In the past five years, fueled significantly by the Affordable Care Act (ACA), we have witnessed a wave of breakthroughs in integrating services more effectively for Medicaid populations. States are making great strides in integrating Medicare and Medicaid for individuals dually eligible for those two illogically misaligned programs. Similarly, both at the federal level — through Medicaid health homes for beneficiaries with complex needs and demonstrations funded by the Center for Medicare & Medicaid Innovation — and at the state level — through accountable care efforts in Medicaid and strong movement toward carving-in behavioral health — we are seeing integrated care breaking out all over.
Going beyond health care for long-term impact
Now an even broader wave is washing over the landscape of publicly financed care. It is the recognition that health care interventions only account for a modest proportion of health outcomes. That realization is particularly powerful when it comes to low-income populations, because the social determinants of health are so often stacked against them — nutrition, housing, day care, schools, socioeconomic environment, employment, public safety, violence, etc. Through our work at the Center for Health Care Strategies (CHCS), we see three major opportunities to further new preventive and integrated care approaches for people served by Medicaid:
1. Broad Prevention
Given the relentless budget pressures they face, simply saying that broad investments in prevention are valuable will not get the attention of Medicaid leaders. Identifying evidence-based interventions for high-cost health conditions facing Medicaid populations — e.g., diabetes, tobacco, and unintended pregnancies — can help build the case for states to invest in prevention. With philanthropic support, CHCS will be coordinating technical assistance to help multiple cross-agency state teams across the country implement prevention efforts in state Medicaid programs.
This “marriage” between Medicaid and public health is a notable breakthrough after years of largely siloed activities across these agencies in most states. For example, through a national effort funded by Kaiser Permanente Community Benefit, CHCS is bringing together Medicaid and public health organizations in five states to reduce obesity among low-income children. Such partnerships offer tremendous promise for testing — and establishing — long-term strategies for health improvement.
2. Upstream Prevention and Intervention for Young Families
Sometimes the pay-off for investments in prevention are so far down the road that it seems almost impossible to engage Medicaid officials. However, a subset of local health plan innovators — e.g., Hennepin Health in Minnesota and HealthShare of Oregon — that work extensively with high-need, high-cost populations are recognizing that almost all of the problems these individuals face start “upstream” on a “socially constructed pathway to super utilization.” Research has shown that early childhood experiences like homelessness, domestic violence, child abuse and neglect, poverty, hunger, and, even, excessive lead levels can set the stage for a lifetime of downstream physical and behavioral health problems. Medicaid leaders in states such as Connecticut and Maryland are seeing the same patterns and considering how to best address them.
It is exciting to see these state and health plan officials make these connections. Despite the long-term nature of the potential return on investment, they are considering investments in prevention strategies aimed at mitigating adverse events in the first 1,000 days of a child’s life. Getting Medicaid stakeholders into productive collaborations with state and local social services, child welfare, and housing agencies as well as schools and community-based organizations will be more challenging than marrying Medicaid and public health. But, the time is right for breakthroughs in this arena to guide broader health system reform. The ACA’s Medicaid expansion and the enrollment of millions of long-uninsured childless adults — many of whom have been homeless, in and out of behavioral health treatment, or in the criminal justice system — have helped clarify for Medicaid decision-makers the costs of doing nothing upstream for vulnerable infants and young children. Recent happenings in Flint demonstrate the need for inspired leadership to capitalize on what Medicaid can do to support preventive services.
3. Downstream Intervention for High-Need, High-Cost Adult Populations
The breakthroughs in integrating services for adults with complex needs continue to happen, in large part, because the human and financial costs of inaction are so exorbitant. There is ever-more evidence about the overlapping social, physical, and behavioral health comorbidities that are associated with the highest-need, highest-cost subset of the Medicaid population. Recognizing the need for integrating health and social services is a first step among many design and implementation challenges facing those trying to identify, find, engage, and sustain treatment for these populations. The National Governors Association and the Centers for Medicare & Medicaid Services are helping states develop strategies for intervening and efforts like CHCS’ Complex Care Innovation Laboratory, made possible by Kaiser Permanente Community Benefit, are bringing together leading providers and health plan innovators to accelerate the identification of better complex care models. The recently announced national center to improve care for complex populations will provide other critical supports to advance the field and Transforming Complex Care, an upcoming CHCS effort supported by the Robert Wood Johnson Foundation, will help other providers in spreading ways to care for high-need, high-cost patients.
Immutable budget lines and bureaucratic silos do not serve individuals with complex needs well. Fortunately, we are beginning to see more and more opportunities to cross those lines and to create more responsive systems of care. There is a wellspring of new partnerships that Medicaid can pursue — such as with state public health officials, local social services organizations, schools, and community-based organizations — to help improve long-term health outcomes for those who need it most.