How Medicare Addresses Social Determinants of Health

It takes more than health care to be healthy. There are many factors that affect your health outside of the doctor's office—how much money you make, where you live, and access to resources like fresh food and clean water, for starters.

Medicare is becoming proactive by designing programs that address these very issues. The Centers for Medicare and Medicaid (CMS) believes doing so will reduce healthcare costs for Medicare and Medicaid beneficiaries alike. More importantly, it will help to promote public health programs that keep people healthier longer.

Social Determinants of Health Care

Healthy People 2020 is an initiative taken by the U.S. Department of Health and Human Services with the goal to decrease preventable diseases and injuries, eliminate healthcare disparities, improve quality of life, and promote health for all people. The initiative has identified five social determinants that affect our health.

• Economic stability: The ability to pay for food, housing, and other life essentials (i.e., prescription medications) has an obvious effect on health. Access to job training, jobs with a livable wage, and opportunities for stable employment are also key.
• Education: Level of education and literacy affects health and well-being. Not only are people more likely to have increased job opportunities, but they are also more likely to adopt healthy behaviors if they have more education.
• Social and community context: Communities with high rates of crime, violence, or discriminatory practices have a negative effect on health while safer communities that are more accepting of different cultures are more likely to thrive.
• Health and health care: Access to health care, especially primary care, helps to decrease illness and promote health.
• Neighborhood and built environment: Access to local food markets, quality housing, and transportation has a direct effect on your quality of life. It can be harder for people to thrive in neighborhoods with concentrated areas of poverty and fewer resources.

These are only some of the many ways social determinants can affect your health.

Accountable Health Communities Model

CMS is aware that social determinants affect health. For example, lack of food could lead to malnutrition and with it a number of medical complications. Lack of housing could increase someone's risk for physical injury. Lead found in paint or copper pipes of old buildings could cause poisoning in young children. Poor ventilation in some buildings could trigger breathing problems for people with asthma, COPD, and other respiratory conditions. Low income could lead to an inability to afford life-saving medications like insulin.

These situations can cause people to become sick or otherwise have flare-ups of their chronic medical conditions, increasing their need for healthcare services. When they are healthier, their health expenditures are likely to go down. In that way, addressing social determinants of health can improve health outcomes and decrease healthcare spending.

For these reasons, CMS initiated the Accountable Health Communities Model in 2017. They know there are many community-based resources available. The problem is not everyone knows about them. The goal of the Accountable Health Communities Model is to close that gap and to raise awareness of these programs.

As of March 2020, a total of 30 organizations are participating, receiving funding of $1 million each to use over a five-year period. Clinicians in these organizations are tasked to identify local resources that are available to the people in the communities they practice. They must also screen all Medicare and Medicaid beneficiaries to determine if certain social needs are being met. When they are not, clinicians will refer their beneficiaries to community organizations that will hopefully address those needs.

The government funding is not intended to develop community-based programs that address health-related social determinants directly. Instead, the Accountable Health Communities Model is a public health model that aims to boost awareness and establish community partnerships. The model is expected to run for five years. At that time, CMS will assess the effects on health outcomes and healthcare spending. Hopefully, in time, funding will be provided to expand on those public health programs.

Medicare Savings Programs

The biggest social determinant of health is financial instability. Low income and outright poverty make it difficult to pay for medically necessary care. Whether it is the cost of doctor's visits or prescription medications, not everyone can afford it.

Thankfully, CMS has multiple programs in place to help people that cannot afford Medicare copayments, coinsurance, deductibles, and premiums. There are four different Medicare Savings Programs (MSP) that cover certain expenses for Medicare Part A and Part B.

• Qualified Disabled & Working Individuals (QDWI): This MSP is not available to all Medicare beneficiaries. Specifically, it is intended for people under 65 years of age who qualified for Medicare based on a disability but who were no longer eligible for premium-free Part A when they went back to work. The program covers Part A premiums.
• Qualifying Individual (QI): This MSP covers Part B premiums.
• Qualified Medicare Beneficiary (QMB): This MSP is the most extensive and covers Part A premiums, Part B coinsurance, Part B copayments, Part B deductibles, and Part B premiums.
• Specified Low-Income Medicare Beneficiary (SLMB): This MSP covers Part B premiums.

In order to qualify for any of these Medicare Savings Programs, you need to be eligible for, if not enrolled in, Medicare Part A. You must also meet certain income and asset requirements. To find out if you qualify, reach out to your state Medicaid office or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) to apply.

Part D Prescription Drug Coverage and Policy Changes

CMS is taking action to drive down prescription drug prices. This includes lifting pharmacy gag clauses that prohibited your pharmacist from discussing lower-cost options. Medicare Advantage plans use step therapy for medications covered under the Part B benefit. This encourages doctors to prescribe less expensive options to start and to use more costly options only when treatment has failed.

In March 2020, CMS proposed the Part D Senior Savings Model to specifically decrease insulin costs for Medicare beneficiaries. Insurers would decrease insulin copays to a flat rate of $35 per month, saving an estimated 66% off current prices and pharmaceutical companies would adjust costs and contribute more towards the coverage gap known as the donut hole. These changes will not take place until 2021.

CMS also proposed changes to Part D plans to negotiate with pharmaceutical companies for medications that are in the six protected drug classes. That includes antidepressants, antipsychotics, chemotherapy agents, HIV/AIDS drugs, immunosuppressants, and seizure medications. Traditionally, nearly all medications in these classes were covered. This policy could make some options less expensive but could potentially make it harder to access certain medications.

While these policies may help to decrease costs to the health system at large, they may not always be beneficial to the individual. Simply put, some people may not respond to certain lower-cost medications and may need a more expensive drug. They may need a medication that only has a brand name option. Oftentimes, out of pocket costs can be prohibitive.

Part D Prescription Drug Coverage and Extra Help

If you are having a hard time paying for your medications, consider getting Extra Help. Similar to a Medicare Savings program, this program subsidizes costs for Medicare beneficiaries. To be eligible, you must be enrolled in Part A and/or Part B, live in one of the 50 states or the District of Columbia, and meet certain income and asset criteria.

There are two versions of Extra Help. For the most needy, Full Extra Help covers Part D premiums for plans with premiums below your state’s benchmark amount. As of 2019, you are then only responsible to pay a $3.40 copay for generic drugs, an $8.50 copay for brand-name drugs, and no copay after $5,000 is spent in out-of-pocket drug costs.

If your income and assets qualify you for Partial Extra Help in 2019, you will pay a monthly premium that depends on your income, an annual deductible (an $85 deductible or your plan’s deductible, whichever is cheaper), and a 15% coinsurance or plan copay, whichever is cheaper. After you spend $5,000 in out-of-pocket costs, you will pay either a copay ($3.35 for generic drugs and $8.50 for brand-name drugs) or a 5% coinsurance, whichever is greater.

You can apply for Extra Help online, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778), or apply at your local Social Security office. 

A Word from Verywell

Access to health care is only part of the equation. There are many social determinants that affect our health ranging from how much money we have to where we live. Resources that address these social needs can improve the health of not only individuals but also whole communities. Thankfully, CMS is taking action to address unmet social needs. By building community partnerships through the Accountable Health Communities Model, subsidizing healthcare costs for beneficiaries with low incomes, and enacting policy changes that will decrease drug costs, Medicare is paving the way towards better health for all.