Rethinking health policy: State strategies look beyond access to care, focus on other factors that lead to poor outcomes and higher costs

When it comes to improving health outcomes, many policymakers look first to strategies that can provide better care for people who are ill. But some experts argue that medical care itself accounts only for a small part of positive health outcomes. The vast majority of interventions that can make people healthier, and reduce spending on health care, need to happen long before someone enters a doctor’s office.
That’s why states across the Midwest are exploring ways to address so-called “social determinants” to health — from low levels of income and education, to high levels of community violence, to a lack of access to housing and transportation.

For example, a 25-year-old male who has a college degree will live, on average, another 56 years. For males who did not complete high school, life expectancy is cut by more than nine years. This disparity is similar among females, according to National Center for Health Statistics data.

Infant mortality, too, appears to vary depending on the mother’s level of education. Among mothers who do not complete high school, 7.7 infants in 1,000 do not survive. For mothers who have graduated from college, the rate drops to 3.3.
But what exactly causes this link between education (a non-medical indicator) and health?
Researchers from the Center for Social Disparities in Health point out that those with less education are also less likely to have health knowledge, literacy or problem-solving skills. These disparities, in turn, can then lead to poor diet, a lack of exercise and higher rates of smoking.
Those with lower educational attainment are also more likely to be unemployed or to be working in low-wage jobs, a fact that lessens the likelihood that they have access to health insurance or sick leave. And the data analyzing the impact of another social factor, income, show equally grim outcomes. About one-third of adults with incomes below poverty have a chronic disease, while about 9 percent of adults with incomes over 400 percent of the federal poverty level have such illnesses, according to the Robert Wood Johnson Foundation.
Low-income individuals and families are also more prone to live in unsafe housing or dangerous neighborhoods, and less likely to have easy access to healthy food (or be able to afford it).
“Much of the policy focus around reducing health disparities has been geared toward improving access, coverage, quality and the intensity of health care,” according to a 2008 study led by researchers at Harvard University. “However, health is more a function of lifestyles linked to living and working conditions rather than health care.”
Focusing on health, not health care
States are now experimenting with new ways to address these “upstream” causes of common illnesses.
In South Dakota, for example, Gov. Dennis Daugaard made it a goal to improve his state’s infant-mortality rate, which was among the highest in the Midwest. A state task force researched the causes of infant mortality — lack of prenatal care, smoking during pregnancy and unsafe sleep practices in infancy — and developed ideas to address them.
South Dakota’s new strategies have included expanding access to prenatal care, community support systems for expectant and new mothers (including home visits), and a statewide awareness campaign (“For Baby’s Sake”) about safe sleep practices. Through a partnership with a private donor, “safe sleep” kits are distributed to low-income families; these kits include a portable crib and safe sleepwear for babies.
In this year’s State of the State addresses, several governors in the Midwest mentioned the need for eliminating “silos” in government services (Nebraska Gov. Pete Ricketts) or combining the state’s health and human services departments (Michigan Gov. Rick Snyder) to better align all state programs with the varying needs of beneficiaries.
Ohio Gov. John Kasich has also called for a more holistic approach to providing social services, including asking more questions about why individuals and families are in poverty — which often is linked to poor health — in the first place.
“We need to be in our schools. We need to be in our communities. We need to be in our synagogues. We need to be in our churches,” he said in his State of the State address earlier this year. Identifying causes and preventing health issues can be a challenge, however, under the nation’s current health system, which puts more emphasis on paying for and improving health care.
Take the example of a child with asthma, a condition that is best controlled when mold, pet hair and dust is eliminated from the home. “Maybe the family needs a vacuum cleaner,” Rosenthal says. “But how do you pay for a vacuum? Medicaid won’t pay for that.”
One idea, then, is to allow individuals to have more control over their personal care. In Texas, a “self-directed care” program gives low-income individuals with mental illness access to a pot of money to purchase things they need.
“It might not necessarily be what Medicaid would have covered — such as a bus pass to get to the gym,” Rosenthal says. “If you give that person some control over the money, they can buy what they need to stay healthy.” But because states can only use Medicaid funds for approved services, policymakers must often find other ways to cover nonmedical health expenses for at-risk populations. Rosenthal points to federal or other public-health grants for specific purposes (such as diabetes prevention or asthma management) that could serve as “wrap-around” funding.
“What states are doing is maximizing what they have, and that extra [funding] makes you able to treat the whole person,” she says.

Rise of community health workers
Another strategy for states is to bring help directly to individuals in their communities. Community health workers can educate underserved and at-risk populations about how to stay healthy, and also connect individuals with medical care if they need it.
Because they are recruited from the communities they serve, these health workers often are able to provide culturally sensitive information and translation services. “These are lay health providers that are connected to their communities,” Rosenthal says. “They are instrumental in being connectors between health professionals and people [who need care].”
“Community health worker” is a broad term. It encompasses a number of different types of workers, with duties and training that can vary widely. Some can provide basic information about public programs (such as medical assistance, food stamps or child care) or make referrals to appropriate medical professionals. 
Others coordinate transportation, schedule appointments and/or offer follow-up care. Some are volunteers; others are paid by local programs or nonprofit organizations.
But states also now have a chance to pay community health workers, via a new federal rule on Medicaid. This new rule, adopted last year by the U.S. Centers for Medicare and Medicaid Services, allows Medicaid reimbursement for preventive services delivered by nonlicensed providers. These services include: health education, care coordination, home visiting, lactation consultation, diabetes prevention and parenting education.
In order for these services to be eligible for reimbursement, they require a referral from a licensed Medicaid provider. To take advantage of this new funding flexibility, states can submit a plan amendment with the federal government. Once the plan is approved, these services are eligible for the traditional federal Medicaid match.
Minnesota became the first Midwestern state to take advantage of this new federal funding source. (Community health workers have participated in Minnesota’s public health programs since legislation was passed in 2007.)
These workers must be certified by completing a curriculum approved by Minnesota’s university system and then be supervised by a health professional (for example, a physician, advanced-practice nurse or mental-health provider).
Ohio legislation dating back to 2003 created certification requirements for community health workers. Under state law, these workers must complete a state training program and pass a criminal background check. They cannot perform any services that require a professional license. And just as they do in Minnesota, community health workers in Ohio must be supervised by a health professional.
State’s role in training, certification
Illinois lawmakers passed a bill last year (HB 5412) that creates an advisory board to develop training and certification requirements for community health workers. The newly created board is currently working on a recommendation to the legislature regarding curricula and reimbursement options.
The 2014 Illinois law also gives these workers new legal recognition. “[It] will help people in the community by creating a path for these workers to become respected members of the health care team,” Illinois Rep. Robyn Gabel, sponsor of the legislation, said when the bill was signed into law. “Their role is critical because they help implement the patient’s health care plan, and help patients better understand their conditions to achieve a path of good health.”
Two other Midwestern states have put in place programs that also offer training and certification, though they do not include reimbursement for community health workers through Medicaid. Indiana’s program was established in 2013 by its Division of Mental Health and Addiction. Upon completion of a three-day training program, community health workers receive a certificate and can serve individuals in settings such as hospitals, schools, churches and community centers.
Nebraska’s Department of Health and Human Services, meanwhile, has developed a training and certification program that includes online and in-person education. The federal Affordable Care Act also provides some new opportunities for states to strengthen community-based services, including incentives to place patients with chronic conditions in health care homes.
These health care homes are primary-care facilities or physicians’ offices that agree to take on coordinating all of a patient’s care. They receive an additional payment from Medicaid or a private insurer — beyond the normal fees for individual services. The extra payment allows a medical practice to offer chronic-disease management, health education and other wellness services. (These typically aren’t incentivized in a fee-for-service system.)
As part of their coordination of care, health care homes can partner with community health workers to address acute care or social-service needs.


On measures of poverty, income and health insurance, some positive signs in Midwest

Every year, the U.S. Census Bureau releases data on three factors with links to health outcomes: poverty rates, access to health insurance, and levels of household income. The Great Recession (which lasted 18 months, from December 2007 to June 2009) and its aftermath caused poverty rates to rise and income levels to fall in many Midwestern states. But the most recent federal statistics point to some more-promising trends.
  • Poverty rates have at least stabilized or begun to fall in many Midwestern states. Still, across the region (with the lone exception of North Dakota), the percentage of people living in poverty in 2013 is higher than pre-recession levels.
  • The Midwest has traditionally had lower rates of people without health insurance. In 2013, for every state in the region, the percentage of people without health coverage was below the U.S. rate of 14.5 percent. Uninsured rates, both nationally and regionally, are expected to fall significantly under the Affordable Care Act. During the first two months of 2015, for example, the national uninsurance rate had dropped to 12.3 percent, according to the Gallup-Healthways Well-Being Index.
  • One striking difference among the 11 states in the Midwest are trends in median household income. For most of the Plains states, income levels are considerably higher than they were prior to the national economic downturn. In contrast, as of 2013, income levels had not yet returned to pre-recession levels in three Great Lakes states: Michigan, Ohio and Wisconsin. But between 2012 and 2013, median household income levels rose in most Midwestern states and did not fall in any of them.
  • With the exception of Illinois, income inequality is less pronounced in the Midwest than it is across the country. Between 2012 and 2013, income inequality rose nationally and in four Midwestern states: Illinois, Indiana, Iowa and Nebraska, according to The Washington Post.



Stateline Midwest - April 20151.25 MB