Taking On Too Much

This issue of Managed Care was billed as being about Medicaid managed care and vulnerable populations. But as grumpy editors often say, that’s a topic not a story. And it didn’t take us very long to discover that the story was social determinants of health.

Lola Butcher, a regular contributor to these pages, does an excellent job of exploring the many issues involved in going “upstream” to address the social determinants of health. Hers is, by and large, an encouraging account. The belief that social determinants can be dealt with is strongly held, and Butcher reports on some success stories. The partnership of the ProMedica Health Care System in Toledo and philanthropist Russell Ebeid seems to be making real, concrete changes for the better in that city’s UpTown neighborhood.

Contributing Editor Richard Mark Kirkner, who writes our Legislation and Regulation department, reports on how ACA expansion and value-based payment are pushing Medicaid managed care organizations to tackle social issues. Last year, the Kaiser Family Foundation said one of the “trends to watch” in Medicaid is the growing number of states that require Medicaid managed care organizations to screen beneficiaries for social needs. Screening is not solving but it’s a start.

Zachary Hafner of the Advisory Board warns against complacency and tinkering with payment models that shuffle financial risk around but do little to reinvent the underlying care model.

The appeal of intervening at the causal level instead of cleaning up the mess of the effects is understandable—and laudable. Still, all of this talk about, and efforts directed at, the social determinants of health makes me nervous. We are asking health care to shoulder an awful lot: housing, nutrition, deep-seated inequities. And is it a distraction—or perhaps a deflection—from dealing with health care’s problems? Problems like the market power of larger and larger providers and prices that mean this country spends approximately twice as much on medical care as other higher-income countries.