The Atrómitos Way

#058: The Missing Layer: Why We Keep Rebuilding Social Care and Never Finish It

• Atrómitos, LLC • Season 5 • Episode 58

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 35:06

We’ve seen it before, and we will probably see it again: using state and federal dollars, we fund a social care program for five years, it works, and despite robust results, one budget cycle takes it out. But it doesn’t have to be this way. What if, rather than a rolling series of demonstrations that can disappear with a waiver, a rule change, or a vote, integrated health and social care could be hardened into infrastructure?

On today’s episode, Atrómitos founder, president, and CEO Michealle Gady does a solo deep dive on precisely that topic. She explores the challenges and opportunities in integrating health and social care in the United States, with insights informed by her decade working alongside the state agencies, health systems, payers, funders, and community organizations building the programs that connect health care to the housing, food, transportation, and support that actually determine whether people stay well.

Key Takeaways

The other 80%. Clinical care accounts for roughly twenty percent of your health, while the other 80% occurs outside the health care system. How do we address a person’s need for food, or housing, or a ride to the doctor with the same seriousness we’d bring to a diagnosis of diabetes or heart disease?

Learning from experience. What can we learn from those previous demonstrations? Where has the patchwork fallen short in the past, and how do we avoid those pitfalls in the future? What factors, other than cost savings, should be considered as metrics for success of these programs?

For further reading, we encourage our viewers to visit our website, where you can find a blog post on this topic: https://www.atromitosconsulting.com/the-missing-layer-social-care-infrastructure/

As well as a paper we published in July, with all the evidence and the financing model laid out: https://www.atromitosconsulting.com/reports/integrating-health-and-social-care/



Atrómitos Knowledge Hub Promo

--

This podcast is a production of Atrómitos, a woman-owned boutique consulting firm creating a better way for our health and human services provider clients to achieve their goals by strengthening internal operations, enhancing financial stability and evaluating public policies.

Want to know more about the firm behind the podcast?

In addition to our podcast, we've developed additional resources to improve your understanding of both long-standing and emerging issues important to leaders in the health and human service provider, government and philanthropic sectors.

Our articles, policy briefs and infographics provide you with information you can use to reach your organization’s goals. 

  • Atrómitos Way Podcast Website: www.atromitosconsulting.com/atromitos-way
  • Follow us on LinkedIn: www.linkedin.com/showcase/the-atrómitos-way
  • Articles: https://atromitosconsulting.com/atromitos-way/progress/
  • White Papers: https://atromitosconsulting.com/atromitos-way/unlocking/
Narrator

Welcome to the Andromeda's Way podcast, where we candidly discuss the everyday challenges facing health and human service providers, including government agencies, philanthropies, and advocates. Clinical care accounts for roughly 20% of your health, while the other 80% occurs outside the healthcare system. How do we address a person's need for food or housing or a ride to the doctor with the same seriousness we would bring to a diagnosis of diabetes or heart disease? On today's episode, Andromeda's founder, president, and CEO Michelle Gady does a solo deep dive, exploring the challenges and opportunities in integrating health and social care in the United States.

Michealle Gady

Here's a fact worth sitting with. The most thoroughly evaluated Medicaid social care program in the country, one with published evidence that it cut medical costs and kept people out of the emergency room, stopped running for a year. The program didn't fail. DC didn't pull the plug. Instead, a single state legislature declined to pay its share, and that was enough to turn it off. That program is North Carolina's healthy opportunities pilots, but the specific state and program are irrelevant. This is how the whole country does it. We fund something for a short period of time, it works, and one budget cycle takes it out. We call these things pilots or demonstrations, and we mean it. Small, finite, and yet we're still surprised every time one shuts down. Welcome to the Eudromatous Way. I'm your host, Michelle Gady. Today I want to talk about why that keeps happening and what it will take to build something permanent. The U.S. spends more on health care than any other country. This isn't news. We all know this. But did you know that more than 17% of everything our economy produces is what it costs to deliver health care in the country. And we still finish near the bottom among wealthy countries when you look at whether people are actually healthy. We live shorter lives. More of our mothers die in childbirth. And the gap between the longest lived and shortest lived Americans is more than 20 years. So we're buying the most expensive care on the planet and getting the worst results. And here's why. Clinical care accounts for about 20% of your health. The doctor, the hospital, the prescription. The other 80% occurs outside the healthcare system. It's your housing, whether there's food in the kitchen, whether you have safe, reliable transportation, it's your neighborhood and how you spend your days. So what that means is we've built our largest and most expensive sector around the smallest part of the problem. And today that's what I want to talk to you about, the other 80%. It's about addressing somebody's need for food or housing or a ride to the doctor with the same seriousness we'd bring to the diagnosis of diabetes or heart disease. Before we get into those details, though, let me clear up two terms because people use them, though they mean the same thing, and really they don't. So the first is social determinants of health. Social determinants of health are the major conditions that shape a whole population, like the housing market, income, education, and discrimination. On the other hand, the healthcare system uses a narrower term, which is health-related social needs. And that describes how the conditions affect a person. So for example, this patient can't afford groceries. That patient is about to lose her apartment. So if you think about it in a common way, you know, something we deal with every day, social determinants are the weather, and the needs are you standing in the rain. As a nation, we have to work on both. But today we'll focus on health-related social needs. And so why am I talking about this now? Last year in 2025, it was a year that particularly exposed something a lot of us had been grumbling about privately for years. The infrastructure we've built to connect health and social care is real and it works, but it can be undone in a moment. And so let's talk through the timeline of 2025 and 2026 because that really matters. So actually, if we take a minute and we go back a little further, a lot of this started to become really transparent when the Medicaid unwinding after the pandemic started. It pushed millions of people through coverage changes and it showed how much this whole apparatus, the integration of health and social care, really depends on somebody staying continuously enrolled in coverage. This is something we've known from a health perspective for quite some time. But as we build this integration between health and social care, it becomes even more prominent. What we saw after the Medicaid unwinding was how the whole apparatus really takes months to get the services to work in a way that produces an outcome. And so if you're turning in and out of coverage, that can't happen. That continuous access to the service can't happen. Then last spring, the federal government stepped back twice. In March, CMS rescinded the guidance on health-related social needs. In April, it ended the federal match of two programs with highly forgettable names, the designated state health programs and designated state investment programs. So while their names are forgettable, the programs are significant. These programs had grown from under a billion dollars in 2019 to about 2.7 billion in 2025. And they were quietly paying for the workforce, the data systems, and the public health backbone that eight states were leaning on to create their health and social care integration programs. Then in July of 2025, Congress passed a budget reconciliation law, public law 119-21. It's commonly called the One Big Beautiful Bill Act, even though the Senate deleted that name. So on paper, the law has no title at all. You can make with that what you like. The law tightens the budget neutrality math on the Medicaid waivers this work relies on. So any savings now have to be federal Medicaid savings certified by the CMS Actuary. If you're familiar with the program, the Medicaid program, you know that it is a federal-state partnership program. And so the federal government pays a portion of the cost and the state government pays a portion of the cost. And now under the law, the savings must all accrue to the federal government. The law also adds work requirements that every state must meet by January of 2027, along with new eligibility checks that have to occur every six months. And the effect on health and social care integration of these changes really isn't subtle. As we saw with the Medicaid unwinding, if you lose coverage, whether it's because you didn't know you needed to demonstrate that you were meeting work requirements or you didn't know that you needed to demonstrate continued eligibility every six months. If you lose your coverage, you also lose not just access to your healthcare services, but any social care services that you were receiving as a part of that. So in this particular case, CHERN stops being a bug of the Medicaid program and starts being the design, really. To be fair, the law isn't, I guess, all bad. It did create the rural health transformation program that includes about $50 billion that's going out to all states. But the funding runs out in just a few years. Additionally, while the funding can pay to build the coordination between health and social services, it can't pay for the food. It can't pay for the ride. It can't pay for the housing repair. So if you think about it, it funds the plumbing, but forbids the water. And then, of course, around the same time, North Carolina suspended its healthy opportunities in July of last year, which was less than seven months after CMS approved a five-year renewal that runs through 2029. So in this case, the federal government approval was in hand. The evidence of its effectiveness was in hand, but the program stopped anyway because the legislature, and largely in particular, a single legislator, wouldn't approve the appropriation of the state match. So again, that's one state. And I did promise you that there is a pattern. So let me be clear that North Carolina isn't special. It's just the best documented. Let's look at the accountable health communities model. That provided six years of funding for building screening and navigation across dozens of communities. And then it closed in 2023 with no successor. Some of those organizations found other funding. Others wound down the work within a year. And in fact, the majority wound down. So then let's just also look at the Making Care Primary, which is another federal program. It was designed to run about 10 and a half years, but got canceled 12 months in, taking with it the social needs payments that practices had already hired people to use. Or the 700 or so hospitals that are getting ready for social needs screening under the CMS team model, which the federal payment rule quietly deleted last October. So it kept the requirement that participants in the team model refer people to social service providers, but it took away the screening requirement that finds them. So states can switch this off, so can DC, and it has repeatedly, without anybody ever having to vote on whether integration is a good idea. And the next tests are already on the calendar. California's demonstration expires at the end of December. New York's expires in March of 2027. Both of them cover social care networks, and both of them renew under the new budget neutrality math, where the savings have to be federal, Medicaid only, and inside the demonstration window. Much of the best evidence in this field doesn't look like that. As for North Carolina, the case is instructive. The state finally passed its first full budget since 2023 this past summer. It does restore healthy opportunity funding, but as at a significantly reduced rate. So rather than the roughly $80 million that was needed, it only allocates $25 million. And the program has been dormant for the last year. So restarting it, particularly at a fraction of the cost, relying on an infrastructure that was at least partly dispersed while it waited, is at best going to be difficult. Now, none of this matters if the underlying idea doesn't work. So let me be clear about the evidence, including where it's then, because overselling is part of how we got where we're at. The scale of the need isn't in dispute. Food insecurity affects about 15% of the population. Housing insecurity runs somewhere between 9 and 20%, depending on how you do the math. And both are higher among people on Medicaid and people served by community health centers. And these really aren't edge cases. We're not talking about a very small number of people. In fact, this is the daily reality of the people our public programs exist to serve. And on the outcomes, the evidence is strong enough to act on. So, for example, medically tailored meals for people with diet-sensitive chronic conditions cut hospital emissions and emergency room visits, and the biggest effects show up in congestive heart failure and complicated diabetes. Community health worker programs have more than a decade of replicated trials behind them, and permanent supportive housing reliably reduces hospital and emergency use among the people who use the most. Then there's the number everybody cites. So in North Carolina, the SHEP Center at the University of North Carolina reported net Medicaid savings of $164 per member per month across more than 31,000 people over two and a half years. The savings grew over time, and they were largest for people who got more than one social service. So the program was working by the numbers. At the moment, it was switched off. Now, here's where I want to be careful. Because this is where people oversell, and we don't want to do that. The evidence does not say that every social care intervention saves money. Some do. Some are cost neutral and still produce better outcomes. So what does that mean? It means that things are better and they didn't cost any more than they otherwise would have. And some are simply the right thing to do, ledger aside. So despite the savings that may or may not be produced. And a mature public policy can hold all of that at once. And so really what we're talking about, the what the argument is, is what should we be measuring? Right now, almost everybody sells social and healthcare integration on cost savings. So invest in social care, save on healthcare. And sometimes that's true. But if you anchor everything to savings, you'll fund whatever pencils out inside five years and leave the people with the greatest need behind. The better measure is well-being, whether people, families, and communities can actually flourish. That covers the moral case, that avoidable suffering counts on its own. It covers the clinical case because people who are housed, fed, and safe respond better to treatment. And it covers the economics without pretending every intervention pays for itself immediately. There are also two findings that should change how we build these services. The first is that savings often lands outside the payer that paid for them and typically later than any single waiver period or test period. The second one often gets skipped. And so the people with the highest need usually aren't the people with the highest spending. So if you design the whole thing to maximize Medicaid's return, you'll aim these services at whoever generates healthcare savings instead of whoever needs them most. So maximizing Medicaid ROI and serving the people with the most need aren't necessarily the same goal. And in fact, sometimes they're the opposite. So really that's the durability problem. The second problem is reach. What does any of this act who does any of this actually get to? So here's a way to think about it. Once you see it, you kind of can't unsee it. Think about the process of health and social care integration as a chain with four links. You identify the need, that's the first link. You refer the person somewhere, that's the second link. You coordinate all of the pieces, that's the third link. And then you deliver the actual service, the food, the rent, the ride. That's the fourth link. And every one of those links costs money and so therefore it needs to be paid for. But here's the pattern across everything we've built. Where a program can serve everybody, it funds some part of the first three links and quits later in the chain, particularly when it comes to the delivery of the services. And where does fund delivery, it only serves a narrow, eligible slice of those in need. Almost no program does both. And as I said, delivery is the piece that is almost never paid for. So let me go through some categories. If we think about health systems, those programs move fast and they coordinate right up to the point of the edge of the hospital's catchment area. So if a hospital discharges somebody to a town where the system has no presence, then the patient's on their own. And the whole thing rides on community benefit business case, which means it's the first on the topping block when a hospital system's margins get tight. Now let's think about payers. Payers have the payment machinery down cold, but the service stops at the edge of the plan's membership. So if you change plans, you lose it, you lose that benefit. And what's covered gets renegotiated on a yearly basis. So whether you have a service this year and whether you have that service next year depends on the renegotiation. Then you've got the federal demonstrations, the referral platforms, the 211 lines, all very useful and important. But the demonstrations are time-limited and mostly don't cover the cost of the service itself. And while the platforms, the referral platforms, move information and sometimes they move payment, they aren't the funder. And 211 provides invaluable information for folks who are looking for services that they need. So they provide the referral, but they may not do the screening and they certainly don't pay for the delivery of the services. Now let's think about the eligibility gates. So we talked through some of the sources of payment and where those limitations are, but let's think about the eligibility components, what I'll call the eligibility gates, because this is the part that really gets me. So if you start with everybody in the country, that's about 340 million people. So think about this kind of as a funnel. So 340 million people go into the funnel. And then the funnel takes out anyone without continuously qualifying coverage. So narrow that to Medicaid, then to the people continuously enrolled, then to the regions that actually have approved waivers for health and social integration programs. Then to the people who have both a qualifying health condition and a documented social need. And then narrow it down one more time to the people who are actually found, screened, and connected to something. Every one of those gates sounds reasonable on its own. But when you stack them together, you take a country of 340 million people and very quickly narrow it down to, on best case scenario, about 1.7 million people who are actually served. And the people who fall out at each gate are often exactly the people with the most need. So people without insurance, rural communities and tribal communities, the family that earns just a little too much to qualify, the daughter who is trying to manage her father's dementia from three states away. There's also a much larger group that the gates never even see. So if your insurance isn't connected to any social care network, then nobody screens you. And your needs never get identified in the first place. You don't get excluded, you stay invisible. So those are two different problems, and payer-based screening solves neither. So there's the diagnosis. Two problems, not one. There's structure, where whole categories of people reach these services only by accident, and there's durability, where the whole thing can be reversed in a single budget cycle or change in administration. Last year wasn't bad luck. It was a stress test. And what we saw is that the patchwork failed. So what's the fix? Let me say it plainly. And then I'll tell you why it isn't a daydream. We build the missing layer, a social care network you can use because you live there, not because you qualified for something. It doesn't matter what insurance you have, what you earn, or what your health status is. It pays a network of community organizations to actually deliver the services. And it draws on enough different funding sources that losing any one of them doesn't shut it down. We've done this before plenty of times for things we decided were too important to gamble on. Public libraries, public health departments, 911, the police department, public transportation. None of them are perfect, but all of them are real. And you use them because you live in the community, not because you qualified. At some point, the country decided that each of those were essential and took them out of the reach of month-to-month discretion. Social care is sitting at the same table right now. And this isn't fantasy because every piece of this system is already built. It already exists. We're not inventing a new tool. We're simply assembling the ones we already have. We need to bring the funding sources together. So federal Medicaid really is only one of eight funding sources and probably should account for just about a third of the funding instead of being the single point of financial failure. The rest is hospital community benefit dollars pooled regionally, state revenue, Medicare Advantage supplemental benefits, employer-sponsored access, philanthropy, private pay on a sliding scale, and federal grants. So Community Care of the Lower Cape Fear, which is in New Hanover County in North Carolina, was one of the regional network leads for healthy opportunities. And at Andromedus, we've worked with them for years. When the Healthy Opportunity Pilots stopped, they did something that's worth watching. Instead of waiting for the state, they started building a universal residency-based network for New Hanover County. So any resident, any payer, any background. It's anchored by the New Hanover Community Endowment, which in June of this year put $2.5 million behind the launch, which was on top of an earlier planning grant of a million and a half awarded last year. In the funders' own words, they see what Community Care of the Lower Cape Fear is doing as possibly the first social care network of its kind in the country. And so while I'm pointing at one organization in one county, let me be clear about what that is and what it isn't. So obviously it's not a national program. It's a test of whether an infrastructure built on Medicaid can be made universal and durable. If it works, it's a template across the country, particularly in states like Washington and New York and California. If it hits walls, then the walls are the findings. And both community care of the Lower Cape Fear and the rest of us across the country can learn from those findings. So I don't want to leave you with a diagnosis and a wish. So I do want to talk about what we can actually do. I see four steps, and they essentially share one principle: build it at the community level and own it there so that no single authority can switch it off. So what does that mean? So let's think about this in steps. If we think about step one, build it first and finance it second. Community foundations should anchor the standup with three to five year grants. Launch capital with an end date, it shouldn't be a forever subsidy. And hospitals should move at least a quarter of their community benefit spending into regional social care pools within the next two years. They already have the discretion. There's no federal or state law that needs to be enacted in order to enable that. Step two, sign up every payer you can. A network built on one Medicaid waiver dies with that waiver. A network that contracts with Medicaid plans, Medicare Advantage plans, commercial plans, and employers at the same time doesn't. Every state already rewrites its managed care contracts on a set schedule, and it can require those plans to meet their social need obligations through the regional network instead of building its own. Step three, change these networks from contractors into public utilities. So right now, a social care network is a vendor or grantee. Both of those rely on contracts, and contracts end. Nobody has to renew one. When nobody does, the network is gone. A fire department works differently. So does a rural electric co-op, and so does a public water system. We decided those services are essential and we put that decision into law. They have to serve everyone in their geographic territory. They can't be shut off because money got tight in one year, and they hold reserves. So a single bad budget doesn't stop a service. States can do the same for social care networks, set up a funding floor they can count on, require them to serve every resident of the region, and have them hold a few months of operating money in reserve. Then a budget fight suspends the argument instead of the services. Then step four, connect the networks to each other instead of waiting for DC to connect in. This is how 211 was built. About 200 independent nonprofits, one shared code, shared standards, and no corporate parent. Regional social care networks can do the same. Share the data standards, the rate floors, and the credentialing. Keep the governance and the money local. That's scale without headquarters. And it holds up whichever way federal policy turns. Which brings me to the point I most want you to keep. Don't wait for DC. What's missing isn't another federal program. It's the conviction that a community can start now with funding already on the table without waiting for the next guidance, waiver, or reauthorization. The last two years taught us that anything built mainly on federal and state authority can be reversed. That's not a reason to walk away from these authorities since every public dollar still flows through them. It's a reason not to hang the whole structure on them. The question isn't whether to integrate health and social care. That's already happening everywhere. And much of it is done by community organizations on a shoestring. The question is whether it hardens into infrastructure or remains a rolling series of demonstrations, pilots, and tests that expire with a waiver, a rule change, or a vote. We've made the harder choice before fire departments, public schools, public health, 911. We decided those were too important to leave to discretion, and social care belongs on that list. Right now, as far as I can tell, exactly one place in the country is trying to build it in a single county by people who decided not to wait. One isn't a movement. Nothing is stopping the next one except somebody deciding to start. And I'd like the next few years to be the point when we stop calling this work a pilot. This has been the Adromatus Way. I'm Michelle Gady. Until next time.

Narrator

Thank you for listening to this episode of The Adromatus Way. This podcast is a production of Adromatus, a woman-owned boutique consulting firm that creates a better way for our health and human services provider clients to achieve their goals by strengthening internal operations, enhancing financial stability, and evaluating public policies. Please follow the show and leave a review. You can find previous episodes and more content on our website, Adromatas Consulting dot com slash Adromatas Dash Way. That's A-T-R-O-M-I-T-O-S. We'll see you next time.