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Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity

Issue Brief
  1. “About Social Determinants of Health,” World Health Organization, accessed April 25, 2018, http://www.who.int/social_determinants/sdh_definition/en/.

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  2. “Healthy People 2020: Social Determinants of Health,” Office of Disease Prevention and Health Promotion, accessed April 25, 2018, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.

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  3. J. Michael McGinnis and William H. Foege, “Actual Causes of Death in the United States,” The Journal of the American Medical Association 270, no. 18 (Nov. 10, 1993):2207-2212, doi:10.1001/jama.1993.03510180077038 and Ali H. Mokdad et al., “Actual Causes of Death in the United States,” The Journal of the American Medical Association 291, no. 10 (March 10, 2004):1238-1245, doi:10.1001/jama.291.10.1238.

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  4. Steven A. Schroeder, “We Can Do Better — Improving the Health of the American People,” New England Journal of Medicine 357 (Sept. 20, 2007):1221-1228, doi:10.1056/NEJMsa073350.

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  5. Gopal K. Singh, Mohammad Siahpush, and Michael D. Kogan, “Neighborhood Socioeconomic Conditions, Built Environments, and Childhood Obesity,” Health Affairs 29, no. 3 (March 2010):503-512, doi: 10.1377/hlthaff.2009.0730.

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  6. Vincent J. Felitti et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, no. 4 (May 1998):245–258.

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  7. Raj Chetty et al., “Where is the Land of Opportunity? The Geography of Intergenerational Mobility in the United States,” The Quarterly Journal of Economics 129, no. 4 (Sept. 14, 2014): 1553-1623, doi: 10.1093/qje/qju022.

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  8. The Food Trust, Healthier Corner Stores: Positive Impacts and Profitable Changes (Philadelphia, PA: The Food Trust, 2014), http://thefoodtrust.org/uploads/media_items/healthier-corner-stores-positive-impacts-and-profitable-changes.original.pdf.

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  9. National Farm to School Network, accessed April 20, 2018, http://www.farmtoschool.org/.

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  10. Caroline Franck, Sonia M. Grandi, and Mark J. Eisenberg, “Agricultural Subsidies and the American Obesity Epidemic,” American Journal of Preventive Medicine 45, no.3 (Sept. 2013):327-333, doi:http://dx.doi.org/10.1016/j.amepre.2013.04.010.

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  11. “Promoting Health Equity through Education Programs and Policies,” Guide to Community Preventive Services, last updated Oct. 13, 2015, accessed Oct. 28, 2015, http://www.thecommunityguide.org/healthequity/education/index.html.

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  12. Linda Rudolph et al., Health in All Policies: A Guide for State and Local Governments (Washington, DC and Oakland, CA: American Public Health Association and Public Health Institute, 2013),  https://www.apha.org/topics-and-issues/healthy-communities/health-in-all-policies; Centers for Disease Control and Prevention – Division of Community Health, A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease (Atlanta, GA: U.S. Department of Health and Human Services, 2013), http://www.cdc.gov/nccdphp/dch/pdf/HealthEquityGuide.pdf; Guide to Community Preventive Services, http://www.thecommunityguide.org/index.html; Institute of Medicine, Applying a Health Lens to Decision Making in Non-health Sectors: Workshop Summary (Washington, DC: The National Academies Press, 2014), http://iom.nationalacademies.org/reports/2014/applying-a-health-lens-to-decision-making-in-non-health-sectors.aspx; and Robert Wood Johnson Foundation, Time to Act: Investing in the Health of Our Children and Communities (Princeton, NJ: Robert Wood Johnson Foundation, Jan. 2014), http://www.rwjf.org/en/library/research/2014/01/recommendations-from-the-rwjf-commission-to-build-a-healthier-am.html.

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  13. “Health in All Policies,” American Public Health Association (APHA), accessed April 25, 2018, https://www.apha.org/topics-and-issues/health-in-all-policies.

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  14. Garth Graham, MaryLynn Ostrowski, Alyse Sabina, Defeating The ZIP Code Health Paradigm: Data, Technology, And Collaboration Are Key (Health Affairs Blog, August 6, 2015), https://www.healthaffairs.org/do/10.1377/hblog20150806.049730/full/.

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  15. AHC awardees are community “bridge” organizations that will serve as hubs in their communities to provide screening and referral services, provide community service navigation services, and encourage alignment between clinical delivery sites and community services.

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  16. Kaiser Commission on Medicaid and the Uninsured, The State Innovation Models (SIM) Program: A Look at Round 2 Grantees, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Sept. 2015), http://kff.org/medicaid/fact-sheet/the-state-innovation-models-sim-program-a-look-at-round-2-grantees/.

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  17. Center for Medicare and Medicaid Innovation (CMMI), State Innovation Models (SIM) Round 2: Model Test Annual Report One, December 2017, https://downloads.cms.gov/files/cmmi/sim-round2test-firstannrpt.pdf.

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  18. Ibid.

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  19. Ibid.

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  20. Ibid.

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  21. Some states use Section 1115 expenditure authority to authorize spending of federal dollars on delivery system reforms that otherwise would not be available under current law. For more information, see: Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers.

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  22. “Organizational development for CCOs and/or CCO community advisory councils,” Oregon Health Authority, accessed April 27, 2018, http://www.oregon.gov/oha/HPA/CSI-TC/Pages/TAB-Topic-Description.aspx?View=%7B627F9379-D9FC-4478-8E56-F7E5AFFF7805%7D&SelectedID=11.

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  23. Oregon Health Authority, Health-Related Services (Salem, OR: Oregon Health Authority, Health Policy and Analytics Division, Nov. 2017), http://www.oregon.gov/oha/HPA/CSI-TC/Resources/OHA-Health-Related-Services-Brief.pdf.

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  24. Chris Demars, Oregon Bridges the Gap between Health Care and Community-Based Health (Health Affairs Blog, Feb. 12, 2015), http://healthaffairs.org/blog/2015/02/12/oregon-bridges-the-gap-between-health-care-and-community-based-health/.

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  25. Ibid.

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  26. Oregon Health & Science University, Center for Health Systems Effectiveness, Evaluation of Oregon's 2012-2017 Medicaid Waiver Final Report (Portland, OR: Oregon Health & Science University, Dec. 2017), http://www.oregon.gov/oha/HPA/ANALYTICS/Evaluation%20docs/Summative%20Medicaid%20Waiver%20Evaluation%20-%20Final%20Report.pdf.

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  27. Ibid.

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  28. RCCOs are part of the state’s larger Accountable Care Collaborative (ACC). In phase II of the ACC (scheduled for implementation in 2018), the state will replace RCCOs and behavioral health organizations (BHOs) with Regional Accountable Entities (or “RAEs”), which will be responsible for connecting enrollees with primary and behavioral health care.

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  29. K. John McConnell et al., “Early Performance in Medicaid Accountable Care Organizations: A Comparison of Oregon and Colorado” JAMA Internal Medicine 2017;177(4):538-545. doi:10.1001/jamainternmed.2016.9098 https://www.ncbi.nlm.nih.gov/pubmed/28192568.

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  30. Rachael Matulis and Jim Lloyd, The History, Evolution, and Future of Medicaid Accountable Care Organizations (Hamilton, New Jersey: Center for Health Care Strategies, Inc., Feb. 2018) https://www.chcs.org/resource/history-evolution-future-medicaid-accountable-care-organizations/.

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  31. Jocelyn Guyer, Naomi Shine, Robin Rudowitz, and Alexandra Gates, Key Themes From Delivery System Reform Incentive Payment (DSRIP) Waivers in 4 States (Washington, DC: Kaiser Family Foundation, April 2015),  http://files.kff.org/attachment/issue-brief-key-themes-from-delivery-system-reform-incentive-payment-dsrip-waivers-in-4-states.

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  32. Ibid.

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  33. Ibid.

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  34. Mathematica Policy Research, Medicaid 1115 Demonstration Interim Evaluation Report: Delivery System Incentive Payments (Princeton, NJ: Mathematica Policy Research, Jan. 2018), https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/dsrip-interim-eval-report.pdf.

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  35. The Kaiser Family Foundation State Health Facts. Data Source: Analysis of annual 50-State Medicaid Budget Surveys conducted by the Kaiser Family Foundation and Health Management Associates (HMA), 2000-2017. Beginning in 2014, the survey was completed through a partnership with the the National Association of Medicaid Directors (NAMD), “States that Reported Health Homes In Place,” https://www.kff.org/medicaid/state-indicator/states-that-reported-health-homes-in-place/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

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  36. Office of the Assistant Secretary for Planning and Evaluation (ASPE), Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Evaluation of Outcomes of Selected Health Home Programs Annual Report - Year Five. (Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, May 2017),  https://aspe.hhs.gov/basic-report/evaluation-medicaid-health-home-option-beneficiaries-chronic-conditions-evaluation-outcomes-selected-health-home-programs-annual-report-year-five#execsum.

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  37. On June 26, 2015, the Centers for Medicare and Medicaid Services (CMS) issued an Informational Bulletin to “assist states in designing Medicaid benefits, and to clarify the circumstances under which Medicaid reimburses for certain housing-related activities, with the goal of promoting community integration for individuals with disabilities, older adults needing long-term services and supports, and those experiencing chronic homelessness.”

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  38. The state provides these services under its section 1915(c) home and community-based services (HCBS) waivers for persons with disabilities and the mental health rehabilitation benefit in the Medicaid state plan.

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  39. Julia Paradise and Donna Cohen Ross, Linking Medicaid and Supportive Housing: Opportunities and On-the-Ground Examples (Washington, DC: Kaiser Family Foundation, Jan. 2017), http://files.kff.org/attachment/Issue-Brief-Linking-Medicaid-and-Supportive-Housing-Opportunities-and-On-the-Ground-Examples.

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  40. QUEST Integration, Special Terms and Conditions, #11-W00001/9, approved October 1, 2013 through December 31, 2018, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/hi/hi-quest-expanded-ca.pdf.

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  41. Kathleen Gifford, Eileen Ellis, Barbara Coulter Edwards, and Aimee Lashbrook, Health Management Associates; and Elizabeth Hinton, Larisa Antonisse, Allison Valentine, and Robin Rudowitz, Kaiser Family Foundation. Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018, (Washington, DC: Kaiser Family Foundation, Oct. 2017), https://www.kff.org/medicaid/report/medicaid-moving-ahead-in-uncertain-times-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2017-and-2018/.

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  42. The final sample of nearly 100 plans across 31 states captured approximately 40% of Medicaid beneficiaries in comprehensive MCOs. Additional detail on the methods underlying the survey and characteristics of plans, as well as full survey results, are available in Topline & Methodology Report.

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  43. The scope and depth of plan activities in these areas were not clear from the survey responses.

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  44. Again, the scope of these activities is not clear from survey responses.

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  45. CDC, Community Health Assessment for Population Health Improvement: Resource of Most Frequently Recommended Health Outcomes and Determinants (Atlanta, GA: Office of Surveillance, Epidemiology, and Laboratory Services, 2013), https://stacks.cdc.gov/view/cdc/20707.

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  46. Deloitte Center for Health Solutions, Social determinants of health: How are hospitals and health systems investing in and addressing social needs? (New York, New York: Deloitte, 2017), https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-addressing-social-determinants-of-health.pdf.

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  47. Ibid.

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  48. Caitlin Thomas-Henkel and Meryl Schulman, Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations (Hamilton, NJ: Center for Health Care Strategies, Inc., Oct. 2017), https://www.chcs.org/media/SDOH-Complex-Care-Screening-Brief-102617.pdf.

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  49. Anna Spencer, Bianca Freda, and Tricia McGinnis, Center for Health Care Strategies, and Laura Gottlieb, MD, University of California, San Francisco, Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons (Hamilton, New Jersey: Center for Health Care Strategies, Inc., Dec. 2016), https://www.chcs.org/media/CHCS-SDOH-Measures-Brief_120716_FINAL.pdf.

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  50. Deborah Bachrach, Jocelyn Guyer, Sarah Meier, John Meerschaert, and Shelly Brandel, Enabling Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools (New York, New York: The Commonwealth Fund, Jan. 2018), http://www.commonwealthfund.org/~/media/files/publications/fund-report/2018/jan/bachrach_investment_social_interventions_medicaid_rate_setting.pdf.

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  51. MaryBeth Musumeci, Robin Rudowitz, Elizabeth Hinton, Larisa Antonisse, and Cornelia Hall, Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

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  52. CMCS Informational Bulletin, “Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates,” Center for Medicaid and CHIP Services, June 30, 2017, https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.

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  53. Centers for Medicare & Medicaid Services: Innovation Center New Direction Request for Information, September 2017, https://innovation.cms.gov/Files/x/newdirection-rfi.pdf.

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  54. “Centers for Medicare & Medicaid Services: Innovation Center New Direction,” CMS, accessed April 25, 2018, https://innovation.cms.gov/initiatives/direction.

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  55. Centers for Medicare & Medicaid Services: Innovation Center New Direction Request for Information, April 2018, https://innovation.cms.gov/Files/x/dpc-rfi.pdf.

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  56. Executive Order 13828 of April 10, 2018, Reducing Poverty in America by Promoting Opportunity and Economic Mobility, https://www.gpo.gov/fdsys/pkg/FR-2018-04-13/pdf/2018-07874.pdf.

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  57. In June 2015, CMS issued an Informational Bulletin to clarify when and how Medicaid reimburses for certain housing-related activities, including individual housing transition services, individual housing and tenancy sustaining services, and state-level housing related collaborative activities. In January 2018, CMS issued a State Medicaid Director Letter providing guidance on state Section 1115 waiver proposals to condition Medicaid on meeting a work requirement. CMS explicitly stated the demonstration opportunity does not provide states with the authority to use Medicaid funding to finance employment support services. Predating this guidance, a few states implemented voluntary work referral programs. Federal Medicaid funds also cannot be used to finance work referral programs.

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  58. January 11, 2018 CMCS State Medicaid Director Letter (SMD-18-002), “Opportunities to Promote Work and Community Engagement among Medicaid Beneficiaries,” https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf.

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  59. Ibid.

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  60. MaryBeth Musumeci, Rachel Garfield, Robin Rudowitz, Medicaid and Work Requirements: New Guidance, State Waiver Details and Key Issues (Washington, DC: Kaiser Family Foundation, Jan. 2018), https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/.

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  61. Ibid.

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