A recent article published by the American Journal of Public Health (AJPH) affirms what is at the core of Community Catalyst’s mission: a strong, organized consumer health advocacy movement is critical to moving states to extend health coverage to low-income people. The authors Timothy Callaghan, MA, and Lawrence R. Jacobs, Ph.D., found that the prevalence of a well-organized consumer advocacy infrastructure in a state moved it closer to the closing the coverage gap—regardless  of partisan control in state legislative and executive offices. They cite research suggesting that despite operating under challenging political environments, consumer health advocates influenced decision makers through tactics such as effective grassroots mobilization, media engagement, letter-writing campaigns and voter engagement initiatives.  Within our network of consumer health advocates, we’ve seen examples of advocates maximizing opportunities to influence coverage gap decisions in their state.

Advocates drive progress in closing the coverage gap

The authors found that after the Supreme Court handed down its decision making Medicaid expansion an option rather than a mandate, states either immediately took action, tepidly moved forward or remained obstinately opposed. According to their research, when a state in the latter category finally does close the gap, it is often because of a strong, coordinated and vocal group of advocates working to put consumer interests first.

In Louisiana, with a Governor ardently opposed to closing the coverage gap term-limited out of office, a real discussion around Medicaid expansion began to take shape in early 2015. Advocates visited parishes across the state, met people in the coverage gap and elevated their stories. Advocates hosted a gubernatorial candidate forum on health care and by Election Day, all major candidates had agreed that expansion was necessary, though they differed on how to go about it. Ultimately, Democrat John Bel Edwards won the Governor’s race and within hours of taking office, signed an executive order expanding Medicaid.

In Montana, a multi-year campaign to close the coverage gap commenced in 2013, where advocates implemented strategic grassroots organizing efforts elevating consumer voices.  Advocates conducted public education events, implemented letter-writing campaigns, canvassed targeted districts, and engaged thousands of volunteers to elevate the stories of people in the coverage gap. After directing 11,000 calls to legislators and generating 8-10 earned media pieces each week, advocates were able to successfully pressure lawmakers to approve legislation triggering the state to seek federal approval to close the gap. In November 2015, CMS approved Montana’s proposal to extend health coverage to over 70,000 Montanans.

Even in states that still have coverage gaps, advocates continue to keep the conversation relevant, holding lawmakers accountable for the harms their constituents face from their failure to close the gap. Following the failure of Governor Haslam’s Insure Tennessee plan to pass through a key committee last year, Tennessee advocates organized a strong, grassroots and media engagement campaign keeping lawmakers accountable. This response moved lawmakers to take Insure Tennessee back up again in committee last year, and kept the coverage gap conversation alive in the state. In Alabama, advocates worked behind the scenes to make sure Governor Bentley’s Health Care Improvement Task Force understood how essential closing the coverage gap is to Alabama’s health care infrastructure. Advocates were persistent in moving Governor Bentley to shift his stance on expansion and begin exploring options for closing Alabama’s gap. One thing is certain for the remaining coverage gap states: the persistence and dedication of advocates can and will make a difference.

Community Catalyst is working hard to provide leadership and support to state partners pushing decision makers to expand Medicaid. We have built, and continue to build, systems of advocacy across the nation to close the coverage gap. We provide resources and technical assistance, and help guide advocates leading state campaigns to learn from each other. Given the challenges inherent with influencing decision makers in remaining non-expansion states’ political environments, we help share the most effective tools, ideas and strategies across state lines to ensure advocates are best-equipped to push decisions makers to support expansion. AJPH’s article just confirms what we’ve known all along: well-organized state consumer health advocates are critical to ensuring the 3 million people still caught in the coverage gap will one day gain coverage.

 

There is increasing acknowledgement nationwide that the social and economic conditions in which people live play an enormous role in health. Clinicians and hospitals cannot make their patients healthier by solely focusing on what happens inside the clinic walls. Rather, improving health in a significant way means forging collaborations between clinicians and community-based organizations that address those social and economic conditions. The recent initiative announced by the Center for Medicare and Medicaid Innovation to establish Accountable Health Communities by funding clinical-community collaborations is evidence of the importance that policymakers are at long last attaching to these conditions.

This new emphasis is the reason we’re so excited about a new study from our friends at the Maryland Citizens Health Initiative (MCHI), a long-time Community Catalyst partner. Health Policy Hub readers may recall a guest blog we published last March about the steps MCHI has taken to transition their work to health system transformation. Since that post, MCHI has continued to expand its health system transformation work, and has focused on exploring programs that create collaborations between hospitals and faith/community-based organizations.

Specifically, MCHI is piloting a Faith Community Health Network in Maryland. The model is based on a program in Memphis, TN – the Congregational Health Network developed by  Methodist Healthcare – in which the local hospital system and faith communities work together to keep congregants and the local community healthier. In Maryland, MCHI is working with LifeBridge Health to pilot a similar program in three LifeBridge hospitals, one urban, one rural, and one suburban. With a successful pilot, MCHI is hoping that this model can be refined and adopted by other hospitals in Maryland.

To inform their work, MCHI conducted a study—developed with support from Community Catalyst and in partnership with the Urban Institute Health Policy Center—that examines examples of collaborations between hospitals and faith/community-based organizations. The paper identifies five particular programs with proven track records. In one such project - Project RED (Re-Engineered Discharge) - adult patients in a Boston hospital were given access to Discharge Educators, who could be congregational or other volunteers who have received specialized training. The Discharge Educators followed a step-by-step program prior to discharge to be sure that both the patient and the physician understood the patient’s condition and what the patient should do when s/he returned home. Participants in Project RED had a 33 percent lower rate of emergency room (ER) visits and a 28 percent lower rate of readmission within 30 days of discharge as compared to patients receiving typical discharge care.

For more information about Project RED and the other four programs discussed in the paper, we invite advocates and others to take a look at the research MCHI has compiled, and to watch this space for updates on how advocates in Maryland and other states are working to address the social and economic determinants of health.

Thanks to a clarification by CMS regarding the “free care” rule a little over a year ago, schools can be reimbursed for services provided to Medicaid-eligible students. This was a subject of a conference call and toolkit released earlier this month from HHS and Department of Education regarding how to support deeper coordination between health and education entities. Prior to the clarification issued by CMS in late 2014, schools were barred from receiving Medicaid reimbursement for health services. For example, if your school supported Early Periodic Screening, Diagnosis, and Treatment (EPSDT) related services such as vision screening, or managed chronic care conditions such as asthma, they could not be reimbursed by Medicaid even if the child was a Medicaid enrollee. There were two exceptions to this rule:

1)      The child was enrolled in an Individualized Education Plan (IEP) or

2)      The child was receiving services under the maternal and child health services block grant.

However, with the “free care” restriction lifted, there is now an opportunity for Medicaid to more broadly support preventive health activities such as screening and chronic care management. Schools are now able to further advance their pivotal role in increasing access to needed care and improving long term child wellness. This latest change in policy prompts a broader conversation about how schools and health care entities work together to increase access to health services for vulnerable children, especially because schools are a vital partner in advancing health equity goals for children (learn more about policy change here). Children’s health advocates are always looking for ways to make Medicaid work more intelligently; partnering with education and public health advocates to provide health services to children in a school setting should, and now can, be a primary pathway to prevention and better health outcomes.

So how are states doing?

In order to implement the new policy, states need to review which Medicaid services and providers are currently allowable in a school setting; due to the past restrictions on billing, there may be a need to revise or alter existing policy at the state level. In many cases, states will need to submit a state plan amendment to CMS with the new policy approach.

Over the past year, a handful of states quickly moved on this change in policy. Two examples include Louisiana and California. In 2011, Louisiana transitioned to Medicaid managed care and, in the process, developed a state plan amendment to allow Medicaid to pay for school nurses for special education students (those on an IEP, one of the two previous exceptions). With the change in the free-care rule, Louisiana will reimburse Medicaid-eligible services for all children enrolled in Medicaid, not just those for children on an IEP. While it is too early to assess the impact of this change, it is worth noting that close to 60 percent of Louisiana children are Medicaid-eligible and nearly 7 percent more are eligible but unenrolled, so the impact of this free-care policy change is truly significant.

In California, the legislature passed a law in late 2015 instructing their Medicaid agency to reimburse Medicaid health care services in schools when a managed care company denies payment. The bill enables local education agencies (LEAs) to receive Medicaid dollars through a billing option program; in response to the free-care rule change, the state also submitted a state plan amendment  to CMS requesting ability to reimburse Medicaid services when there is no response from the insurer. This change will enable LEAs to more comprehensively draw down Medicaid dollars and sustain health services provided in a school setting.

There is ongoing work to do in implementing these changes in billing at both the state and local level. However, the process in California also highlights unique opportunities for stakeholders to engage in work around the relationships and dynamics between systems, such as:

  • Working with Medicaid agency and local education agencies to redesign billing relationships
  • Helping to re-think how educators view health services
  • Examining how health providers think about schools as levers of health system change

Is your state drawing down needed dollars for schools?

As advocates contemplate varying political landscapes and design their 2016 policy agendas, directing more Medicaid dollars to school settings is one way to expand access to health care services for Medicaid-eligible children. It provides an additional location and touch-point to meet children where they are, ensuring that they have complete access to necessary preventive and health care services. Finally, Medicaid dollars that are directed at supporting a school health provider workforce is meaningful for local budgets and long term Medicaid savings. Advocates are important and needed partners in implementing the “free care” change in policy. Our Substance Use Disorder team developed a tool for advocates working to expand access to SUD screening in school-based settings. Stay tuned for a forthcoming resource to help guide advocates partner with states to reimburse school health services through Medicaid.

As advocates reach out to Medicaid agencies and local school boards to assess where the state stands on this new opportunity, we look forward to working with you to send Medicaid to school! 

In the initial blog post of this series, we mapped out Community Catalyst's policy agenda for Health System Transformation (HST). One issue that rises to the top of our agenda is redirecting resources to address social determinants of health, which we believe is essential for achieving better care, better health and better value for vulnerable populations.

Why are we looking at social determinants of health?

Social determinants of health – which encompass factors outside of the health care system that influence one’s health – have been central in recent health policy and health system change discussions. “Upstream factors” such as social, environmental and behavioral influences like food, housing, employment/working conditions, gender and culture play a significantly large role in promoting health and potentially lowering health care costs. This is illustrated in the Community Health Rankings Model featured in our recent report, The Path to a People-Centered System.  Furthermore, data from The American Healthcare Paradox and Leveraging the Social Determinants of Health: What Works?report clearly demonstrates that higher ratio of social-to-health care spending correlates with statistically better health outcomes.

The U.S. health care system is the most costly in the world, but our population’s health outcomes are worse than most other Organization for Economic Co-operation and Development (OECD) countries[i]. A driver behind this gap could be the significant imbalance between spending on medical care and social services: in the U.S., for every dollar spent on health care, only about $0.9 is spent on social services. In comparison, for every dollar spent on health care, OECD countries spend $2 on social services. Given the clear importance of social determinants of health in improving population health outcomes and reducing costs, it will be essential to move health care dollars from the delivery of medical care into areas that address upstream health factors.

Currently, efforts to redirect resources to social determinants of health are happening all around the country, testing intervention measures that adapt to local needs and conditions.

In Massachusetts, various foundations, government agencies and law firms fund Medical Legal Partnership Boston, an interdisciplinary team of health care staff, attorneys and paralegals, to provide direct legal assistance to low-income patients, ensuring their basic needs are met for housing and utilities. They also provide training and education so these patients can become advocates themselves to access early detection and preventive care services. The impact of their services is significant: by connecting low-income families to utilities, food and housing services, they are able to demonstrate improved health outcomes for the population they serve.  

The Northwest Bronx Community and Clergy Coalition has a grant through the BUILD Health Challenge to work with Montefiore Hospital to address asthma in their community. The partners are working with tenant organizations in the Bronx to rehabilitate “sick” buildings to prevent and treat asthma that is linked to housing conditions.

Maine Equal Justice Partners (MEJP) is a legal aid organization that finds solutions to poverty by making sure people have their basic needs met. The organization provides direct services while running a robust advocacy program around health care, income security, and housing. MEJP has spent significant time and resources on closing the Coverage Gap in Maine. This year, MEJP wanted to better understand community members’ needs and surveyed 1,000 Maine residents who were low-income. By far, the greatest need was housing. Respondents specifically said that having secured housing would improve their health and other areas of their life. Because this was a new arena for MEJP, the staff began consulting with national partners and members of the Maine Affordable Housing Coalition. When examining the state funding streams for housing, MEJP discovered that 85 percent of the general assistance fund went toward housing support. Instead of relying on emergency funding, MEJP successfully advocated for increases in access to ongoing housing subsidies and is continuing to advocate, with the support of a newly-created Affordable Housing Working Group to ensure greater access to affordable housing and therefore, a healthier population.

As traditional health advocates, we will have to broaden our scan of community partners. Many organizations and entities already exist to secure affordable housing, promote healthy food options and address issues in communities. We need to translate our skills in health policy organizing to skills in relationship building. This means traditional health advocates will need to learn the language of the various social arenas and support their policy agendas. For example, those interested in the impact of food on health will need to learn about the prevalence of food deserts in communities. With new partners and a broadened view of health care, we can promote innovation and payment policy agendas that include these social structures as interventions in health care, ensuring a healthier population of people.

 


[i] K. Davis, K. Stremikis, C. Schoen, and D. Squires, Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, The Commonwealth Fund, June 2014.

Flint: How Did This Happen And What Does It Mean?

In my opinion, the biggest health care story of the week is the continued fallout from the lead contamination of the water supply in Flint, Michigan. The Flint crisis underscores two egregious faults of the U.S. health care system: underinvestment in population health and persistent disparities based on race and class.

While Governor Snyder did recently apologize, this is a never event. It simply should not happen. The reason it did can be traced back to a cost-cutting decision made by the emergency manager Gov. Snyder appointed to run the city's finances. Gov. Snyder is something of a moderate in his party (he championed the expansion of Medicaid under the ACA, for example). Nonetheless, the anti-government/pro-austerity ideology which has come to dominate today's GOP stands indicted by the public health meltdown in Flint.

Progress Closing The Coverage Gap, But Election Shadow Looms

There was a lot of discussion of Medicaid this week, with Louisiana moving forward, and progress in South Dakota. But in other states, not so much.

Governor John Bel Edwards (D-LA) signed an executive order to expand coverage and the state is now looking at ways it can expedite enrollment for hundreds of thousands of low-income uninsured residents. Meanwhile, CMS Administrator Vikki Wachino has just completed a visit to South Dakota and both federal and state officials are reporting progress in their discussions. On the other hand, a legislative committee in Wyoming dealt a setback to Governor Matt Meade's effort to close the gap in his state, while Tennessee lawmakers appear intent on waiting for the outcome of the 2016 presidential election before making a move. Given the health and economic benefits of coverage, frankly there is no excuse for waiting.

ACA Replace Debate Takes An Unexpected Turn

Six years after taking control of the House, Republican Congressional leaders won't commit to actually producing a replacement plan. That's not the unexpected part. That would be at other end of the ideological spectrum where Bernie Sanders has touched off something of a firestorm with his “Medicare for all” proposal. Of course, as John McDonough points out, the plan is dead even before it arrives in Congress so the debate is more symbolic than real. However, symbols can be important. In this case, Senator Sanders is using his plan not so much as a guide to policy, which it is not, but to signal to liberal activists in the Democratic Party, whose support he needs to win the nomination, that he is one of them. Since no major progressive health legislation is going to pass the Congress, a more realistic question for the candidates is how they would use the executive authority they do have to improve the ACA. Of course, that is much too wonky a conversation for public debate, so don't expect it any time soon.

Drug Prices Remain A Hot Topic

Dean Baker offers a more charitable read of the utility of Sanders' health plan, but what is most interesting and helpful about his column is his takedown of the pharmaceutical industry for their price gouging. PhRMA has upped their lobbying expenditures as part of their campaign to fend off any action to rein in prices, but the issue continues to attract attention from both sides of the aisle. Next week, the Center for American Progress follows up their fall report with a briefing on policy options to reduce drug spending that includes researchers, physicians, members of Congress and industry stakeholders.

Too Much Of A Good Thing?

The Commonwealth Fund is out with a blog highlighting the fact that competition in both federal and state marketplaces remains robust overall, but having a lot of plan choices is a mixed blessing. As Trudy Lieberman points out, too many choices can make it difficult, if not impossible, to compare plans.

One solution would be to standardize plan offerings across the metal tiers to make comparisons easier. The Obama administration is considering creating standardized benefit plans in the federal marketplace, but their proposal does not go far enough because it leaves the decision on whether to offer the standard plan to the discretion of carriers.

More evidence that people are generally not very good health care shoppers comes from a new study published in JAMA Internal Medicine that found that people with high-deductible plans were not any better at price shopping for care than people with more traditional coverage. The new study aligns with earlier research from the National Bureau of Economic Research that found that high deductibles were at best a blunt instrument for health care cost containment — causing people to alter their behavior in ways that were not necessarily rational or beneficial to their health. 

And Finally... The Secret To Health Care Quality Revealed (It's Not Quality Measurement)

The best health policy quote of the week comes from Avedis Donabedian, considered by many to be the father of modern health care quality measurement. In an excellent New York Times article that highlights much of what is wrong with our current approach to health care quality measurement, Professor Robert Wachter from University of California San Francisco Medical School quotes Donabedian, then nearing the end of his life, as saying, "The secret of quality is love." Hard to top that.