Investing in Health: A Bold and Pragmatic Federal Action Plan

This blog was written in partnership with Melinda K. Abrams, Senior Vice President at the Commonwealth Fund. 

COVID-19 has exposed and intensified long-standing problems in our country, including deep cracks in the U.S. health system and racial and economic injustice. As the Biden administration mounts its response to these interrelated crises, there is an opportunity and imperative to rethink the approach of federal leadership in creating a healthier America.

Over the past decade, policymakers and industry leaders have pursued significant changes in the way we deliver and pay for health care, moving away from financially incentivizing volume and fee-for-service care to linking payment more closely to value. To date, these efforts have focused on health care. This includes recent initiatives that recommend changes to federal policy regarding the way medical services are delivered and reimbursed.

But changes to care will not be enough to improve the health of all Americans. An estimated 20 percent of health outcomes are linked to medical care; the remaining 80 percent stem from socioeconomic, environmental, and behavioral factors collectively referred to as drivers of health (DOH). Certain factors — such as homelessness, hunger, exposure to intimate partner violence (IPV), adverse childhood experiences, and racism — are linked to poorer health. At the same time, a growing evidence base has shown that addressing these drivers of health can improve health outcomes, increase affordability of care, and advance equity.

People broadly agree that there is a need to invest in what we all need to be healthy — safe homes, healthy food, a stable income. The health care sector can play an important role by partnering with community organizations and encouraging or providing services that address the drivers of health. Many state and federal policymakers, providers, payers, and public health experts have begun to move in this direction. Recent federal guidance supports states in addressing drivers of health in Medicaid and the Children’s Health Insurance Program. The federally funded Health Care Payment, Learning and Action Network (HCPLAN), a coalition of health care leaders and payers, has made a commitment to making patients’ social needs central to providing high-value care that improves population health and well-being.

Yet the growing number of efforts remain widely variable and unevenly applied. We know enough to set clear expectations regarding the role of health plans, providers, and regulators to align efforts to address the drivers of health in a systematic way. Doing so requires a new set of federal policy and regulatory choices and includes not only aligning financial incentives but developing a community-level infrastructure and shifting the role of clinicians and payers to collaborate with community partners.

There is a need to invest in what we all need to be healthy — safe homes, healthy food, a stable income.

North Carolina offers a case study of successfully aligning financial, regulatory, and policy levers to “buy health” (and not just health care) for their population. For example, after recognizing that 47 percent of North Carolina women have experienced IPV, the state committed to buying health and ensuring equity in every part of its delivery system. Recognizing the relationship among DOH, the state mandated screening for IPV, food insecurity, and housing instability and other social investments in the state’s Medicaid managed care contracts, while simultaneously building a statewide coordinated care network to connect people with community resources. This agenda has spurred broad support as an effective use of taxpayer dollars, galvanized private payers and physicians, and leveraged existing federal and state dollars to improve health.

Building on the evidence of interventions to address drivers of health, the North Carolina experience, and other examples from across the country, a newly released report, Investing in Health (supported by the Commonwealth Fund and Blue Shield of California Foundation), lays out options for the Centers for Medicare and Medicaid Services (CMS) to leverage its purchasing power, regulatory authority, intra- and interagency partnerships, and bully pulpit to chart a new path that could result in better health and outcomes for all Americans. This plan identifies seven strategies for CMS’ consideration:

1. Address DOH in combatting COVID-19 by providing housing supports, meal delivery, and internet or phone access to people who cannot isolate or quarantine in their current housing arrangement.
2. Integrate DOH into payment and policy for providers and payers by incorporating social risk factors (food insecurity, housing instability) into payment models.
3. Develop shared resources or “assets” to enable DOH interventions, such as information exchange platforms and community-based social services networks.
4. Maximize participation in public programs that address DOH, including expansion, access, and enrollment in Medicaid, as well as collaborating with other federal agencies to increase enrollment in key programs, such as the Supplemental Nutrition Assistance Program.
5. Create new standards for DOH quality, utilization, and outcomes measurement across Medicaid/Children’s Health Insurance Program, Medicare, and commercial payers.
6. Make DOH central to the Center for Medicare and Medicaid Innovation (CMMI) agenda by encouraging more states to test the CMS-approved social service fee schedule developed in North Carolina.
7. Incentivize community accountability and stewardship by encouraging delivery systems and payers to be mindful of their role — as employers, institutions, and stewards of public funds — and acknowledge and remedy long-standing health inequities by investing in community resources, eliminating wage differentials, and addressing structural racism.

The full report describes these strategies and associated changes for Medicaid, Medicare, the marketplace, and CMMI, as well as actions CMS can take to implement those changes. The actions described above have the potential to significantly assist communities ravaged by COVID-19 and health inequities.