Author: Sydney Sanders
September 3, 2024
What is included under the right to health and the right to health itself have long been under debate in the United States. In international law, the International Covenant on Economic, Social and Cultural Rights (ICESCR) recognizes health as a human right, specifically, “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” The United States signed the treaty in 1977, showing its intention to follow the guidelines outlined in its contents. However, the U.S. has yet to ratify, meaning the country is not legally required to uphold the terms of the treaty. This means that for the right to health the United States is not legally responsible for fulfilling its obligations.
Although not legally required under international law, the U.S. does have government-run healthcare programs, the main being Medicaid. Medicaid provides health coverage for “eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities” in the U.S. and was created under the Social Security Act of Amendments in 1965. As of April 2024, over 74.6 million Americans were covered under Medicaid. Although Federal guidelines and requirements must be followed, states in the U.S. “establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services.” Examples of mandatory benefits include services like “inpatient and outpatient hospital services, physician services, laboratory and radiology services, and home health services.” However, states can decide whether or not services such as prescription drugs, dental services, physical therapy, case management, and hospice are included or not under Medicaid coverage. This means that government-run healthcare and what services are included can look very different from state to state.
Although mandatory versus optional services covered under Medicaid vary by state, there are many key aspects of health that do not typically fall under either category. According to the World Health Organization, social determinants of health (SDH) are the “non-medical factors that influence health outcomes.” The conditions of daily life, where people are born, grow up, work, live, and age, all impact a person’s health outcomes. The WHO notes that these conditions are also influenced by existing forces and systems, including, “economic policies and systems, development agendas, social norms, social policies and political systems.” Long-standing institutions that impact social determinants of health exist everywhere, and therefore have a large influence on health inequalities in all countries. The WHO notes, “the lower the socioeconomic position, the worse the health.” The impact of SDH cannot be overstated, and “Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes.”
Social determinants impact health outcomes because all human rights are indivisible, interdependent, and interconnected. According to the Office of the High Commissioner for Human Rights, “this means that one set of rights cannot be enjoyed fully without the other.” For this reason, to fulfill the right to health for all in the United States, we must also focus on the other human rights that impact health most closely. Because Medicaid provides coverage for low-income people and families that are most impacted by social determinants of health, addressing the rights that fall under SDH is crucial.
1115 Medicaid Demonstration Waivers – Addressing Social Determinants of Health
Under Section 1115 of the Social Security Act, the Secretary of Health and Human Services has been given the authority to approve “experimental, pilot, or demonstration projects that are likely to assist in promoting the objectives of the Medicaid program.” The purpose of these demonstrations is to, “demonstrate and evaluate state-specific policy approaches to better serve Medicaid populations.” In practice, this means that states who apply and are selected will have the flexibility to allocate Medicaid funding to support programming, pilots, and demonstrations that go beyond routine medical care and address social determinants of health.
The Section 1115 Waiver allows states to make “certain types of changes to their Medicaid programs that otherwise would not be allowed under law” (NCSL). States have used this waiver for a wide range of policy approaches, including, “reforming delivery systems, improving service systems for behavioral health care (which include mental health and substance use disorder services), integrating behavioral and physical health or otherwise improve behavioral health services, and delivering long-term services and supports through managed care organizations.”
Although Section 1115 waivers have been available to states for decades, before the passage of the Affordable Care Act (ACA), states typically used the waivers to expand coverage to groups not previously covered under Medicaid, to “simplify the enrollment and renewal process, reform care delivery, implement managed care, provide long-term services and supports, and alter benefits and cost-sharing” (The Commonwealth Fund). The ACA expanded eligibility for low-income adults and states began using Section 1115 waivers to “test different approaches to expanding eligibility, including the introduction of premiums and copayments that exceeded federal guidelines.” In 2021, the Center for Medicare and Medicaid Services (CMS) released a State Health Official letter that outlined how states can use the Section 1115 waiver to test the effectiveness of providing SDH-related services and supports. In December 2022, CMS more broadly announced the opportunity to states and began officially offering the new 1115 demonstration.
This new demonstration is significant because it openly acknowledges the impact of SDH on health outcomes for those covered under Medicaid. For the first time, the CMS not only acknowledged, “the important links between HRSN, health coverage, and health outcomes,” but created an opportunity for states to address SDH, “with the goals of improving coverage, access, and health equity across Medicaid beneficiaries.” Through this demonstration, CMS and the U.S. government have officially begun taking steps to expand the right to health and integrate other human rights under health coverage. Specifically, the new Section 1115 demonstration focuses mainly on nutrition and housing supports, such as nutrition counseling and education, medically-tailored meals, rent/temporary housing, and medically necessary home accessibility modifications. Other services may also be covered on a case-by-case basis.
Section 1115 Demonstrations in Action
Many states have already submitted demonstrations, begun piloting their programs, or are in the process of applying and being approved. As of August 2, 2024, 21 SDH 1115 demonstrations have been approved and 15 are currently pending. Across approved states, 10 have been approved for infrastructure funding or delivery systems changed, 19 have been approved for housing supports, and nine have been approved for nutrition supports (KFF).
One state whose 1115 demonstration has been approved is Oregon. The Oregon Health Plan (OHP) 2022-2027 will work to address health inequities through housing, food assistance, and protection from climate events. The Oregon Health Authority understands the impact of social determinants of health, putting in place these “health-related social needs” aimed at helping individuals and families. The OHP notes, “When people go through major life transitions, like losing housing or being impacted by extreme weather, they often lose access to their health care providers, leading to worse health outcomes.” By offering services such as rental assistance, fruit and vegetable prescriptions, and payment for devices that maintain healthy temperatures and clean air, the OHP will work to help their members who are facing certain life challenges and experiencing a greater need.
North Carolina’s approved Section 1115 demonstration waiver includes their Healthy Opportunities Pilots. The North Carolina Department of Health and Human Services (NCDHHS) similarly notes the importance of SDH, saying, “DHHS’ mission is to improve the health, safety and well-being of all North Carolinians. To meet our mission, we must look beyond what is typically thought of as “healthcare” and invest more efficiently and strategically in health.” These pilots cover evidence-based interventions that “address social needs in four domains: housing instability, transportation insecurity, food insecurity, and interpersonal violence/toxic stress” and are delivered through networks of community-based organizations and social service agencies. Specifically, the pilots include a long list of services such as assistance with housing applications, repairs/remediation for issues such as mold or pest infestation, providing funding for targeted nutritious food or meal delivery services, transportation services to social services that promote community involvement, and evidence-based parenting support programs. These pilots are a great way to showcase how it is possible to integrate SDH into healthcare services.
Because the majority of Section 1115 demonstrations have only recently been approved, there is limited research on the actual impact of these programs on health and other outcomes. In North Carolina’s Rapid Cycle Assessment of the Healthy Opportunities Pilots, they note that the structure of the pilots is “feasible, capable of reaching those in need and delivering services to them, and may be offering benefits (albeit small on average) with regard to reducing health-related social need.” Their findings support continuing their Pilots and adjusting them based on their findings.
The Future of Healthcare in the United States
The Section 1115 Medicaid Demonstration Waiver is promising for the future of healthcare in the United States. Although still in the beginning stages, the excitement around the inclusion of social determinants of health, as well as the acknowledgment of the importance of SDH and the approval to integrate social services that address these determinants under government-run healthcare, is moving the United States in the direction of fulfilling the right to health more broadly and effectively.
If these demonstrations and pilots prove successful, the further integration of social services might become more feasible and expected. The National Summit on Health Care and Social Service Integration argues, “Integration of care allows for the provision of services delivered in the home and in the community that prevent falls, address food insecurity and transportation issues, manage chronic disease, support employment and economic independence, reduce social isolation, and address other non-clinical risk factors.” Integrating services for the human rights that most closely rely on each other—like the right to health, housing, and food—allows social service providers to provide more substantial assistance and work to eliminate or reduce outside factors that might be influencing different outcomes.
As individuals, social service providers, states, and the federal government continue to integrate services, comprehension of the interconnectedness, interdependence, and indivisibility of human rights could become understood more broadly and in turn, put into practice. For example, when individuals with chronic diseases are treated with medically-tailored meals, they can better understand the impact nutrition has on their health. When an individual experiencing homelessness experiences improved mental health outcomes after receiving housing assistance, social service providers, advocates, and lawmakers can better understand housing’s impact on one’s health.
The Section 1115 Medicaid Demonstration Waiver is an exciting indication of the changing mindset of what the right to health means in the United States. As these initial demonstrations and pilots are enacted, what is included under the right to health in the U.S. is expanding alongside them.
Glossary
Health inequities: systematic differences in health status or resources between different population groups, arising from social factors
Healthy Opportunities Pilots: the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety and toxic stress to high-needs Medicaid enrollees
Health outcomes: the impact of a healthcare service or intervention
Home health services: examples- home doctor or nurse visit, physical, occupational, or speech therapy
Hospice: medical care designed for the end of someone’s life
Indivisible: unable to be divided or separated
Inpatient hospital services: examples- rehabilitation services, surgeries, childbirth, serious illnesses that require monitoring, psychiatric care
Interdependent: (of two or more people or things) dependent on each other
International Covenant on Economic, Social, and Cultural Rights: multilateral treaty adopted by the United Nations General Assembly in 1966 that outlines economic, social, and cultural human rights
Laboratory and radiology services: examples- urine test, blood test, x-rays, CT scans
Mandatory benefits: benefits or perks required by federal, state, or local law
Medicaid: a healthcare insurance program for Americans with limited income or who meet other qualifying criteria. It is available nationwide, but coverage and eligibility rules vary from one state to another, as the program is jointly run by the federal and state governments
Optional benefits: benefits or perks not required by federal, state, or local law
Outpatient hospital services: examples- annual physical exam, same-day surgeries
Ratify: whereby a state indicates its consent to be bound to a treaty.
Social Security Act: signed into law by President Franklin D. Roosevelt in 1935, created Social Security, a federal safety net for elderly, unemployed and disadvantaged Americans
World Health Organization: the international body responsible for public health
Section 1115 Waiver: a waiver that allows states to obtain federal approval to operate Medicaid programs in ways that differ from federal standards and requirements
Social determinants of health: non-medical factors that influence health outcomes
Socioeconomic position: the position of an individual or group on the socioeconomic scale, which is determined by a combination of social and economic factors
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