NY will use Medicaid funding for housing, transportation and food

New York is rolling out a new pilot program that uses Medicaid funding to help low-income residents access resources including housing, food and transportation. State health officials are betting the effort will make New Yorkers healthier and help them avoid complex clinical care without driving up overall spending.

It’s well-established that social factors like stable housing and access to nutritious food contribute more to a community’s health than the care people get at the doctor’s office. But Medicaid coverage for nonclinical needs is still limited. The state is in the midst of expanding that coverage on a trial basis with the help of a three-year, $7.5 billion waiver from the Biden administration.

Some $500 million of that funding is being used to create regional hubs, known as social care networks, that link health care providers with community-based organizations so they can better connect patients to social services and track outcomes. Health care advocates say that for the initiative to be successful, the state will need to ensure those community partners get enough of the funding.

“The social care networks will help us transform how we support communities with the greatest unmet needs,” Gov. Kathy Hochul said earlier this month, when she announced the state’s nine networks, including three that will cover New York City.

Organizations that plan to participate in the program say they are hoping they will get funding to expand the existing work they do to connect people to services, in addition to collaborating on new ways to meet people’s needs.

The nonprofit health care and social services provider Housing Works aims to build up its work helping people apply for supportive housing — a lengthy and complex process that involves a psychiatric assessment.

Reimbursement for that work from existing government contracts “is so low,” said Jessica Diamond, executive director for community health care at Housing Works. “It’s making it challenging to stabilize and continue this resource.”

Michael Clarke, Housing Works’ senior vice president of programs, said he hopes the new funding will also allow his organization and others to help a broader pool of New Yorkers.

“There's a lot of people who currently fall outside of the eligibility requirements [for certain resources], but likely if these needs aren't addressed, they will meet those eligibility criteria in years to come,” Clarke said.

In addition to supporting social care networks, the new federal waiver will allow the state to use Medicaid dollars to directly fund other services for some patients — including rental assistance, help with utilities, nutritional services and respite centers where people can recover after leaving hospitals if they have nowhere else to go.

“We have a premise that receiving these services is likely to reduce medical care in higher-cost settings like a hospital or other institutional setting,” state Medicaid Director Amir Bassiri said when the waiver was first approved earlier this year. “The longer-term goal is ultimately better care, better outcomes at or below the same cost.”

The three-year waiver is an opportunity for New York officials to identify non-clinical interventions that offer a lot of bang for their buck, so they can make the case that funding should continue in the long term.

The physician group Somos Community Care will lead a social care network in the Bronx. An existing network of health care organizations known as the Staten Island Performing Provider System will lead another covering Staten Island. A third led by the nonprofit Public Health Solutions will cover Brooklyn, Queens and Manhattan.

Anthony Fortenberry, the chief population health officer at Callen-Lorde, a community health organization serving LGBTQ+ patients, said the social care networks will place more emphasis on tracking what happens to patients after they are referred to social services.

“If a physician writes a referral for an X-ray, we track those referrals and we follow up on the referrals to make sure that we're closing the loop consistently,” Fortenberry said. “Many entities are not doing the same if you, for example, refer a patient to a food pantry.”

Groups that are planning to participate in the pilot say they are optimistic that it will be effective, but caution that the state must monitor how the groups leading the social care networks distribute money, to make sure smaller community-based organizations can participate.

Ngozi Moses is executive director of the Brooklyn Perinatal Network, an organization that works to improve maternal health outcomes. She her group's participation in the last Medicaid waiver project was limited because of a lack of funding.

She said organizations like hers need funding up-front to help them participate in these kinds of initiatives, because they can’t afford to scale up on their own.

“When the three years are over, if the state is not careful, community-based organizations could be exactly where they started or worse,” Moses said.

This time around, the groups leading each social care network will be required to ensure that the community-based organizations they’re working with have the resources they need up front, including staff, technology and administrative support, said Danielle De Souza, a spokesperson for the state health department.

She added that the health department recognizes that the delivery of health-related social services “is most successful through the support of a strong network of a diverse set of community-based organizations supporting the Social Care Network lead entities.”

The social care networks are expected to launch in the coming months and will have online portals where Medicaid members can complete self-assessments and obtain referrals to different services.