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“How North Carolina Is Using Medicaid to Address Social Determinants of Health” by Nicole Rapfogel and Jill Rosenthal
North Carolina has developed a large-scale, comprehensive approach to addressing unmet nonmedical needs—including food, housing, and transportation insecurity—through Medicaid. Using a Section 1115 Waiver, the state has undertaken a major effort to put Medicaid dollars toward evidence-based interventions to target social determinants of health: the Healthy Opportunities Pilots program. The pilots program is an innovative approach that integrates a standardized screening process, referral and feedback system, care management, and enhanced programming within the Medicaid program and builds on existing infrastructure in coordinated care and social services. North Carolina will receive $650 million over five years in federal Medicaid funds to support its endeavor to connect patients to social services, $100 million of which can be used for capacity building.
The North Carolina Department of Health and Human Services (NCDHHS) will evaluate the pilots program rigorously and anticipates finding effective delivery of pilot services, increased screenings for social risk factors, more connections to social services, decreased social risk factors, improved health care outcomes, and lower health care costs.
The Healthy Opportunities Pilots program
To qualify for the Healthy Opportunities Pilots program, participants must demonstrate at least one health risk factor and one social risk factor. Pilot services correspond to needs associated with each social risk factor.
Health risk factors:
- Adults with two or more chronic conditions or repeated emergency department use or hospital admissions
- High-risk pregnant women
- Infants and children at high risk or with one or more chronic conditions
Social risk factors and pilot services to address them:
- Homelessness and housing insecurity
- Pilot services: tenancy support; housing quality and safety; legal referrals; security deposit and first month’s rent; and short-term post-hospitalization housing assistance
- Food insecurity
- Pilot services: food support and meal delivery
- Transportation insecurity
- Pilot services: nonemergency health-related transportation
- Risk of witnessing or experiencing interpersonal violence
- Pilot services: interpersonal violence-related transportation, legal referrals, and parent-child supports
North Carolina took important steps to prepare for the program
The NCDHHS has built the infrastructure needed to carry out the pilots program, including:
- Transitioning Medicaid from fee-for-service arrangements to managed care, enabling plans to more efficiently pay for nonmedical services
- Conducting a rigorous process to develop a fee schedule to pay human service organizations for delivering pilot services
- Creating a nine-question standardized screening tool for health care providers to determine if patients have unmet social needs
- Building a statewide bidirectional referral platform, NCCARE360, to connect community-based organizations, social service agencies, and health care providers to address social determinants of health
- Using federal funds to support human service organizations in building capacity to offset increased demand
Takeaways for other states
Following North Carolina’s innovative approach, other states considering developing more robust programs to treat whole-person health could take the following steps:
- Leverage federal Medicaid dollars to mitigate state budgetary constraints.
- Expand existing coordinated care efforts.
- Build on existing community resources and relationships.
- Develop infrastructure for data collection and sharing.
- Think big.
To create meaningful and lasting change and address persistent health inequities, states must focus on the social and economic factors underlying disparities. Other states interested in advancing whole-person health should closely monitor North Carolina’s Healthy Opportunities Pilots program and consider adopting similar approaches.