How to Advance Health Equity? A Roadmap for Service Access Using Medicaid Waivers: The Case of New York

With the approval of New York’s Medicaid Waiver on January 9, 2024, which invests $6 billion in new funding, the New York State Department of Health is well positioned to advance health equity and reduce health disparities. The waiver embraces value-based payment strategies that align reimbursement for care with population health outcomes, while making major investments in addressing the social determinants of health (SDOH)/health related social needs (HRSN) services (roughly ? of waiver dollars) such as medically tailored meals, housing supports or transportation for medical appointments.?

NYS has laid out in its Social Care Network RFP $500 million in SDOH Infrastructure investments, which will include capacity development (e.g. new hires and training), as well as Health IT implementation and social care claims processing.? The magnitude of this investment allows for the complexity and cost of investments in tech infrastructure to bridge care across sectors These investments in turn will support an expected $3.1 billion in social care claims made to the Medicaid Managed Care Organizations (MCOs).?

As Social Care Network candidates and the NYS Department of Health consider infrastructure investments, they should prioritize investments that streamline service enrollment across state agencies, including government programs like SNAP/WIC. These investments would:?

• Meet requirements laid out in the CMS Waiver Acceptance Letter,?
• Enrollment of eligible, but not yet enrolled people in government programs represents one of the largest sources of investment in health equity, and the impact of government programs on health and reduction in healthcare costs is well established by research, and?
• Provide essential data that would be useful for providers delivering care, and Social Care Networks and State policymakers trying to understand and advance health equity.

This blog post also outlines how the state should achieve improved service enrollment from a technology perspective.

NYS Medicaid Waiver Prioritizes Enrollment in Government Programs Across State Agencies

Notably, the Centers for Medicaid and Medicare Services (CMS) approval letter included special terms and conditions that requires the NYS Department of Health to (emphasis mine):?

• Have partnerships with “other state and local entities (e.g., HUD Continuum of Care Program, local housing authority, Supplemental Nutrition Assistance Program (SNAP) state agency) to assist beneficiaries in obtaining non-Medicaid funded housing and nutrition supports.”
• Share a HRSN Implementation Plan, which includes “a plan for tracking and improving the share of Medicaid beneficiaries in the state who are eligible and enrolled in the SNAP, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Temporary Assistance for Needy Families (TANF), and federal and state housing assistance programs, relative to the number of total eligible beneficiaries in the state;” and?
• Ensures “eligible beneficiaries are enrolled to receive SNAP and/or WIC services” and “avoid duplication or displacement of existing food assistance/nutrition services…”
• Submit Quarterly and Annual Monitoring Reports, which include the percentage of Medicaid beneficiaries enrolled in other public benefit programs (such as SNAP and WIC) for which they are eligible.

Scale of Social Service Investments and Impact on Health Outcomes and Health Equity

Consider national Payor investments across all SDOH domain interventions ($1.9 billion between 2017 and 2021) . During the same time period $378 billion was spent on SNAP alone, nearly 200X the amount spent by the largest 20 Managed Care Organizations covering the lives of 2 out of 3 Americans. While the intended $3.1 billion in social services spending by Medicaid under the Waiver is a historic investment in health equity, it is still a fraction of the $8.92 billion the NYS Office of Temporary and Disability Assistance spent on SNAP (in 2022), or $5 billion that will be spent on NYS’ Comprehensive Housing Plan.?

Leveraging these other sources of social support is critical, as non health insurance Government Benefits, most which operate outside of the auspices of the NYS Department of Health, are impactful on health outcomes. Enrollment in SNAP, a food subsidy program has been shown to reduce healthcare costs ($1,400-$4,100 per person annually) . Special Supplement for Women Infants and Children (WIC) has been shown to reduce the likelihood of preterm birth by 48%, saving $58,917 per preterm birth (in healthcare costs for the baby and mother). Yet just 42% of eligible older adults are enrolled in SNAP and 50% of eligible people are enrolled in WIC nationwide .? Eligible Americans don’t access more than $80 billion in benefits–food, financial aid, education, and healthcare.

Center Investments in Government Benefits Infrastructure in Community Based Organizations and Hubs Workflows

State and federal agencies have historically increased enrollment in government programs like SNAP, WIC or Medicaid by funding community-based organizations (CBOs) that have trusted relationships in hard-to-reach communities. While this has led to successful enrollment in for example the Affordable Care Act Health Insurance Marketplace , too often the technology tools CBOs are equipped with by government agencies for this purpose are siloed enrollment systems that require duplicate data entry and do not integrate with the CBOs case management system. One Area Agency on Aging with a $90 million budget must enter client data into eighteen distinct systems. The need to enter data into multiple systems means staff have less time per client and people are less likely to enroll in all the programs for which they are eligible. Streamlining redetermination of eligibility for Medicaid is of particular importance right now as the end of the COVID-19 pandemic has meant that people can lose their Medicaid enrollment if they do not mail and return documents proving their eligibility. For example, South Carolina determined that 95% of the Medicaid recipients who lost their coverage did so for procedural reasons.?

Reusing required documents and information from Medicaid members to automate preliminary eligibility determinations and complete enrollment/recertification forms for multiple programs for these individuals (and their families or households)? is critical to the success of the cross agency partnerships called out in the waiver.? Providing the tools to Social Care Networks and their partners to do this will be a significant advance.??

The idea of the "one-stop-shop" service navigator, or Hub is not new. In fact, it is so common that federal and state funding is often allocated via these hubs.

Administration for Community Living funds services for elderly via states and regional Area Agencies On Aging (AAA). US Department of Housing and Urban Development funds housing and homeless services through regional Continuums of Care and Administration for Children and Families funds child care and early learning programs through Child Care Resource and Referral Centers (CCR&Rs). The problem is that when 100 government agencies create 100 "one-stop-shops" responsible for service navigation and enrollment you get 100 siloes. (Note 100 is actually the number of government agencies in both Tompkins County, when including all cities towns and villages and New York City). I will write a more comprehensive blog post on this issue later.

Streamline Data Access & Enrollment via Application Programming Interfaces (APIs)

Application Programming Interfaces enable data to flow from one system to another, or functionality (like eligibility screening to be accessed across websites/apps). They enable data reuse, which makes possible auto filling forms for applying or recertifying for government programs. Despite bureaucratic misunderstandings, sharing data between state government agencies and with healthcare provider, payer, and social care provider partners for the purposes of informing people of their eligibility and streamlining eligibility enrollment is both legal and commonplace. A National Landscape Analysis that surveyed 47 state government agencies on data coordination between programs showed that 90 percent of the states reported Medicaid and SNAP share data with at least one other program . Twenty-nine of the respondents who shared data had a full integration, meaning they had a single system for eligibility determination and staff played roles determining eligibility for two or more programs. Eight had partial integration and ten had no integration. Sixty six percent of respondents shared data with MCOs and 45% with non-profits. Despite this, non-API based methods used for data sharing varied and were not necessarily reproducible or scalable. None of the states shared SNAP enrollment data with third party organizations helping people enroll in benefits via APIs the way Medicaid enrollment and billing is made possible via APIs embedded in electronic health records.??

Building systems/apps for program enrollment that are meant to be interoperable with both healthcare and social care systems is essential to improving access to services because (1) of the vital role clinical and social care providers play in reciprocal service navigation; and (2) enabling consented data reuse to automate eligibility and enrollment workflows improves efficiency and effectiveness across any whole person care project. Requiring procured government benefit systems (accessible via website or app) to make their systems available via APIs would reduce duplicate data entry for people applying for multiple programs, within or across multiple agencies.?

Ensure Secure and Trusted Data Exchange with Certified Technology

State and Federal government agencies have processes for ensuring that technology partners responsible for information exchange are secure and follow all relevant regulations. For example, Models that could be emulated for streamlining enrollment in SNAP and other government programs via APIs include the Medicare Administrative Contractors (MACs), which process Medicare Fee-for-Service claims and the “Certified Health IT Product List (CHPL) , a comprehensive and authoritative listing of all certified health information technology that have been successfully tested and certified by the ONC Health IT Certification program.” A similar process could be created for certified social services eligibility and enrollment apps. Once certified, upon obtaining the patient’s consent, the app would be allowed to access State program eligibility and enrollment data. A certified app (i.e., electronic health record/case management system) would be able to reuse information that it has for the person being enrolled much the same way that Medicaid/Medicare billing can be made from any Electronic Health Record. Electronic health records can support eligibility screening and submission of required Medicaid enrollment data from the EHR without staff having to go to a government website and re-enter patient data.?

Leverage SDOH Data to Advance Health Equity

Investments in SDOH interoperability that improve enrollment in government benefits could also have the impact of making SDOH data available to both medical and social service providers, so that each team member can deliver contextual care as described in Medicaid Waivers. For example, New York’s proposed waiver seeks to understand “all the physical and behavioral health and social factors impacting a patient and their family.” Reusing data already collected in other forms/by other agencies could minimize patient burden without compromising on data quality. For example, SNAP Application forms collect information on household income, wealth, education, and housing status.

Roadmap for SDOH Interoperability and Cross Agency Governance

It is important to note that siloed technology investments naturally occur from siloed state agency programs and tech budgets. Bold new initiatives such as the NYS Medicaid waiver open up the question of what governance mechanisms might lead to investments in technology as a shared service across State agencies? Potential approaches include blended funding streams and cross-agency partnerships that result in expanding the governing board of an independent agency such as a health information exchange, public authority, or State Department of Information Technology. In New York State the New York eHealth Collaborative and the six Regional Health Information Organizations (RHIOs) with teams experienced in person-matching, consent and other data governance related issues, Health Information Exchanges are well positioned to play a leading role in addressing the aforementioned challenges.?

New York has a unique opportunity due to the approval of the Medicaid Waiver and the existing health information exchange infrastructure to advance health equity by improving enrollment in other government benefits that show a longstand track record of evidence of their impact.?

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Matt Bishop is CEO of Open City Labs , an award winning digital health company that develops software to streamline enrollment in government benefits, social services and clinical care, while unifying patient data in integrated Care Plans, which was the first to implement in production the Gravity Project’s FHIR SDOH referral standard and is recognized as a Success Story by the Gravity Project . He is a member of the HIMSS Social Determinants of Health Committee and active contributor to numerous ANSI accredited standards bodies, including Health Level Seven International , The Gravity Project, the co-author of the IHE International 's 360x-SD (SDOH closed loop referral), National Directory for Healthcare Directory and numerous subcommittees within DirectTrust .