Healthy Opportunities: Worth the Investment? WNC Health Policy Podcast Ep. 10
Photo credit: Towfiqu Barbhuiya
The Healthy Opportunities Pilot, or HOP, is a program that uses Medicaid funding to address some upstream health issues like food access, transportation, housing, and interpersonal violence. By addressing these root issues, the program hopes to both improve health outcomes for North Carolinians, saving them and the state money. In the last budget, money was set aside to support this program. However, despite being approved last December and on the Governor's budget, the North Carolina General Assembly has removed HOP funding for the next two years, and the pilot programs like Impact Health are required to wind down their services, expecting a total shutdown by the end of the month, June 2025.
This raises an important question for North Carolina: What will the state be gaining or losing by removing HOP?
In this short series of the Western North Carolina Health Policy Initiative podcast, we'll be taking a look at this pilot program from a few perspectives to help educate our listeners and policymakers about what's on the table. Today we'll look at an evaluation of HOP to better understand how the program is working and its impact on the state's bottom line.
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About the WNC Health Policy Podcast: In each installment, we speak about different public health strategies for improving health and well-being in Western North Carolina (WNC). The WNC HPl is a collaboration between the NC Center for Health & Wellness at UNCA and MAHEC, with generous support from the Dogwood Health Trust.
Individual opinions, findings, conclusions, or recommendations expressed in this podcast are those of the author(s)/interviewee(s) and do not necessarily reflect the view of the WNC Health Policy Initiative or its host institutions of the University of North Carolina Asheville (UNCA), Mountain Area Health Education Center (MAHEC) or our funders.
Transcript
AR: Andrew Rainey (WNC HPI)
SB: Seth Berkowitz (University of North Carolina)
Resources:
“Medicaid Spending and Health-Related Social Needs in the North Carolina Healthy Opportunities Pilots Program” by Seth A. Berkowitz, MD, MPH1,2; Jessica Archibald, MSA1; Zhitong Yu, MPH1; et al (Journal of the American Medical Association) https://jamanetwork.com/journals/jama/article-abstract/2830892
NC DHHS Healthy Opportunities Pilot infopage: https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities
Impact Health: https://impacthealth.org/
INTRO
[Sound of a creek running]
Seth Berkowitz: I think the people who are involved in this work day to day know the good that is being done when someone who didn't have healthy food to eat gets a healthy meal, that their health is going to get better, they're going to feel better, their overall situation is going to change. I think people know that, you know, being able to put people in the community to do this kind of work when they want to and the desire is there to do it when that funding comes and people are able to help support each other. That's just kind of a good thing for everyone.
[Banjo music plays]
Andrew Rainey: You're listening to the Western North Carolina Health Policy Initiative Podcast, a collaboration between the North Carolina Center for Health and Wellness at UNCA and MAHEC, with generous support from the Dogwood Health Trust. I'm Andrew Rainey. In each installment, we speak about different public health strategies for improving health and well-being in Western North Carolina. Recorded on the flickering Internet waves of mountainous Appalachia, in this installment we'll hear about the results of the Healthy Opportunities Pilot program evaluation.
NC BUDGET SUMMARY
AR: This summer, North Carolina's House and Senate will be working to finalize our biennial budget on June 30th, beginning July 1st, 2025 and covering the next two fiscal years. One of the biggest contested areas is the impact of the budget on Medicaid programs. With the rebase not expected to cover current cost and the loss of other health programs, North Carolinians are wondering how the budget will impact our health. Inside this budget is the fate of what's known as an Innovative Pilot Program across three regions, including Western North Carolina: the Healthy Opportunities Pilot, or HOP.
HOP is a program that uses Medicaid funding to address some upstream health issues like food access, transportation, housing, and interpersonal violence. By addresAsing these root issues, the program hopes to both improve health outcomes for North Carolinians, saving them and the state money. In the last budget, money was set aside to support this program. However, despite being approved last December and on the Governor's budget, the North Carolina General Assembly has removed HOP funding for the next two years, and the pilot programs like Impact Health are required to wind down their services, expecting a total shutdown by the end of the month, June 2025.
This raises an important question for North Carolina: What will the state be gaining or losing by removing HOP?
In this short series of the Western North Carolina Health Policy Initiative podcast, we'll be taking a look at this pilot program from a few perspectives to help educate our listeners and policymakers about what's on the table. Today we'll look at an evaluation of HOP to better understand how the program is working and its impact on the state's bottom line. Joining me is Seth Berkowitz, an Associate Professor of General Medicine and Clinical Epidemiology at the University of North Carolina Health Medicine, with expertise in both research and evaluation of interventions to address health related social needs. Seth is one of the lead researchers on one recently published evaluation on Medicaid spending in the Healthy Opportunities Pilot.
EVALUATING THE NC HEALTHY OPPORTUNITY PILOT
AR: Thanks for joining me, Seth.
SB: Thanks for the kind introduction. Thanks for having me on the podcast.
AR: So the Sheps Center has been doing an evaluation of the Healthy Opportunities Pilot to see if it's been impacting health and what that cost. Could you give us a little background on what the Sheps Center is?
SB: Yeah. So the Sheps Center is a health services institute within UNC. It's a transdisciplinary center, so it doesn't live in any, you know, particular school or department, and brings together people with different expertise, medicine, public health, economics, health policy, and those kinds of things. My work in particular is largely focused on issues that you might call health related social needs - so things like food insecurity, housing and stability, transportation barriers, how those affect health outcomes, and how interventions to address those issues might improve health. In the Sheps Center, we often will work in partnership with North Carolina Medicaid, evaluating different programs and initiatives.
And so HOP, the Healthy Opportunities Pilots is one of those initiatives that North Carolina Medicaid is doing under what's called 1115 Waiver Authority: So the federal government grants a state the ability to do some new and innovative things with its Medicaid program to better address the health of Medicaid beneficiaries. But part of that is that it needs to be evaluated and determined whether it actually is having the anticipated impacts that people hope it will have. In this case, we have been evaluating those efforts.
AR: Who all is on the team doing this evaluation?
SB: Yeah. So that's a great point. These are big projects, they're very much team efforts. It's not anything that anyone person can do alone. Just on the evaluation side - so not all the people involved in actually running HOP and delivering services and doing the important work - but on the evaluation side, we have a team of five co-investigators with expertise in different areas, like health economics, implementation science, pediatrics, qualitative research. And so some of the people who are involved in that work, and these are the co-authors on the paper, are Marisa Domino, Kori Flower, Maihan Vu, G[uarav] Dave.
We also have a strong team of research assistance and project managers who are doing a lot of the data collection you, making sure things work. And then also data analyst Jessica Archibald and Zhitong Yu, Myklynn LaPoint and Salma Ali have all put lots of time into making these kinds of evaluations possible. And again, that is honestly really just scratching the surface when you think of all the people within North Carolina DHHS and all the people in Western North Carolina and the other regions of the state delivering services, as well.
AR: Can you give a little background for listeners on the rationale for why the Healthy Opportunities Pilot was created in the first place?
SB: Yeah, so, the rationale of the Healthy Opportunities Pilots overall is that for many people - not just Medicaid beneficiaries but in this case specifically for Medicaid beneficiaries - the health services that people buy and pay for with tax dollars and other things may not work as well as they could when people are also facing other threats to health. You know, as an example, say you have diabetes and you’re prescribed medications to lower sugar. That can be very effective. But if you're unable to afford healthy foods, you might not be getting the full benefit of those treatments. And so the medical care that is being used just isn't having the effect that it could if you were to address some of these other issues.
And so HOP is a network of intervention options that can address some of these barriers that are not things that traditional medical care has usually tackled, but that still have a really important impact on health. And the idea behind HOP is that by addressing these things, you could make healthcare work better and produce better health outcomes. And so the purpose of the evaluation was to see whether that idea actually bears out in reality.
AR: So what did you all find in the evaluation? Did the HOP approach show that healthcare would work better and create better outcomes for those who are eligible to enroll?
SB: Yeah. So I thought we found some results that really were in support of the underlying conceptual model of HOP - the idea that by addressing some of these issues, people will be healthier both on their own and by making the healthcare itself work better. So we found that HOP was associated with lower use of emergency department visits. It looked like HOP was probably associated with lower hospitalizations, as well. And then when those kind of expensive forms of healthcare utilization decrease, you might expect that there is a decrease in healthcare spending, and that bore out as well.
AR: That's really promising. So HOP has been improving health outcomes for folks enrolled and as a result also cause Medicaid healthcare spending to go down.
I can imagine HOP cost a little bit up front, so I wonder if you could describe a little bit more how the spending plays out and where the savings are?
SB: Yeah, so we followed people for up to a year after they enrolled in HOP. People can be enrolled for different periods of time, obviously. Some people, you know, they're may have their needs stabilized fairly quickly and then they no longer need to receive services. Other people may need to be on the program longer. But overall, we followed people for up to a year after their enrollment date. And what we find is that around the times that people enroll in HOP, starting even before they actually enroll in HOP, healthcare spending starts to go up, suggesting that people are enrolling in HOP because they're in a form of crisis or worsening health, bad social circumstances that is leading to increased spending. That higher spending continues for a little bit of time after enrolling as sort of things get stabilized, but then we see a declining trend in spending over time, suggesting that the program is helping to resolve some of these issues.
And when we compare other Medicaid beneficiaries who also have similar health related social needs, but are in different parts of the state and thus don't receive the HOP services, what we see is what's called a differential spending trend - meaning that if you take the other people, estimating what we think would have happened had folks in Western North Carolina not had access to HOP. Spending was lower than we think it would have been in the absence of the program, again suggesting that it's improving health. And when we? Say spending. We looked at both medical spending but also spending on the services itself. And so even accounting for the amount that is being spent to deliver the food and other things like that, we still see a lower trend suggesting that people's health really is improving and they're just not needing these more expensive healthcare services despite getting HOP services, which people did actually get the services. It wasn't just that they enrolled in the program, but then never heard from anyone. People did receive services, there was spending on services. But even accounting for that, we still saw a decreasing spending. Trend.
AR: Could you give us some exact figures like the dollar saved from implementing this initiative after those initial cost to get things up and running?
SB: Yeah. What we found was that the decreasing trend in spending was about $85 per person enrolled in HOP per month. So you can multiply that out for a year. So that's the difference between what we think would have been spent on medical care for people had they not received HOP versus what was spent on medical care into direct services after at the time that people enrolled in HOP.
AR: Regarding that comparison of projected money saved versus the money actually spent, could you describe the research design a little bit to tell us how you determined that money was actually being saved?
SB: Yes. So we're very concerned about showing that the results are not just due to random chance. They aren't things that would have happened anyway even if you didn't have the program. And in North Carolina, HOP was only implemented in certain areas of the state. So Western North Carolina had HOP, and two parts of eastern and southeastern North Carolina had HOP. But a lot of other areas of the state did not have it. And from an evaluation perspective, what that meant is that there were people in fairly similar circumstances to the people who did receive HOP who didn't just based on where they happened to live in the state. So they were also Medicaid beneficiaries, they also had health related social needs that would have qualified them for HOP had they been in areas where it was offered, but they just weren't able to get the program for these sort of administrative reasons.
And so that gives us what in research we call a “good estimate of the counterfactual.” What we think would have happened had people not been able to receive HOP. And so our analysis was designed to compare people in HOP to what our estimate, our best guess would have been, in terms of what would have happened had they not been in HOP, and having people who were in very similar circumstances, but just in slightly different parts of the state let us have a good estimate of that compared with many other types of studies, we think. And so for that reason, we have high confidence that, you know, the results that we're seeing are more likely to reflect the actual impact of the program, rather than things that just would have happened regardless of whether the program was there or not.
AR: What are some of the implications of these results, whether on the state’s decision to continue the program or otherwise?
SB: HOP did get renewed as part of the overall Medicaid 1115 waiver renewal. I think some of these findings were helpful in that process for showing the benefits of the program in terms of trying to decide whether to continue the program or not and it supported that.
I do think there are learnings at the national level. You know, Medicaid is available in all 50 states, but is a state-run program, and so it can be very different in different states. And many states at this point are trying to address health related social needs, like food insecurity, as part of their Medicaid programs, but HOP is still fairly unique in its comprehensiveness, and in the way that it did so. And I do think North Carolina is seen as a national leader with his experience, and I think there is a lot that was learned in North Carolina that other states are making use of, as well. And so I think there's both the impact in North Carolina in the region specifically where HOP is - you know, Western North Carolina certainly is a key one - but also nationwide as well.
AR: As you finish this evaluation for the pilot and there's a look at what expansion of the program can look like, how will evaluating the next phase of Healthy Opportunities look?
SB: Yeah, we think the goals broadly are similar in the continuation. So, the hope is that HOP will be expanded to more people throughout the state of North Carolina. Details for that are still being worked out, and of course it depends on legislative appropriations to be able to do that. But the state did receive the authority to do it statewide and is trying to do that. The Governor's budget proposes funding for HOP, amongst other things, to expand the number of people who can have access to. But I think we're always learning about what services are more effective and how things can be refined. And so there likely will continue to be iterations there about how to deliver services, who may benefit most from them, how to provide them, you know, more efficiently and effectively, and so likely will continue to be some changes as things go on. But overall, I think, from a perspective of building on success, basically.
AR: Do you think implementation across the entire state, rather than in these specific pilot areas, will change how well the program works?
SB: Yeah, I think it's a great question. I actually think the way that the Department of Health and Human Services has designed the HOP program helps to mitigate some of those concerns. The way that HOP works is that in each region in which HOP operates, there's what's called a network lead, an organization that helps to coordinate the network of services that will be delivered, and then they work with what are called HOP administrators - insurance plans or others who, you know, patients have Medicaid benefits through, and access the programs in those ways. And the state recognizes that there's not one state level way to do this, it's going to be regional. And so even as the program may expand to additional regions, that same structure will be maintained.
And so the network leads operating in Western North Carolina will continue to operate very similarly there. It's just that other regions of the state might establish their own network lead and their own network of organizations to provide services.
So I think the overall structure will be very similar and you'll essentially still have a number of regional programs even as the coverage in terms of the proportion of the state covered increases. And so I think you're right. Anytime a program grows and scales up, there is always potential for change, and there's just sort of potential for change over time anyway. But I think the design maintains a lot of the elements that seem to be working well, at least in the initial go-around.
AR: Despite the successes you've found, it seems that at the moment there hasn't been funding allocated to the HOP for the next two fiscal years. Have you seen very much interest from state legislators in the results of the evaluation?
SB: So the results on the health of Medicaid beneficiaries are of course very important, and I think legislators are very interested in that. These are people who live in their districts and that they're representing, and so they obviously want them to be healthy.
I think the other thing that our evaluation doesn't speak to, but I think is very salient and is kind of obvious almost anyone when you think about it, is the impact of HOP spending on local communities.
So you know, our evaluation, because it's CMS, the organization that runs Medicaid for the federal government, you know, they're interested in the effect it's having on Medicaid beneficiaries and so that's sort of what this evaluation is. But think about the spending on HOP services, you know - if you're spending money to provide healthy food, there's a benefit to the actual Medicare beneficiary themself. But there's also a community-based organization that is employing people in the community that are providing that. They may be purchasing the food from local farmers, and so it's strengthening local food systems. It's providing jobs in the area.
And so I think, you know, a lot of people are seeing these local impacts on the economic situation in Western North Carolina and other parts of the state through HOP spending that go far beyond the benefit to Medicaid beneficiaries, as important as those are. And that's I think another thing that people pay attention to.
AR: We heard that there is the direct return on investment from reduced ER visits and that sort of thing earlier. But what I'm hearing is there's also this ROI of improved economic activity on the local level, suggesting the phrase, “you gotta spend money to make money.”
SB: Yeah. I mean, I think…you know in economics, there’s this concept of the money multiplier, meaning that when you spend a dollar it doesn't mean that a dollar is destroyed, it can actually generate even more economic activity than that initial dollar. So this number isn't specific to HOP or anything, but in general evaluations of things like Medicaid expansion or just sort of healthcare services in general have found money multipliers greater than one, meaning that a dollar spent on services like HOP might generate $1.50 or $2.00 in economic activity. And so you're actually pushing things forward and stimulating the local economy through providing these services again, in addition to all the health benefits which is the primary justification for doing these programs,
AR: What's coming up for future work on this evaluation?
SB: I'm certainly interested in looking at the summative evaluation results for the initial version of the HOP program. We're sort of working on those numbers now. We'll probably have double to maybe even more than double the number of people that we had, and so we'll really let us on home in on some more questions in detail. We've got good data on aggregate things, but when you start going into specific groups - age with this clinical condition, and living in this area - yeah, it gets a little small. And so now we have more people to look at those things. So I'm really interested in that.
I'm very interested to see how more people may be able to access HOP over the next five years, because of the authority to expand it. I certainly hope that the state, you know, recognizes the value that it HOP is providing through, you know, legislative appropriations and enables those services to keep going out to North Carolinians who really can benefit from it and also benefit North Carolina communities at the same time.
AR: How can folks find the full results?
SB: Yeah, so the full report is publicly posted on the North Carolina Medicaid website. If you search North Carolina Medicaid HOP, there's a whole web page about the HOP program, and then there's an evaluation and reporting section. And so this is the full 100+ page report that has been reviewed and approved by CMS and is all there publicly. All the math is there, all the charts and figures are there, so you can kind of see everything there.
The paper that was published in JAMA in February, that I think is paywalled and so you know that may need a library access or something like that to get to it. But the full report that that paper draws from is totally free and open to the public, publicly posted on the North Carolina Medicaid website.
AR: Any final thoughts for folks before we close up?
SB: I think the kind of secret to success in HOP has been that there's a strong network of community-based organizations to provide these services. You know, these are at their heart local programs, it's neighbors helping neighbors basically. And you know I think we're involved in sort of the academic work and almost the “bean counting” in a sense of tallying up, what does that mean?
I think the people who are involved in this work day to day know the good that is being done when someone who didn't have healthy food to eat gets a healthy meal, that their health is going to get better, they're going to feel better, their overall situation is going to change. I think people know that, you know, being able to put people in the community to do this kind of work when they want to and the desire is there to do it when that funding comes and people are able to help support each other. That's just kind of a good thing for everyone.
You know, again, I think these programs work because there are networks of caring individuals who are good at helping other people and really want to make that happen. And so I think everyone involved should take pride in the good work.
AR: That's being done if listeners want to discuss the results with you or your team members, how could they?
SB: So I'm Seth Berkowitz at the University of North Carolina at Chapel Hill. All the contacts and everything are there, so always happy to talk with. Folks.
AR: Thanks for giving us a breakdown on this evaluation to give listeners a better sense of this health policy as legislators consider whether or not to keep funding it.
SB: Thanks for having me on the podcast. Great discussion.
OUTRO
AR: You've been listening to the Western North Carolina Health Policy Initiative Podcast, a collaboration between the North Carolina Center for Health and Wellness at UNCA and MAHEC, with generous support of the Dogwood Health Trust. To listen again or learn more about public health issues in Western North Carolina, check out the website at wnchealthpolicy.org, or listen to more of our shows on Apple Podcast or Spotify.
If there's a Western North Carolina health issue that you'd like to hear more about, speak about or have comments about anything you've heard on an HP I podcast, feel free to send us an e-mail at info@wnchealthpolicy.org, or write a comment on wherever you listen to podcasts.
Music in this podcast includes “Old Ballad” and “Little Margaret,” performed on banjo by Kath and Phil Tyler, found on the Free Music Archive, is licensed under an Attribution Non Commercial Share Alike 3.0 United States license. Additional music on the podcast included the track “Some Nights End” and “Night Watch” by the Blue Dot Sessions. These tracks are found on the Free Music Archive under license Attribution International CBY 4.0.
Stay tuned to our next episode where we'll hear more about HOP from the Western North Carolina Network lead Impact Health, service provider Caja Solidaria, and a participating family:
Caja Solidaria: I'm out delivering food and I go visit my friend, let's say it's Joe, right? And what's Seth’s’ data shows is exactly Joe's story, that we have this peak in healthcare costs early on and then those costs taper off so that we actually end up saving money.
Impact Health: It's also less costly than when Joe has a full blown heart attack, meaning a quadruple bypass. That's a very expensive form of care, and it doesn't improve quality of life or health outcomes. So that's another aspect of which kind of care do we want to pay for.
HOP Recipient: I think like with the Healthy Opportunities Pilot for my family, it means the food that we get each week, you know, it's been a huge, huge help.
AR: Remember that you can always reach out to your representatives in the House and Senate to offer your two cents on the future of health policy in North Carolina. During the month of June 2025, that includes the opportunity to amend or revise the budget during their legislative sessions. Thanks for listening.
Connect with your elected leaders to express your views at the links below:
