Trump administration's false rhetoric on the social determinants of health

Social Determinants Of Health: A Public Health Concept In Conflict

By Danielle Garrett, Ann Hwang, Clare Pierce-Wrobel
Health Affairs Blog, May 30, 2018

The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health. The new battlefront over health programs for the poor is taking place over what has historically been a progressive concept: social determinants of health.

This approach builds off of extensive public health research that shows changing health behaviors is most effective when paired with changes to the broader environment that enable those behaviors. In practice, this often involves removing barriers to services and increasing access to successful interventions.

Same Words, New Meaning

In January 2018, when the Centers for Medicare and Medicaid Services (CMS) announced that it would allow states to implement work requirements as a condition of receiving Medicaid coverage, the letter from CMS to state Medicaid directors employed language with seemingly familiar tones as it noted the many “determinants of health.” It went on to state that, “CMS recognizes that a broad range of social, economic, and behavioral factors can have a major impact on an individual’s health and wellness, and a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes.”

Secretary of Health and Human Services Alex Azar echoed the letter from CMS when he noted that many state officials were discussing requests for work requirements. "It seems to be getting a great deal of excitement to deal with the social determinants of health," Secretary Azar shared during a February press conference in Indianapolis announcing the federal government’s approval of a Medicaid work requirement waiver for the state of Indiana.

While described as being about social determinants of health, the proposed policy from CMS actually takes an antithetical approach. If a beneficiary doesn’t meet the work requirements, this policy imposes a barrier to health care access by locking that individual out of Medicaid coverage. Rather than addressing the underlying factors that might contribute to lack of employment, such as need for education, training, transportation, the availability of jobs in the community, and poor health itself, the policy utilizes a punitive approach.

All Sticks And No Carrots

Punishing people for not engaging in a desired behavior by removing their access to care has very real consequences for people’s health and might actually exacerbate undesired health behaviors. It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care. Such an approach will likely make it even more difficult for individuals to find employment in addition to impacting their health.

The history of safety net programs has shown work requirement policies to be unsuccessful in improving employment or health status. For example, when Wisconsin implemented a work requirement for their food support program, more than three people lost coverage for every individual who gained employment. Lack of health insurance coverage is associated with a variety of poor health outcomes and a lack of access to care.

Creating A New Barrier To Health

While truly addressing the social determinants of health involves removing barriers that prevent people from making healthy decisions, punitive policies such as work requirements create an environment where people face more barriers to making healthy decisions. Medicaid work requirement waivers currently under development also demonstrate how these policies can inequitably distribute these barriers. A proposal under consideration in Michigan, for example, would disproportionately enforce the requirements for urban centers and communities of color that are facing major health and employment crises—like Flint—while exempting mostly white, rural communities.

An agenda that attempts to change health behaviors by making it harder to make healthy choices runs the risk of actually worsening health outcomes, increasing disparities, and diverting investments away from evidence-based interventions that improve health. We should not be fooled by the contorted language from CMS about “social determinants” that is being used to promote policies that only make it harder for people to make the healthy choice.


After Years of Trying, Virginia Finally Will Expand Medicaid

By Abby Goodnough
The New York Times, May 30, 2018

Virginia’s Republican-controlled Senate voted on Wednesday to open Medicaid to an additional 400,000 low-income adults next year, making it all but certain that the state will join 32 others that have already expanded the public health insurance program under the Affordable Care Act.

Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in elections last fall and voters named health care as a top issue.

The House passed the Senate bill within hours; it will now go to Mr. Northam’s desk. The measure includes a requirement that many adult recipients who don’t have a disability either work or volunteer as a condition of receiving Medicaid — a provision that was crucial to getting enough Republicans on board.

“That is debt, and I have four kids who are going to be having to pay for that for the rest of their lives,” Senator Amanda Chase, a Republican from Chesterfield, said of the federal funds spent on Medicaid expansion, explaining her vote against it on Wednesday.

This year, Republican governors and state lawmakers, encouraged by the Trump administration, have focused on adding new requirements for Medicaid eligibility, such as requiring adults without disabilities to work or volunteer, and many beneficiaries to pay premiums.



By Don McCanne, M.D.

It is an outrage that Trump administration officials contend that taking away health benefits from individuals who are unable to find qualifying employment is a policy that "may improve health outcomes."

We can be thankful to Danielle Garrett, Ann Hwang, and Clare Pierce-Wrobel for writing this article and for Health Affairs for publishing it. It is important that the nation understands what these policies really mean. As the authors state, "It is nonsensical for a policy that is pitched by policymakers as improving health to actually do the opposite, as people will lose access to health care."

This is not some theoretical consideration; it is really happening. Virginia legislators have fought Medicaid expansion for years and now agree to it only because the work requirement was added.

We are seeing more pleas for everyone to come together to address these social problems for the betterment of all of us. But when a policy goal of accessible and equitable health care for all conflicts with a policy goal of erecting barriers to health care (work requirements, unaffordable deductibles, narrow provider networks, spartan plans, unaffordable benefit tiers, etc.), how can we ever find common ground?

Those supporting health care for all clearly hold the moral high ground. Those who would deliberately create barriers to health care for some should explain to the rest of us the moral basis for their positions that seem to rest on very shaky ground. They should provide us with a credible explanation of how they are sharing with us a firm moral footing. The fact that health care costs money is not an adequate excuse since we are already spending enough to provide care for everyone if we would just change our policies to those that work, such as with an improved Medicare for all.

Really. It is depressing to see our nation's political leaders support these inherently cruel policies. What is it that the voters see in them? Aren't we entitled to a reasonable explanation of why these legislators should be the ones to dictate policy?

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