EHF’s Journey in Advancing Medicaid Non-Medical Drivers of Health featured by Grantmakers in Health

In GIH's View from the Field, EHF's Shao Chee Sim shares lessons learned as we worked to change policies and advance funding to address non-medical drivers of health -- an effort to not only change the way state agencies think about health, but how they pay for it.

From our beginning in 2013, Episcopal Health Foundation (EHF) has been laser-focused on changing the conversation on health in Texas to focus on addressing the non-medical, root causes of poor health.

Access to affordable medical care is vitally important, but it is only 20 percent of what contributes to a person’s overall health. The remaining 80 percent is determined by social and economic status, health behaviors, community safety, physical environment, and much more. From grantmaking to working with community partners and congregations to providing research, EHF supports solutions that address underlying factors impacting health.

Over the past few years, EHF also worked to change policies aimed at advancing funding to address non-medical drivers of health (NMDOH)—an effort to not only change the way state agencies think about health, but how they pay for it. EHF invested resources to support the Texas Health and Human Services Commission (HHSC) and Medicaid Managed Care Organizations (MCOs) in their efforts to address the non-medical health needs of more than 5 million Medicaid beneficiaries across the state.

The cornerstone of this effort is a multi-year Texas MCO NMDOH learning collaborative, a collaboration between EHF, HHSC, the Texas Association of Health Plans (TAHP), and the Texas Association of Community Health Plans (TACHP).

The MCO Learning Collaborative, along with other efforts, contributed to two major Medicaid policy developments in 2023:

  1. In February, HHSC released a groundbreaking policy document called the Texas Medicaid and CHIP Services Non-Medical Drivers of Health Action Plan, which is the first major policy document released by the state relating to NMDOH policy. Specifically, the plan identified three major non-medical focus areas: food insecurity, housing, and transportation.
  2. In June, Texas Governor Greg Abbott signed HB 1575, a bill that requires HHSC to develop standardized screening questions related to non-medical needs and allows community health workers and doulas to become billable provider types under case management for HHSC’s children and pregnant women’s program.

As we take stock of these encouraging policy changes, we wanted to share insights from a health philanthropy perspective and explain how these policy wins happened in Texas by highlighting EHF’s strategies and lessons in supporting timely research, addressing terminology concerns, and cultivating relationships.

Research Matters

Many of the policy developments are due in no small part to EHF’s investments in relevant research. The findings from our funded reports generated much needed attention from HHSC and MCO stakeholders and played a key role in shaping their NMDOH work.

  1. In 2021, EHF contracted with the Center for Health Care Strategies (CHCS) to assist HHSC in convening a NMDOH expert panel and authoring a report on innovative state Medicaid strategies. As part of this project, CHCS published an environmental scan highlighting evidence on interventions, tools, and resources related to food insecurity, housing, and transportation. This research informed the development of HHSC’s NMDOH Action Plan in 2023.
  2. In 2022, EHF released Moving Upstream: How Texas Medicaid Could Use In Lieu Of Services to Address Non-Medical Drivers of Health, highlighting how asthma remediation, food is medicine, and services related to housing programs can improve health outcomes. Based on the report, the state’s Value-Based Payment and Quality Improvement Advisory Committee issued two NMDOH-related recommendations in its legislative agenda report to the State Legislature.
  3. In 2023, EHF released Approaches For Addressing Non-Medical Health Drivers Through Medicaid Managed Care: Landscape Study and Actuarial Analysis, an analysis of cost drivers of Medicaid beneficiaries with high-risk pregnancies. The authors found that high-risk pregnancies are about twice as likely to have had a non-medical health need as non-high-risk pregnancies. They also estimated that the health care cost of high-risk pregnancies in Texas was $776 million. The cost estimate was cited repeatedly by legislators in both the House Select Committee on Health Care Reform and the Senate Health and Human Service Committee in explaining the rationale for filing HB 1575.

Terminology Matters

When EHF engaged consultants to conduct a review of why certain NMDOH bills failed during the 2021 legislative session, the primary finding was that the legislation referred to social determinants of health or SDOH, and that no one really knew that the term meant.

When HHSC and state legislators used “NMDOH” instead of SDOH in its policy and legislative documents, there appeared to be more buy-in and support for the work. Equally important, HB 1575 was framed as expanding billable provider types to include community health workers to improve health outcomes of pregnant women on Medicaid. With a defined population and a specific intervention, the bill is now on its way to becoming law in September 2023.

Relationships Matter

EHF’s relationships with HHSC, TAHP and TACHP are not typical funder-grantee relationships. We understand that a state health agency has a much bigger budget and responsibility than EHF. We also realize that MCOs do not seek foundation funding because they often have more financial resources available.

We were interested in achieving a “win-win” scenario by articulating how EHF could add value and contribute to their efforts in advancing the NMDOH agenda. For instance, EHF’s journey with the health insurance plan associations began with a simple survey to better understand their members’ motivations, barriers, and facilitators in NMDOH strategies. That request led to the first-ever statewide MCO NMDOH survey and the creation of the learning collaborative.

Over the years, EHF staff cultivated relationships with these groups through in-person and virtual meetings to learn the many perspectives, priorities, and pain-points of HHSC and MCO leaders. We have earned the trust and respect of our partners as evidenced by ongoing requests to partner on various efforts. These solid relationships and reputational capital have positioned EHF as a neutral thought partner, convenor, and go-to resource for state agencies, health plans, health care providers, nonprofits, and policy organizations in shaping the NMDOH agenda in Medicaid.

This is a Long Game

Upon reflecting on EHF’s journey, we understand the work is complicated and messy. In health philanthropy, we need to be patient and nimble in navigating changing federal and state contexts. More than just celebrating two policy wins, we are committed to redoubling efforts to provide support and partnership opportunities with HHSC and MCOs in implementing the NMDOH Action Plan and HB 1575.

We cannot do this alone. In the coming years, we will deepen our collaboration with HHSC, MCOs, peer funders, health care providers, social service organizations, and other stakeholders. This work is all part of a collective effort to advance the Medicaid NMDOH policy agenda, and most importantly, to improve the health outcomes of Medicaid beneficiaries throughout the United States.