The midterm elections of 2018 are now behind us, and there is ample reason for health care advocates and consumers to take heart from a number of the outcomes. Most significantly, the end of single-party majorities in both chambers of Congress has averted the danger of a repeat of 2017’s legislative attempts to repeal the Affordable Care Act and cut Medicaid. Health care advocates are also rejoicing that health care loomed large for midterm voters nationally, and Medicaid fared well in key state ballot initiatives. But what might election night outcomes mean for health care policy initiatives that expand beyond access and coverage, and focus on the root causes of poor health, such as social and economic determinants?
With the threat of ACA repeal in the rearview mirror, we think the time is ripe for states, localities and health care institutions to double down on identifying ways to drive investment to address the social and economic determinants of health (SDOH). Here are three key ways health care advocates can help the health care system engage proactively on SDOH:
- Allowing Medicaid to directly address SDOH. As our friends at CCF note, states have latitude to use Medicaid to address SDOH. Fortunately, the Centers for Medicare and Medicaid Services (CMS) also illustrated its willingness to help states makes these investments by recently approving a Medicaid Section 1115 waiver submitted by North Carolina. Beginning in fall 2019, North Carolina health plans in certain areas of the state will screen their enrollees for whether or how they’re being affected by four social determinants of health – housing, transportation, food insecurity and interpersonal safety/toxic stress – and then refer affected enrollees to community-based social service providers who can help address their health-related social needs.
- Engaging nonprofit hospitals and public health. Hospitals can use community benefit, community health needs assessments and other strategies – to work locally on SDOH. Environmental justice group Health Care Without Harm recently surveyed a sampling of hospital community benefit staff, gathering information and tips on ways food security organizations can best approach hospitals to engage them on this issue. Many public health departments use similar processes, with a few taking steps in recent years to elevate SDOH as departmental priorities (see a homegrown example here, in Massachusetts).
- Supporting grassroots initiatives to address SDOH. Our partners at the Northwest Bronx Clergy and Community Coalition (the Bronx, NY), APANO (Portland, OR) and Pillsbury United Communities-Waite House (Minneapolis, MN) worked closely with community residents and grasstops partners to build energy and knowledge to win health care support for healthy housing and a “green jobs” program. They found that for grassroots partners and community residents, learning that certain social and economic systems (and the policies that support them), can shorten lives and limit health, has been a powerful motivator and useful organizing framework for getting local health care institutions invested in SDOH.
While we’re certainly excited that federal policymakers seem interested in investing in SDOH, they’ve also taken some troubling steps to cut access to critical resources and services that can address them. For example, even though CMS recently approved North Carolina’s waiver, we’ve also seen the agency repurpose language and rationales commonly used to support SDOH to support detrimental work requirements in Medicaid, a proven barrier to coverage. The Trump Administration has also proposed massive cuts to housing and food assistance services that millions of Americans rely on to make ends meet. Similarly, both the recent federal budget and the Tax Cuts and Jobs Act of 2017 slashed millions of dollars for the Prevention and Public Health Fund, a critical source of public health funding that the Centers for Disease Control and Prevention (CDC) has historically used to support state and local community health programs.
Overall, while the midterm election results provide advocates working to build private and public investment in SDOH initiatives more room to maneuver, the shake-up in Congress still leaves the administration with powerful tools to undermine core programs that will weaken the social and economic safety net. Moving forward, we’re going to be proactive – but also vigilant.