‘It’s never been done before’: Medicaid to address non-medical determinants of health

For years, staff at Hunger and Health in Watauga County have distributed food for free to families in need.

“We’re the largest food pantry and the only free pharmacy in Watauga County,” said Ben Loomis, the grants and program manager at the organization. They also serve nearby Ashe and Avery counties, offering people in these rural communities phone consultations with a registered dietitian and support building out their nutrition profile and a healthy food plan.

Starting March 15, Hunger and Health — along with more than 90 other organizations throughout 33 western and eastern North Carolina counties — began scaling up their work and getting reimbursed for parts of it when the state officially rolls out the Healthy Opportunities Pilot: a first-in-the-nation project which hypothesizes that if we use health care dollars to pay for non-medical health-related services, medical costs will fall and people’s overall health will rise.

The project, often abbreviated as HOP, draws its funding from Medicaid, specifically the 1115 waiver that also authorized the state’s transition to managed care. The federal waiver program gives states the flexibility to try “experimental” ways to improve the health of their Medicaid population. The waivers approved by the feds are also evaluated to see if they’re able to save Medicaid dollars long term.

In North Carolina, the waiver means that the state can use up to $650 million in Medicaid money to pay for things such as the delivery of healthy food boxes, paying for someone’s first month’s rent or a security deposit, and case management for families experiencing domestic violence. 

“I’m sure you’ve heard the statistic that 80 percent of somebody’s health is estimated to be in avenues outside of traditional health care,” said Betsy Tilson, the Chief Medical Officer for the NC Department of Health and Human Services at a launch event for the pilot in western North Carolina. “We want to get at that other 80 percent.”

The pilot will be rolled out in three topical phases: food and hunger-related services on March 15, housing and transportation services on May 1, and finally services aimed at promoting interpersonal safety on June 15. 

“We want to be very intentional and strategic and pragmatic about how we’re going to address that and how we leverage our dollars in a new way to buy health — not just health care — but buy health,” Tilson said. 

So, how do people find these services?

There’s a couple different ways, explained Robyn Hamilton, the former director of Impact Health, which is leading the pilot in western North Carolina. 

“The primary way,” she said, “is that Clarissa is going to see her provider for some particular reason. The provider notices she looks a little disheveled. ‘Everything going okay, Clarissa?’ ‘Well, I’ve been living out of my car for the past week.’ ‘Oh, tell me more.’”

From there, the provider will (ideally) send in a social worker, who will take more information. The social worker will see that the patient is on Medicaid and will then reach out to a care manager from the patient’s Medicaid managed care plan and explain the situation. Patients can also reach out to their care manager directly, to expedite the process.

“They say, ‘Hey, listen, I’ve got Clarissa here, and we need to figure out how we can qualify her for some housing assistance, and also, she’s probably going to need some groceries, so let’s see what we can do to do that,” Hamilton narrated.

Simply having Medicaid is not enough to qualify for the pilot. People also need to have a qualifying health condition, such as a high-risk pregnancy, and a “social risk factor,” such as housing insecurity. 

The care manager, who works for the Medicaid managed care organization, will determine if the person meets the eligibility criteria. If they do, the work then moves onto the platform NCCARE 360, which uses software created by the national technology company Unite Us, to streamline the connection between medical providers, the managed care organizations, and the participating social service organizations. 

The care manager or the social worker will go on NCCARE 360 and send out an alert to the organizations that housing and food services are needed in this particular area. 

“And then a human service organization on the other end says, ‘Yep, I can help you with that.’ They take on that referral. They then are responsible for reaching out and connecting with Clarissa to make sure that they can fulfill that service and bring that full circle,” Hamilton said.

Once the services have been provided, the organization will submit an invoice to Impact Health, which will review it, ensuring that it’s complete — i’s dotted, t’s crossed — and provides a service that’s covered through the pilot. Impact Health then submits the invoice to the managed care plan, which then reimburses the organization directly.

First step: food

While the actual logistics of the project are complicated and new, the work is not. One of the guiding principles of the pilot is to not reinvent the wheel, but instead to help expand the capacity of people and organizations that have been doing this work and have existing community relationships.

One such organization is Caja Solidaria, which means the solidarity food box. Caja is a mutual aid organization that sprang up at the start of the pandemic with the goal of helping the Latin American community in Henderson County access healthy produce. Through the pilot, Caja Solidaria will provide food boxes to Medicaid participants, either for pick up or delivery.

Sonya Jones, one of the co-leaders of Caja Solidaria and the coordinator of the Henderson County Committee for Activity and Nutrition, said the organization’s participation in the pilot felt like a natural fit.

“Mutual aid is a cooperative economic strategy,” Jones said. ”We have members who buy-in every weekend. We buy wholesale food from local farmers, and from local food distributors. So we’re really interested in building the local economy and local wealth and resilience as part of increasing access to fresh fruits and vegetables.

“What’s different about the Healthy Opportunities Pilot is that Medicaid is interested in paying for those boxes,” she said. “Basically, we’re inviting Medicaid into our cooperative economic strategy.”

Bounty and Soul, a food justice organization in Buncombe County, has a similar mission. Paula Sellars, the deputy director of operations, explained that when the pilot begins they’ll distribute food boxes filled with contents from MANNA, a massive food bank serving 16 western NC counties and the Qualla boundary.

“Bounty and Soul as an organization is founded on basically what we call whole person health,” Sellars said. “We have three pillars. One is called Produce to the People, and that is our program that provides plant-strong foods to the community, to everyone — we don’t ask about need.” 

The organization calls its second pillar Rooted in Health, where they provide nutrition and cooking education, in addition to fitness and mindfulness classes, and the third pillar is the Farmers Alliance.

“Right now we have 46 local farms that we partner with, who we buy produce from, healthy fresh produce,” she said. Ideally, as the project gets more established and they work out the kinks, they’ll fill the food boxes with produce from their partner farmers and shelf-stable items from MANNA.

“Our intent in the big picture is to support the local food economy,” she said, meaning buying from farmers in Buncombe, Henderson, Transylvania and McDowell counties so they can remain financially sustainable, and distributing that produce to local people in need.

“As we know with this whole supply chain debacle going on nationally, the more local you are, the stronger your local food system is, the better off your community is.”

As they get closer to the launch date, they’ve found their way through numerous logistical hurdles. One of the most recent included figuring out where they’d source and store the actual boxes for the food.

“There have been numbers thrown around like 800 to 1,200 referrals per month, so now think about this,” Sellars explained: if Bounty and Soul gets 800 referrals per month — 800 cases for which the organization needs to provide between ⅓ and ⅔ of each person’s weekly food consumption — and let’s say each referral is for a family of four, that means they could need around 3,000 boxes.

“Think about the physical boxes!” she said, “Think about how many boxes that is!”

They’ve found a solution for this specific problem, but with so much in flux more difficulties are bound to arise.

Transportation, housing could make the difference for some

Once the food component of the pilot has rolled out, next comes housing and transportation. That’s where Jamie Beasley will come in. He’s the executive director of Working Wheels, which both collects donated cars and sells them — at a very low price — to families in need, and also covers 90 percent of the cost of repairs for people who already have cars. 

“If you can’t get to your doctor or you can’t get to the pharmacy or you can’t get to the specialist or you can’t get to the YMCA to exercise, then that’s certainly a determinant of your ability to be healthy,” Beasley said. 

“The big picture idea of people being able to use their Medicaid card to access services that would help them be healthier,” he said, “I think it’s smart and progressive thinking on how to take care of people.”

Working Wheels will participate in the pilot with its car repair program. The organization can’t commit to giving cars to people through the pilot because they don’t control the supply of cars donated to them — an issue that’s worsened with the supply chain issues brought on by the pandemic. The payment model for the repairs is yet to be determined. Working Wheels may cover 90 percent as they usually do, or they may cover 100 percent. 

“I have a feeling that we’re going to be overrun with demand,” he said. “It might take a while for the workings of the system to be understood by all the players but when you get down to it, if you take people that are on Medicaid, and you figure out how many of them need to have a car repair, it’s going to be a handful.” 

Violence prevention work poses challenges

Due to privacy issues, the interpersonal safety component of the pilot won’t roll out for a few months. 

“I think there’s question marks for every agency that’s involved in the pilot, but specifically for domestic violence, sexual assault, victim-based agencies, there’s a lot of question marks,” said Jennifer Turner-Lynn, the assistant director with the domestic violence agency REACH of Macon County. 

The main issue for these agencies lies in the referral process — the logistical crux of the pilot. Collecting participant’s information and using it to refer them to services based on their needs poses an issue for domestic violence agencies, which have long standing policies of neither confirming nor denying that somebody is receiving services with them.

“The biggest question mark from the North Carolina Coalition Against Domestic Violence, and part of the advocacy work that’s being done between NCCADV at the state level is around confidentiality,” Turner-Lynn said. 

“You have to use those platforms in order to make referrals, that’s how clients are processed basically,” she said. “The problem is that there are some question as to whether or not the platform at this point is completely compliant with [the Violence Against Women] Act.”

Henderson County’s domestic violence agency Safelight initially planned to participate in the pilot, said executive director Lauren Wilkie. But they were concerned about these confidentiality issues with the platform and have pulled out for now. 

Dionne Greenlee-Jones, the interim executive director of Impact Health, which is responsible for coordinating the healthy opportunities pilot in western North Carolina, said the organization is aware of the confidentiality issues and working to resolve it.

Turner-Lynn is hopeful the technical problems will be fixed. Especially because the interpersonal violence part of the pilot holds such enormous potential. 

“Trauma impacts every area of your health,” said Turner-Lynn. “It impacts your mental health, your emotional health, and it definitely impacts your physical health,” she said. 

She cited broken bones from domestic violence that land people in the emergency room, and sexual assaults that don’t result in direct physical injury but which manifest later in psychosomatic symptoms: chronic pain, digestive issues. All that medical care is expensive. 

“What I’m talking about is primary victims, but obviously you also have secondary victims,” she said.  “You may have children living in a home who aren’t actually physically being abused, but witnessing that abuse can also result in psychological complications, or if children intervene in dangerous situations that places them at risk for physical injuries as well.”

Adverse early childhood experiences, such as living in a home with domestic violence, have been shown to negatively impact kids later in life. These types of experiences create toxic stress, which leads the brain to over-secrete stress hormones. The heightened response can cause physical changes in a child’s brain and immune system.

For many of the agencies, their day-to-day operations won’t change. They’ll just be compensated more reliably. For many, the funding and the support feel like recognition for all the time and effort they’ve spent in the trenches, working with precarious budgets, trying to help people fulfill their very basic needs.

“These four things undergird health,” Sellars said, referring to food, transportation, housing and violence prevention. “You can give somebody diabetes medication all month long, but if they don’t have access to healthy food, you’re not gonna get anywhere, right? Or they can have all the money in the world, but if they’re being abused in the evening, they’re gonna have all kinds of mental health and physical health challenges, right?

“The system is finally recognizing that these four social determinants underpin any other health efforts. That’s hugely transformational. It’s a complete paradigm shift for the health care system,” she said. 

“It’s never been done before.”

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.