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Background

The South Carolina Department of Health and Human Services (SCDHHS) is the single state agency responsible for administering the Medicaid program. SCDHHS currently covers approximately one out of every four South Carolina citizens. As a key player in the delivery of health care across the state, the Medicaid program plays a substantial factor in the state's economy. Therefore, it is important that SCDHHS continually explores and experiments with programmatic changes aimed at maintaining stability in the Medicaid program while improving the health of South Carolina's population.

Improving the health and well-being of South Carolina's Medicaid population is the first step in elevating the state's overall health status. To do so requires looking beyond those factors within the healthcare system and more broadly addressing the social and economic determinants of health status. The Office of Disease Prevention and Health Promotion defines the social determinants of health as:

Conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

In January 2018, the Centers for Medicare & Medicaid Services (CMS) issued guidance announcing an additional avenue for states to address social environment issues. This new policy allows Medicaid programs to incentivize community engagement activities among non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability. These programs, executed through section 1115 demonstration waivers, are intended to promote better mental, physical and emotional health, as well as help families rise out of poverty and attain independence.

A significant body of medical literature and scholarly research supports the link between health status and employment. This includes:

  • Unemployment is generally harmful to health and is correlated with numerous health challenges.
  • Unemployed workers are more likely to have fair or poor health, and to develop a stress-related condition, such as stroke, heart attack or heart disease.
  • Unemployed individuals are more likely to be diagnosed with depression.

A study published in the Disability and Health Journal found that participants with any level of paid employment had a better quality of life and that their self-reported health status was higher and the per person per month Medicaid expenditures were less.

Given the large role that state government plays in influencing the social environment of citizens, especially those dependent on social benefit programs, states must take responsible steps to address these needs holistically. Addressing these factors is a critical aspect of South Carolina's efforts to improve the health of its citizens, reduce the costs of health care and eliminate health disparities.

Given strong evidence that employment and community engagement have positive effects on health outcomes, and in light of support from CMS to implement models that incentivize these activities, SCDHHS proposed the adoption of a section 1115 waiver to institute those activities statewide. On Dec. 12, 2019, CMS approved two separate waivers, the Healthy Connections Works waiver and the Palmetto Pathways to Independence waiver, in response to SCDHHS' waiver application. Both of these waivers are a part of South Carolina's Healthy Connections Community Engagement Initiative.

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