CMS/Medicaid/AHCCCS Potential Role

Reallocating a small portion of Medicaid monies, from adult chronic disease management to early prevention through schools, would dramatically improve health for nearly 40 million children nationally.

These CMS monies could pay for 60 minutes of daily physical activity for 13 years K-12 for each child, as well as adequate amounts of quality physical, nutrition and other health education, school counselors & nurses, and other evidence-based preventive health promotion through schools.

This would be highly effective and broadly supported by the public, as it learns of our widespread child health issues. 

Accountability would be essential.

Developmentally appropriate fitness evaluation, activity measurements with Fitbit-type wrist e-bands, and other health-related metrics through schools would provide immediate on-going feedback, and help schools to continuously improve their instruction and strategies. 

In addition, regularly estimating total statewide health cost savings achieved, by calculating Medicaid and other health plan cost reductions, would help ensure quality implementation, continuous improvement, and on-going political and financial support for school-based prevention.

(Student data must be safeguarded, by only using privacy-protected aggregated-only data for accountability.  Individual data would remain at the school and only available to authorized staff there, with parental consent.)

We all want everyone to become healthier by developing healthier habits.  But it is so difficult for adults to change their behavior.  Doctors keep repeating the mantra of exercising more and eating less, in vain—and so patients end up with on-going chronic conditions, dependent on lifelong meds.  If they even take their meds as prescribed—roughly half of patients do not, according to the Mayo Clinic!

Let’s be honest:  The most cost-effective practical way to achieve such broad health improvement, is by having our people develop healthier habits and become empowered to lead healthier lives, through schools.

What CMS Should Do

Here are key elements, which could be included in CMS policies, in order to support developing much healthier habits and better health outcomes, population-wide, through schools:

Re-allocate:  Allow and encourage, and as evidence accumulates—even require—states to permanently allocate 2% of their existing Medicaid Fund monies to evidence-based K-12 preventive education, with certain mandates and health accountability metrics.

• CMS could possibly even require such investment, as a condition of a state receiving Medicaid funds, or at least of receiving Medicaid 1115 waivers, with the credible rationale that the federal government will not be able to continue paying for the lifelong health costs of epidemic chronic diseases, at the levels projected from current prevalence rates of 1 in 3 teens with prediabetes and 4 in 10 with significant mental health challenges.

Add: The federal government could add 2% to existing Medicaid spending on a particular state, so long as it implements minimum requirements and accountability with quality.

• In the current political climate, these additional funds may not be available, but it is worth keeping this option in mind, since the ROI for the federal government is compelling.

Clinical Results: Improvements in aggregated health outcomes would have to be demonstrated by each state, in order to maintain long-term funding for these child prevention programs.  However, as long as progress is being made, schools and states need to know that these funds will continue.  In other words, CMS must provide decades-long conditional commitments to schools and states.  Since the main condition is health improvements including long-term health cost savings trends, CMS can safely make such long-term commitments, and they should be broadly supported by stakeholders. (See below.)

• This would ensure that preventive education strategies are implemented effectively by states and schools.  After all, Medicaid does not pay for ineffective medical “disease management” treatments.  Indeed, it would be important for the political sustainability of this strategy to show on-going evidence that children’s health is improving.
• Individual student data would need to be kept confidential and privacy-protected.  Only aggregated data, e.g., total before and after outcomes at Medicaid-funded pediatric practices, could be used, both for HIPPA compliance and to maintain parental support.
• Locally aggregated outcomes data could even be correlated to local school implementation for additional accountability and continuous improvement.
• (A longer-term goal is to also measure adult outcomes among parents, since parental components will be added and improved over time.)

Long-term: It is important for this 2% funding to be very long-term.  Health habits and outcomes have been deteriorating for almost 50 years.  We need decades of consistent funding to counteract these trends, and to develop radically different population health trajectories

• The right for a state to re-allocate 2% of Medicaid funds should be guaranteed for at least 20 years, as long as improvements in health conditions and costs persist.  This gives states the time and resources needed to re-build their K-12 physical and health education systems, including the staffing and accountability needed for success and on-going support.

Why “2%”?:  This is calculated as 2% of total Medicaid funding for the state, not just 2% of funding for Medicaid for children and CHIP.  This is population-wide prevention, which must start early in life, yet which will have its biggest benefit in adult health—so adult health dollars must help pay for it.  To properly fund the amount of physical activity and health-related instruction time needed to lay this lifelong foundation via K-12, and to provide the long-term health cost savings (and economic upside) among adults, we need to tap into the full Medicaid budget of each state.

• By the same token, even if new money is not available and the existing budget must be reallocated: by only using 2% of the total Medicaid budget, states would have significant flexibility to re-allocate their remaining budget to preserve health care access and quality for on-going Medicaid enrollees, to compensate for a relatively small amount invested in students through schools.
• In a multi-tens-of-billions-of-dollars budget, anyone can find several hundred million dollars, which are not being invested as effectively as they should be—even if “waste, fraud and abuse” is not necessarily the right term.  2% is an amount that any large budget can absorb, certainly massive statewide public health plans like Medicaid/AHCCCS and private plans like UnitedHealth and Blue Cross Blue Shield, and state legislatures.
• 2% from each of these budgets provides the amount needed long-term to move the needle on sustainably improving health habits among children through schools, with an ROI of at least 10x.[Note:  if a state did not expand Medicaid under the ACA, or if a state loses existing ACA Medicaid expansion monies due to triggers or other reductions after federal cuts, then 2% will not provide as much funding.  Other federal health cuts may also put pressure on state budgets.  Given this, it may be necessary to expand other funding sources.]

Population with Disability:  A major portion of Medicaid monies support adults with physical and mental disabilities. Healthy Students Healthy State addresses this with early prevention, postponing the onset and/or reducing the impact of a number of disabling conditions.

• For example,  according to the Cleveland Clinic, musculoskeletal disorders have been by far the most expensive health care condition (though diabetes is now catching up)– affecting nearly 50% of Americans and costing more than $400B+/year in direct medical costs.
• Developing physical and mental health literacy and healthier behavior with quality physical and health education builds more strength and coordination for all students, with “adapted PE” providing additional evidence-based solutions for many with disabilities.  For already disabled students, adapted physical education can significantly improve health, by tailoring physical education to meet the specific needs of disabled children, and preparing them to better live physically and mentally with congenital or other disabilities.  This develops the knowledge, attitude and behavior they need to continue better health into adulthood, even if their disability continues.
• Physical activity is known to improve executive function and cognition of students generally.  But students with learning disabilities benefit even more than normally developing students in improving those skills needed for better academic achievement.
• All students including those with disability need to learn how to avoid hurting themselves physically, as well as how to recover when they do have an injury.  They can also learn the role and importance of medical staff including physical therapy, so that they are likelier to follow through on health advice from professionals, recover more rapidly, and avoid future injuries when they occur.
• Physical activity also helps dramatically reduce anxiety & depression, including ADHD, and can moderate related severe chronic mental disabilities. 
• Funding adequate numbers of school counselors and nurses through Healthy Students Healthy State will also help with the disabled population.

2% saves 20%:  The Healthy Students Healthy State target is for a 2% Medicaid investment to result in 20% long-term cost savings, compared to what costs will be otherwise without preventive K-12 education, based on current projections.

• This includes significant immediate savings in childhood, given the extremely high levels of ADHD, anxiety & depression, child obesity and prediabetes already in the child population, and the proven effectiveness of physical activity and healthier nutrition in improving health outcomes at all ages.

• Health cost savings estimates should be calculated at least annually.  This helps identify any needs for improvement, as well as providing evidence that funders need to maintain long-term support.  (As long as progress is being made, and shortcomings are identified and corrected, funders must be legally obligated to continue their support.  Otherwise, many interested individuals will not feel comfortable spending the time and money needed to make career decisions and develop the skills to teach health-related subjects and to provide health-related services in schools.)

Mandated accountable investments:  To ensure adequate outcomes, CMS should require a minimum of 60 minutes/day physical activity, minimum 120 minutes/week quality physical education, minimum 60 minutes/week quality nutrition & health education, minimum (1:350 in most cases) counselor-to-students ratio, and probably a 1:750 nurse-to-students ratio.  And each school must develop and annually update a quality local wellness policy plan (LWP), as already required by the USDA for schools participating in the federal school meal program.

• The LWP identifies areas of improvement, which the school needs to work on to improve student health and wellness.  However, LWPs have in the past been notoriously superficial, and ignored by school leadership.  That is not acceptable under Healthy Students Healthy State, as weak or non-implemented LWPs endanger success.)

Local school control:  While the vast majority of Healthy Students Healthy State funds are dedicated to funding minimum amounts of physical activity and enough educator compensation for adequate preventive health-related instruction time, counseling, and nursing, each local school’s particular needs to maximize student health may vary considerably.  We need to allow/encourage schools to define their particular needs in their Local Wellness Policy (LWP), and invest accordingly.

• 10-20% of total Healthy Students Healthy State funds allocated to schools may be used to make these locally determined investments by the school community to implement the school’s local wellness policy plan in evidence-based ways.
• For example, schools may decide to expand services to include after-school physical activity, additional social/mental wellness options including clubs and other extra-curricular activities, and additional parental components.  They may do this together with reliable community nonprofit (and vetted for-profit) partners.  They may also use this money to invest in their particular facility and equipment needs.  This is important, because many schools have neglected these for years, and some urban and charter schools do not have adequate facilities of their own, and may need to partner with others, rent additional facilities, etc.

Arizona including Non-Medicaid Students

In Arizona, about 800,000 children are enrolled in AHCCCS, Arizona’s Medicaid program. When combined with KidsCare/CHIP and other CMS program populations, about half of all children in Arizona qualify for CMS-funded health care!

CMS preventive education funds under Healthy Students Healthy State would be focused on schools with high AHCCCS populations.  To give a rough idea, the majority of schools in Arizona have enough students in poverty to qualify as Title 1 schools, most of which would have a high enough percentage of students on AHCCCS to justify funding Healthy Students Healthy State for the entire school with Medicaid monies.

However, even for schools with primarily middle to higher income families, with few students enrolled in AHCCCS, school health and wellness is also important.  We know that about 1 in 4 middle-income teens have prediabetes, and many students are at-risk of developing chronic conditions in young adulthood.

(Of course, parent rights and individual student health data privacy must be protected, with appropriate opt-out opportunities and safeguards.)

What to do about Federal Medicaid/AHCCCS Cuts?

Many people are concerned about the impact of possible Congressional reductions in Medicaid funding, including AHCCCS in Arizona.  What should be done when major cuts are implemented?

Arizona depends heavily on federal monies for health and human services.  The legislature has been cutting state revenue for decades with tax credits and cuts, now totaling over $8 billion in lost annual state tax revenue.  This leaves Arizona particularly vulnerable to federal cuts. And the legislature, like many other red-state legislatures, is highly unlikely to increase taxes to make up for lost federal monies.

There is a tendency for health advocates to react, by prioritizing restoring lost funds, before supporting new investments.

Whatever happens with federal cuts, the health community needs to focus more on prevention. 

This could be challenging when health care providers, who have focused overwhelmingly on disease management in the past, are hurting from lower federal funding.

But we need to move on from our tendency to hope in vain for restored monies, as if we can return to an earlier era.  We are in a new normal. 

And even when it is hard to do, we need to adopt new strategies for an age of limited state and federal budgets.