A pillar of the nation’s social safety net since the 1960s, Medicaid is the largest public source of health insurance. Now, it is becoming something more.
More states are broadening the health coverage program into a hub for fulfilling social needs: helping with housing and transportation, easing the effects of prison life and domestic violence, and providing nutritious food.
With the encouragement of the Biden administration, Medicaid is threading health-related social needs into the program. Because Medicaid is a joint responsibility of the federal government and states, each project stepping into such new territory requires federal approval. Since President Biden took office three years ago, the Centers for Medicare and Medicaid Services has approved these experiments in eight states: Arizona, Arkansas, California, Massachusetts, New Jersey, New York, Oregon, and Washington.
An additional nine states have applied.
“We have states constantly knocking on the door to do this,” said Daniel Tsai, CMS’s Medicaid director.
In a time of political schisms, the enthusiasm is bipartisan. In January 2021, the final days of the Trump administration, CMS suggested to states ways that they could use Medicaid and other public insurance to cope with social needs.
For the Biden administration, the focus on such needs jibes with efforts to lessen health inequities, including the recent US Playbook to Address Social Determinants of Health. CMS worked for more than a year with the White House and other government departments and, in November, produced guidelines on what services states can add under Medicaid, including up to six months’ rent, utility subsidies, and nutritious food. States can devote no more than 3 percent of their overall Medicaid spending to such experiments. They must chip in state money and evaluate the effects.
“Clearly, nobody is saying that Medicaid is here to solve all housing and nutritional needs in the country, nor are we here to take over other agencies,” such as the Housing and Urban Development or Agriculture departments, Tsai said. “Does Medicaid have a role in social needs? The answer is yes. … It’s exciting. It’s groundbreaking. It is not an open check.”
This wave of attention to social needs grows out of a recognition, going back at least three decades, that social determinants of health — essentially, the conditions in which people live — have an enormous bearing on well-being. Medical care, studies have shown, accounts for only 20 percent of the difference in patients’ health, while social risk factors are responsible for half to 80 percent.
"If you are trying to offer health care to improve health, and [a patient] is not able to afford a healthy diet or have a place to live, you end up spinning your wheels," said Seth A. Berkowitz, associate professor of medicine at the University of North Carolina School of Medicine.
At its core, the inclusion of social services into Medicaid has two goals: improving patients’ health and making a dent in the nation’s exorbitant medical costs.
The new CMS guidelines say that any service a state chooses to include must be based on evidence it makes a difference. It remains unclear whether all this works.
“There is this incredible enthusiasm this will be a magic pill,” said Laura Gottlieb, professor of family and community medicine at the University of California at San Francisco.
Yet for now, “the evidence is not anywhere close to supporting these activities,” said Gottlieb, founding co-director of the Social Interventions Research and Evaluation Network, which focuses on the intersection of social and medical care. “The research is [running] behind the policymakers.”
As many parts of the health care system race to identify patients with unmet social needs that can weaken health, Medicaid is going significantly further, covering services for some of the most vulnerable people.
Oregon is building on an older program to create a path to stable housing. Starting in a few months, it plans to phase in a $1 billion project to provide services to beneficiaries at risk of homelessness or undergoing other transitions, such as release from incarceration or a mental health facility.
The services, predicted to reach about 250,000 of the 1.4 million Oregonians on Medicaid, will include moving assistance and up to six months of rent, help affording utilities, meals tailored to a patient’s medical conditions, and climate controls such as heaters and air conditioners.
"I am excited and, admittedly, a little scared," said Dave Baden, until recently the interim director of the Oregon Health Authority, which runs that state's Medicaid program. "Does this six months of rent matter to stabilize their lives? Do I know that it will be successful? No. That's our hypothesis we are testing."