Advancing Non-Medical Drivers of Health Through Policy in Texas

The Texas Consortium for the Non-Medical Drivers of Health brought together over 100 health care stakeholders in two workshops during June 2024 to generate policy ideas to advance the integration of non-medical drivers of health (NMDOH) into health care delivery systems. As the 89th Texas legislative session approaches, the need for new policies to support health care organizations in this work is critical and timely. Consortium participants, including policymakers, researchers, and practitioners, discussed Texans’ needs and identified policy opportunities to move toward effective and sustainable delivery of services to address patients’ non-medical needs. 

Advancing NMDOH Through Policy Change 

According to County Health Rankings, 80% of health outcomes are attributed to social, economic, environmental, and behavioral factors, yet in 2022 more than 90% of U.S. national health expenditures went toward medical services. As medical costs continue to rise, and U.S. health outcomes continue to fall below most developed nations, state and federal policymakers are pushing the health care system to invest more of its resources in non-medical services. 

Centers for Medicare and Medicaid Services (CMS), Texas Health and Human Services (Texas HHSC), The Joint Commission, and National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) now require health care providers and health insurance plans to screen patients and members to identify health-related, non-medical needs, such as food insecurity, housing, and transportation, as a part of quality improvement. In some cases, policies require providers and plans to address these and other identified needs. Providers and plans are often eager to address their patients’ and members’ non-medical needs because they understand the positive impact this can have on health outcomes and subsequent health care utilization. 

Additionally, many sectors of the federal government recognize the benefits of incorporating NMDOH delivery into health care. During both the Trump and Biden presidential administrations, CMS affirmed the importance of addressing health-related, non-medical needs through Medicaid and Medicare and created programs and policy directives to advance that work, such as:

• Accountable Health Communities Model in 2017, which examines the ways addressing NMDOH through clinical-community links improves health outcomes and reduces costs.
• Guidance to State Health Officials in January 2021, which outlines opportunities under Medicaid and the Children’s Health Insurance Program (CHIP) to attend to social determinants of health. 
• In Lieu of Services and Settings in Medicaid Managed Care Guidance in 2023, which encourages states to employ this innovative model to integrate NMDOH into the Medicaid program. 

Many states have also taken advantage of these opportunities, notably the North Carolina’s Healthy Opportunities Pilot in the Medicaid 1115 Waiver, which permits the expansion of Medicaid managed care while preserving hospital funding and was approved in 2018. 

Altogether, the federal bipartisan support for NMDOH services in Medicaid provides an opportunity for Texas. Maintaining the effectiveness and sustainability of this work that centers NMDOH in health care services will require policy changes.

Texas’ Current Policies on NMDOH

In February 2023, Texas HHSC published its Non-Medical Drivers of Health Action Plan for Medicaid and CHIP. The plan lays out a framework for developing policies and programs that incentivize Medicaid health plans and providers to recognize and address needs related to food insecurity, housing, and transportation, while containing costs. The plan’s timeline is ambitious with its full implementation projected for 2025 and identifies policy levers necessary to achieve its goals.

The Directed Payment Programs within the Medicaid 1115 Waiver were approved in 2021 and include NMDOH screening and follow-up plans for participating providers. In June 2023, Gov. Greg Abbott signed into law HB 1575, which recognizes that non-medical factors impact health outcomes. The bill requires that pregnant Medicaid beneficiaries be screened for non-medical needs and offers case management services to connect them with non-medical resources in the community. Additionally, community health workers and doulas can become Medicaid providers to provide case management services. Implementation of the bill begins Sept. 1, 2024. 

With Texas’ upcoming 89th legislative session, we have the opportunity to identify and advocate for supportive policies to implement NMDOH into health care delivery systems effectively and sustainably. 

Key Areas Identified for NMDOH Policy Progress

Consortium stakeholders across the state are investing in NMDOH work on behalf of their patients, and they want supportive polices to make the work more efficient and sustainable. Building on the 88th legislative session’s success in passing HB 1575, and in support of fulfilling the goals of the Texas HHSC’s NMDOH Action Plan, additional policy changes are critical to establish effective and sustainable pathways to connect patients with needed services at scale. 

Stakeholders uplifted the following potential areas of focus for NMDOH policy progress:

1. Metrics and Measurement: Develop consensus on standardized screening and outcome measures to support consistency across health care providers, health plans, and HHSC programs.
2. Managed Care Organization (MCO) Contracts: Incentivize MCOs to increase their investment in NMDOH through value-based payments, value-added services, and new models for investment of MCO profits.
3. Coverage for NMDOH Services in Medicaid:
   • Use existing codes for NMDOH screening and services to provide coverage for this work.
   • Use In Lieu of Services (ILOS) authority to cover particular NMDOH services for specific patients or health conditions.
   • Develop a new Section 1115 Waiver Program to enable a Food Is Medicine Program based on significant evidence of efficacy. 
   • Use the Direct Payment Program in the current Medicaid 1115 Waiver to sustainably fund NMDOH interventions by participating providers.
4. Data Sharing and Communications: Establish policies including financing to support data sharing between health care and community-based organizations to build capacity for interoperability and closed loop referrals.
5. Rural Health Care: Address the unique challenges in rural areas where lack of transportation and limited resources exist. 

Looking Ahead

Based on the input of our stakeholders and additional research and outreach, the Texas Consortium for the Non-Medical Drivers of Health will publish a policy brief in September 2024 to delve deeper into specific policy opportunities and offer policy recommendations for Texas HHSC and the Texas legislature to consider. 

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.