concentrated areas, rural areas have fewer and less connected resources.
It comes with the same bureaucracy as the current healthcare system.
Each community service bills for each service separately, like paying for a refrigerator or a navigation consultation, so that creates more paperwork and administrative burden, which can lead to frustration.
Short-term measures are fewer emergency department visits and lower hospital readmission rates.
Whether the program leads to better quality of life could take years to measure. Will governments have patience?
Support programs that provide basic needs, we know that the answer is providing basic health necessities for folks and taking the administration out of health care
Look for and provide financial support to holistic healthcare programs like Healthy Opportunities and organizations like Impact Health in your community and state.
Take a broader perspective: Are we adding more complexity and burden when we know what works
Many Americans already understand that drivers of health include not only nutrition and exercise and physical and mental health care but also supports most people take for granted like financial services, transportation, housing, and friends and family.
While noble and worthy of investment, are we just recreating a social support network for poor people?