Episode 4 of The 80 Million Podcast: Addressing Social Needs in Medicaid — The Evidence Is In. Now What?
States need to move out of the pilot mindset and integrate interventions with strong evidence into their Medicaid programs.
This blog is based on a recent The 80 Million Podcast conversation with the authors — Rajaie Batniji, Patti Boozang and Mandy Cohen — exploring what the latest evidence on addressing social needs in Medicaid means for policy and practice. The discussion examines why the case for action is stronger than ever, what it takes to scale these interventions, and where states can move now.
Authors: Rajaie Batnjji, Patti Boozang and Mandy Cohen
Editor: Amanda Eisenberg
tl;dr
The evidence that addressing social needs like food, housing and transportation improves health outcomes and reduces Medicaid costs is no longer theoretical. We’ve seen recent data from two efforts: North Carolina’s Healthy Opportunities Pilots (HOP) generated $164 in savings per member per month, according to a new, multiyear evaluation of 31,000 Medicaid enrollees by the Sheps Center at University of North Carolina. The Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities model showed 3%–4% reductions in total cost of care through screening and navigation alone.
Payment remains a major structural barrier. Most of this work — outreach, navigation and coordination — has no billing code under fee for service. Scaling requires value-based arrangements with real teeth, not the “value veneers” that occupy value-based care real estate without changing care delivery. Waymark, a Medicaid-focused care delivery company, addresses this by pairing AI-enabled community-based care teams with value-based contracts designed to measure impact and align payment with proven intervention.
States don’t need to wait for federal action. Managed Medicaid contracts allowing for accountable programs that meet social and clinical needs, using in-lieu-of services authority, and directing rural health transformation dollars toward this infrastructure are all available now. Still, permanent scale will require Congress to move this work from waiver territory into the core Medicaid benefit.
The 80 Million Impact
A disproportionate share of Medicaid spending is driven by a relatively small group of people with complex medical and social needs, which the traditional health care system was not designed to meet. For years, the idea of addressing social drivers of health through Medicaid felt promising but unproven. That era is over.
Two models are paving the way for national innovation.
In North Carolina, HOP is one of the strongest real-world demonstrations that addressing social needs through Medicaid can improve outcomes and reduce costs. The 1115 waiver initiative, which ran primarily in rural areas and reached 38,000 residents, generated $164 in net savings per member per month, which is inclusive of the cost of service and administrative overhead. It also helped navigate people through the enrollment process for benefits they were already eligible for but not yet receiving. More than 40% of North Carolina Medicaid beneficiaries were eligible for SNAP but not enrolled — a gap that was both a health failure and a financial one. That waiver was also approved during the first Trump administration, a reminder that the policy has never been particularly partisan.
Nationally, the CMS Accountable Health Communities model, which ran from 2017 to 2023, screened more than 1 million Medicare beneficiaries for five core social needs — food insecurity, housing instability, transportation, utility needs and interpersonal violence — and provided referral and navigation support to help people connect to services. These interventions led to 3%–4% reductions in total cost of care, per a final evaluation of the program released earlier this year.
Emerging models supported by Waymark, which combines AI-enabled risk stratification with community-based care teams and social needs navigation for rising-risk Medicaid patients, suggest even greater savings may be possible through targeted early interventions.
The implication is straightforward but often misunderstood: the system is already paying for failure to address social needs through avoidable emergency department visits, hospitalizations and fragmented care. Addressing social needs is not a new cost center but rather a way to reduce existing inefficiencies while improving health.
What It Takes to Scale
Implementation is where the theory meets the hard reality. North Carolina’s experience offers a clear lesson: This cannot be done by any one sector of the health care ecosystem. Health care facilities, food banks, housing providers, transportation networks and social services agencies speak different languages, operate on different timelines, and historically have had little reason to coordinate. Building that coordination takes deliberate infrastructure — and someone has to be the quarterback. NCCARE360, a statewide closed-loop referral platform, was initially created with philanthropic funding to knit those partners together into one unified support program.
The single-platform decision was critical: asking a food bank or a community charity to log into a different portal for every managed care plan or hospital system would never work. One platform for the whole state made coordination feasible for the smallest community organizations, which are often the ones with the closest relationships with the people who need help most. For states wondering how to start, the North Carolina model suggests that philanthropy can serve as the seed capital for infrastructure that Medicaid and managed care dollars can eventually sustain.
The Medicaid payment structure is the bigger barrier. Most of the work that makes these interventions effective — outreach, navigation, coordination and care management — doesn’t have a billing code under the fee-for-service model. Health plans with value-based arrangements may satisfy regulatory requirements but don’t change care delivery: an obstacle the panel dubbed as “value veneers.”
Waymark’s approach is to build randomized controlled trials into its value-based contract structure to both demonstrate impact and align incentives properly. The company works with hard-to-reach Medicaid enrollees and improves access to care through community health workers, pharmacists, therapists, and care coordinators. Getting to real impact sometimes requires unwinding those arrangements first, which takes time and trust.
Moving Forward
The federal policy picture is evolving, and it’s not clear that the direction is a positive one for social needs intervention in Medicaid. Some key CMS guidance has been rescinded, leaving states uncertain about where the Trump administration stands. But the underlying support is likely more durable than the policy signals suggest. HOP was approved under the first Trump administration, and the Make America Healthy Again agenda’s focus on food, nutrition and lifestyle-driven health is aligned with the evidence base for social needs interventions. The case for Congressional action to make navigation and social needs services a permanent Medicaid benefit rather than a demonstration program is strong, and it is one of the few places where the evidence base and multiple political priorities actually point in the same direction.
In the meantime, states have more tools available than they may realize. Social needs screening can be embedded in managed care contract renewals today. In-lieu-of services authority can fund these services without a full 1115 waiver, and the $50 billion Rural Health Transformation Program creates opportunities for states to transform care delivery — and give communities the interventions they need to thrive.
The Bottom Line
Listen to the full conversation of The 80 Million Podcast on Spotify, Apple Podcasts or wherever you get your podcasts to hear how states can address social drivers of health in Medicaid, what North Carolina and Waymark have learned about implementation, and what states can do right now — without waiting for Washington.
And don’t forget to subscribe to The 80 Million Podcast.