Reimagining Medicaid, How Medicaid Can Help Address Social Determinants of Health

John Fangman: [00:00:12] Hello everyone! We are excited to welcome you to the HIV Medicine Association's podcast series, Let's Talk HIV. Why Medicaid matters. This podcast series covers the ins and outs of Medicaid, the federal health care program that provides care for millions of low-income Americans. I'm your host, Dr. John Fangman, an infectious disease physician at Mass General Brigham in Boston and an HIVMA member. This podcast episode will dive into how Medicaid is evolving when it comes to meeting patients’ non-clinical needs related to social determinants of health, and what this means for people living with HIV. We're happy to welcome two extraordinary guests with us today who are true experts in this topic. Katie Garfield is the director of Whole Person Care and a clinical instructor at Harvard Law School's Center of Health Law and Policy Innovation. Welcome, Katie.

Katie Garfield: [00:01:04] Thank you so much for having me. Happy to be here.

John Fangman: [00:01:07] Thanks, Katie. And Dr. Michelle Ogle is an infectious disease doctor at Children's Hospital at Montefiore in New York and is also the director of Ryan White funded clinic in rural North Carolina. Welcome, Michelle.

Michelle Collins-Ogle: [00:01:20] Good afternoon. Thank you for having me.

John Fangman: [00:01:22] We are so glad to have both of you with us today. I'd like to start with you, Katie, and if you can help us set the stage first. Can you briefly review what social determinants of health are and how Medicaid is changing to better respond to them?

Katie Garfield: [00:01:36] So at our center, we typically use the World Health Organization definition for social determinants of health, which really defines them as the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. For example, social determinants of health can include things like income, education, food and housing, and the environment that you live in. When we're describing these things at the community level, we're talking about social determinants of health. But I also want to acknowledge that there's a lot of terms that are out there in this space right now. Social determinants of health. Social risks, health related social needs, the list goes on. And which one applies depends on a couple of factors. First, it really depends on whether you're looking at these things at the broad community level or closer to the individual patient. So when we talk about social determinants of health, as you can hear from that WHO definition, we mean the broad conditions in the community that are sort of divorced from negative or positive connotations. So simply food access would be a social determinant of health. And then when we actually get to an individual patient, so an actual individual's food insecurity that's impacting their individual health. We're talking about a health-related social need, and that's often the term that you'll hear in the Medicaid space that health related social need, or HRSN. When we think about social determinants of health, why does it matter to Medicaid? Well, it's because we're seeing a whole spectrum of services emerging in the medical space to respond to those health-related social needs.

Katie Garfield: [00:03:20] For example, someone living with a complex chronic condition like HIV. For them, it's really important to make sure they have the right supports in place to consistently and effectively access the care they need. For example, if someone doesn't have access to stable housing, that means they might not have a reliable place to receive and store medications. And if they don't have consistent access to sufficient and appropriate food, they might be making tradeoffs between paying for care and putting food on the table. Or they may make choices about food, they're going to worsen their condition instead of improving it. So when I think of health related social needs services, I think of things like housing supports. So helping someone find housing, avoid eviction or adapt their home to their medical needs. I think about transportation and I think about nutrition supports like medically tailored meals, medically tailored food boxes, produce prescriptions, the list goes on. And then in terms of Medicaid, we're starting to see growing interest in those types of supports, just as we're seeing that same interest really across the healthcare system right now. And that's because there's a growing body of literature that's showing that if we address a patient's health related social needs, we have the potential to then improve that patient's outcomes.

Katie Garfield: [00:04:40] And in some cases, when we make sure the needs are met, we're actually going to see helpful patterns in the way that patient interacts with the health care system. For example, if you're making sure that an individual living with HIV is food secure, they're going to have the potential to be better engaged in basic, needed care. Right. There's the New York Chain Study that showed that individuals living with HIV who had their food insecurity needs addressed, were less likely to miss appointments and more likely to adhere to medications. On the flip side, we also see studies that show when we address health related social needs, we may actually reduce the need for high-cost services. So there have been several studies that show that if you provide someone who's seriously ill with a meal that's tailored to their medical needs, so a medically tailored meal, that patient is going to be less likely to end up in the ER, less likely to get hospitalized and more likely to go to their home rather than another level of care when they exit a hospital. And all of that really adds up, ultimately resulting in cost savings in that case to the health care system. And we've seen similar studies in the housing space. So. Taken together, Medicaid cares about health-related social needs because doing so actually creates the potential to improve health outcomes in a way that can be really cost effective or in some cases, even cost saving.

John Fangman: [00:06:07] Thanks, Katie. That was an amazing overview of social determinants and social related health needs and really helped me understand that more. Michelle, I'm wondering if you can bring the clinical experience directly into the conversation. How did you and clinic see these social related health needs and social determinants of health in your patient population, and what are the things you see that you could use help with? As a busy clinician practicing in your environments.

Michelle Collins-Ogle: [00:06:33] Very early on in the epidemic, it was realized and understood that a stable housing was extremely important and keeping people engaged in care and achieving viral suppression. There are three really important factors when we're talking about housing that really impact a person's ability to achieve viral suppression, which is the important clinical outcome we want in this discussion. The first one, if we put to the side just the mental anguish of an individual that doesn't have a stable environment, taking their medications for HIV may not be priority because there are other things that they are trying to juggle, if you will, when they're looking at being taking care of their health. But if we look at three factors, one is the access to care. If you're in an unstable housing situation, your ability to even get to an appointment, your ability to access your medication, is greatly compromised. So if I'm in an unstable environment, I don't have a reliable pharmacy that may be able to get to get my medications. Also, if you're in places like rural North Carolina, for example, where there's no public transportation, then you may not have the ability to even get to your provider. So unstable housing puts you in a position where you don't have a reliable way to even access medical care. The second point I'd like to bring up is being maintained or retained into care.

Michelle Collins-Ogle: [00:07:55] Retention and care is extremely important. And what that means when I say retention and care is making your scheduled medical visits. When we schedule our patients in to see us, whether it's every four months, every six months, it's because we need to make sure that they are doing well with their antiretroviral medications and not having any side effects or other barriers that we also refer to as social determinants to a person's ability to receive medical care, because they aren't able to see their provider on a regular basis. So access to care being maintained in care, and then the final point where unstable housing is really maybe the most important factor is adherence. So I mentioned earlier, when you're not in stable housing or in stable housing situation, you may not have some of the basic needs to be able to take your medication. Something as simple as a refrigerator. Several years ago, we had antiretrovirals that required refrigeration, and in rural North Carolina, we actually had people who did not have a refrigerator to put their medications that required refrigeration. So those are really three very important factors. Access to care being maintained or retained in care, and your ability to adhere to your medication regimen or your medical visits that are greatly impacted by people who are victims of unstable housing.

John Fangman: [00:09:17] Thank you, Michelle. Every clinician listening to this will totally resonate with your comments about housing instability and the importance of recognizing and addressing that as a critical element of the basic care model. So you guys have done a great job of helping us frame the issue and understanding what the needs are that our patients are facing and some of the potential services that we could bring to bear. Katie, I'm wondering if you can bring us back to some of the policy issues that are coming up now as is Medicaid is reimagining how to how to provide services and talk to us a little bit about what Medicaid is doing to think about new ways to cover these types of issues and patient care?

Katie Garfield: [00:09:54] I want to start by just acknowledging the beautiful way that Michelle really laid out, the way that the HIV space really understood the impact of social determinants and health related social needs early on, the impact of housing, the impact of nutrition. And so actually, many of the organizations that our center works with had their start in the HIV space because of that early understanding. For example, we work with a lot of nutrition organizations because before we had effective medications to respond to HIV, we had individuals suffering from AIDS Wasting Syndrome where they were quite literally wasting away. And at that time, just getting calories into patients was one of the most effective treatments. We had programs like Ryan White were some of the first to really pay for nutrition supports and integrate them into care because of that recognition. And so in many ways, Medicaid is only just catching up in recognizing the impact of health related social needs and building responsive interventions into coverage and care for individuals with serious chronic illness and other health conditions. And this is really accelerated over the last few years. Between 2021 and 2024, we've actually seen a whole slew of new guidance coming out of CMS, out of the centers for Medicare and Medicaid Services regarding how states can build in payment for health-related social needs into their Medicaid delivery systems. Just this past November, in November 2023, CMS put out this really fabulous table that breaks down in a really shorthand clear way for separate policy pathways that states can use to integrate health related social needs supports into their Medicaid system.

Katie Garfield: [00:11:51] So these four pathways were section 1115 demonstration waivers, home and community-based service authorities, which is actually one of the spaces Medicaid has been doing some of this work the longest. Medicaid managed care pathways, such as in lieu of services. And they also talked a little bit about CHIP and the health services initiatives that states can conduct in the CHIP program. And the guidance, one of the reason it was so helpful, was that it actually outlined ten specific housing services and five nutrition services that CMS essentially said through this guidance can be covered under these pathways and how they can be covered. So these are services like housing, navigation, first month's rent as a transitional service, medically necessary home remediation, nutrition counseling, medically tailored meals, nutrition prescriptions, the list goes on. In response to this guidance that we've seen coming out over the last couple of years, that just makes it much clearer what states can do and with what guardrails. We've seen a lot of state interest. So for example, let's just take a look at one of those pathways that I think has been getting a lot of attention over the last couple of years, which is Medicaid section 1115 demonstration waivers. So these 1115 waivers are a policy pathway that states can use to conduct an experimental pilot or demonstration project in their Medicaid program.

Katie Garfield: [00:13:22] And they're highly flexible. They allow states to provide coverage for new services or populations that might not normally be included in the Medicaid program. In guidance over the last few years, including that framework I just mentioned from November, CMS has really laid out the ways that states can use 1115 waivers to address health related social needs, such as housing and nutrition. And I think importantly, in one of the earlier guidance documents they put out back in December 2022, they noted that states can actually go beyond just payment for these services. States can actually use these waivers to request funding for infrastructure dollars to build up the systems that need to be in place around those services, to allow community-based organizations and health care providers to really be able to partner effectively to make those types of approaches effective on the ground. And so, as a result, we've seen a lot of states applying for these waivers and including housing or nutrition supports in their waivers. So for example, on the nutrition side, there are now eight approved waivers and six pending waivers that actually include some form of the provision of food to address health related social needs. And the vast majority of those waivers also include housing supports. And then there are even some states, like Arkansas and Arizona, that largely focus on housing supports in their 1115 waivers. But importantly, those waivers are really state specific.

John Fangman: [00:14:59] Thanks, Katie. That's an exciting array of approaches to understanding how to address some of these things in our in our clinical practices. And Michelle, I can think of no better person to comment on what's common and what's different in the social needs of our patients than you, as somebody who's working in New York City and has set up a Ryan White funded program in rural North Carolina. Can you comment about what you see as different challenges and opportunities as we deal with variability of needs across states and across regions in the country?

Michelle Collins-Ogle: [00:15:30] Thank you to my colleague Katie for setting this up and actually talking about the evolution of Medicaid and understanding that just medical needs aren't going to get it. That we also have to address the social determinants or these other factors that impact people's ability to access care, be retained into care, and achieve viral suppression. So, as I stated earlier, unstable housing really limits your ability to access care. Do you know what else limits your ability to access care? Transportation. And this is an extremely important issue. And again, I want to go back to the HIV program and the Health and Human Resources Services Administration and their ability to recognize very early on that if we can't get individuals to their either to their pharmacies or to their clinical appointments, we are not going to be able to achieve and maintain viral suppression. So very early on, again in the epidemic, funding was provided through the Ryan White programs to provide transportation, particularly in resource limited areas like the rural counties of North Carolina, so that people are able to make their appointments right and able to get medications and the like. Medicaid is also caught up to that, and they've understood that as well, that transportation is extremely important. It varies from state to state how Medicaid does this. But what I've noticed in the two states I have the distinct pleasure of working in, for example, is how they use their Medicaid funding to provide transportation. So in North Carolina, for example, North Carolina, there are 100 counties in North Carolina, 80% of the state of North Carolina is rural. There is no public transportation in these rural communities. So how do we use the funding? How does Medicaid leverage its funding to make sure that people in these rural communities get to their appointments when there's no public transportation? So what Medicaid has done is through individuals that receive Medicaid for their insurance, they're able to reimburse individual companies, local transportation companies to provide service for people with certain medical conditions.

Michelle Collins-Ogle: [00:17:36] HIV happens to be one of them. So if we have a local transportation service in rural North Carolina, for example, then our patients that have Medicaid are able to use that transportation service. That transportation service is reimbursed through Medicaid for patients that they bring to our clinic. In New York, the same thing happens, but a little bit differently. So in the great state of New York, there are 62 counties in the state of New York. Even though there may be fewer counties, they're more densely populated. So you have more people trying to access services. So transportation, you know, oh, transportation can't be an issue in the state of North Carolina, it has great public transportation system. But two issues with that, one is the cost, you have to pay for public transportation, and people don't necessarily have that. But two, there are more resources and more abilities, if you will, for people to access transportation that is reimbursed through Medicaid. So we have the same types of situation, although it's really nice in the state of New York is that there are taxi cab services, there are other services where they have cars just for people with HIV, for example, to get back and forth to their appointments, they are again paid and reimbursed through Medicaid services.

John Fangman: [00:18:56] Michelle, there's a lot of reasons to love being a part of HIVMA. One is the opportunity to listen to people like you, describing the experience of care in different environments and knitting it all together, really understanding the environment in which that care comes up. Katie, I really appreciated, you know, I'm used to hearing New York and California, but you brought up Arkansas and Michigan and other places. You know, we're seeing the distinct challenges in different parts of the country, but the commonalities too. Can you talk to us a little bit about the future of of this Medicaid and where you see Medicaid innovation around social determinants of health and the social aspects of care evolving in the years to come.

Katie Garfield: [00:19:33] First, I'd say I'm hopeful that we'll continue to see increasing uptake of these opportunities. We continue to hear from additional states, you know, every month, every week at our center that are interested in either exploring or actually pursuing some new health related social need policies. And what I'm probably most hopeful about is that these states aren't just the usual suspects, right, for health care policy. Yes, we see states like California and New York, Massachusetts and Oregon as early adopters of these options. But we're really, as you just noted, starting to see much greater geographic diversity in who's applying for them. Remember that one of the early adopters here, as, as we've heard, was North Carolina. There are community-based organizations across the country that have been doing this for years and years and years, and they just have incredible expertise both in the services they provide and in the communities that they serve. Right. And so there's real value in bringing those organizations into the fold and engaging them in these health care systems so that we can make sure that patients are getting the services they need.

John Fangman: [00:20:53] Michelle, Katie, this has been an amazing conversation for me. I've learned a ton, and I've really appreciated the example that you both provide, and also the reminder of the critical role that advocacy plays in the care of people with HIV and the way we as HIV clinicians and people supporting this population have driven the conversation. But I'd like to close this out with comments first from you, Katie, and then Michelle, on how we as clinicians, who might not have your knowledge base or experience, can get involved locally to engage with our Medicaid programs and bring our voices and the voices of our patients to this really exciting time in Medicaid policy? So, Katie, maybe you go first and then Michelle, you can close this out.

Katie Garfield: [00:21:34] When we talk about policy at our center, we talk a lot about big p policy and little p policy. There is policy at the big P level. This idea of advancing waivers or changes to law or regulation. And oftentimes that's the end goal. But it often starts in little P policy. It often starts at getting your individual institutions to recognize the impact of these issues and start either changing the way that they're delivering services, or if they feel like they can't make the changes on their own. Getting your institutions also to start speaking up around the changes that need to happen in the state, in those sort of slow, momentum building ways, clinicians can have such a powerful voice in calling for these types of changes. And when they do advocate either individually or at the institutional level, they have such an incredible impact because the policymakers involved understand that clinicians really have that first-hand view of what patients need. And so there's sort of an automatic authority to what they're saying, because they live it every day. They are on the front lines of providing care. The other thing I would say is, even if you're in a state that already has these policies, I think clinicians play such a pivotal role in shaping the detail of the policies, because not only can you be a voice to we need this in the first place. That's just the first step. I think it's so important for clinicians to also stay engaged on the implementation conversation. So as you see a policy get rolled out, what's working, what's not. Because remember a lot of these pathways right now are experimental, and so their long-term sustainability depends on success. To make that more likely, we need that sort of feedback to be coming to policymakers over time so they understand what's working, what's not, and that they can make adjustments as they move forward. So we're most likely to achieve that kind of success.

Michelle Collins-Ogle: [00:23:42] People think that if you are advocating that. You have to be an expert, that you have to have a certain level of expertise and knowledge. And many providers, clinicians don't feel that they're comfortable. They have that level of information. They don't feel comfortable sharing because they don't feel like they may be experts. You are the expert of what you do and you are the expert of your community. To start, there is extremely important to understand that we are our voices are extremely important and we are the representatives of our community.

Michelle Collins-Ogle: [00:24:18] People actually hold health care clinicians in high esteem. Having your voice, no matter what level you think you can communicate, is extremely important. So I'd like to leave us with four important points when we talk around advocacy. Point one is to know who your congressional representative is. That's extremely important. You can look that up online. You know your district. You know your zip code. You can know exactly who your congressional representative is. And once you know who the congressional representative is, then you can actually make a personal contact with that person. Number two is to know the statistics of the health care outcomes in not your community where you live, but the constituents of your congressional representatives. Those numbers are very important and very impactful when you're talking about advocacy. Point number three is to actually discuss data and actually discuss community outcomes. Because what I often find is very helpful is to talk about what's going on in the state, for example, and then where the problems are in your constituency. Where the problems are in the community, where my clinic is located, where we're falling short and not able to maintain the same level of care as in other parts of the state. And I would say fourth and most importantly, tell stories. Tell those personal stories about the people you provide care for. I told you earlier a story that I had shared with a congressional representative before about a woman that I was providing care for that was not in a stable living situation. She didn't have a refrigerator. And at that time, one of the antiretroviral medications we used required refrigeration. She didn't have a refrigerator, so all of her medication, her gel caplets, they all melted. So she wasn't able to take her medications. We were able to take that story and actually get funding to provide a refrigerator for this specific person. Those individual stories are very impactful. The story about the person that got put out of their home because they lost their job, because they were diagnosed with AIDS and were ill and unable to work and provide income for their family. Tell those stories about that individual. It's very impactful.

John Fangman: [00:26:26] Katie. Michelle, this has been a phenomenal conversation. I feel educated, I feel clear that this is an important moment for us to lean in and engage, and I feel inspired and empowered with some ideas to move forward. And I can think of this is our last of the four Medicaid series, and I can think of no better way to end than listening to you both and talking about the way forward, which is really exciting and can show the way, quite frankly, for other aspects of healthcare, not just for HIV, because people living with kidney disease, people living with diabetes, everything else can benefit tremendously from these insights. So thank you, thank you, thank you.