Springtime by Salem Lake

A revolution is breaking out where you’d least expect it: North Carolina. This one started as an accident, as many do. The McCrory administration pushed through a commitment to outsource the NC Medicaid program to managed care organizations, then caught its gender-appropriate appendages in the bathroom door and got laughed out of office the next election. Democrat Governor Cooper couldn’t reverse the policy, but his Secretary of Health Cohen got the national HHS to approve a tweaked version focused on the “social determinants” and accelerating the integration of mental health.

This is once-in-a-generation change in the relationship between the government (city, county and state), the large healthcare providers, public health, social service and the rich ecology of community organization and entities. This bets many billions of dollars on social science relying on a complex array of policy, practices and people negotiated and aligned very quickly.

All of this has to work somewhere first. So, way down in the weeds of the policy is a $650M experiment piloting the social sector integration in a few multi-county regions, one of which is likely to include the rolling hills of the Piedmont ,where FaithHealth happens to live. We’ve been meeting for a year, but last week about 140 people from the hospitals, government and social sector spent a day figuring out what this might mean. We gathered at Salem Lake, a city reservoir that earlier civic minds had created so that the citizens could drink clean water. We think the same way about helping our most vulnerable find other things as important to health.

I am amazed that the winding path of Medicaid transformation has led to this opportunity align and connect these sectors differently. And this pilot comes with enough money to do something new at scale : $2-300M to the social sector partners—not hospitals.

Two caveats give pause. First, while this should be enough cash to do something new, it is only about 20% beyond the run-rate of the social sector in these counties today. It is possible—even likely—that those millions would disappear like water into hot sand, merely filling in the current gap in funding that every social sector organization struggles with already.

Secondly, the money is still tethered to medical Medicaid. It is for members of the program who will experience “case management” for social stuff just as they do for pills. A doctor with a computer prescribes social things from a short list.

Here’s a science tip about social determinants. They are social. If they are not social, they do not determine anything. The state has identified four kinds of “healthy opportunities” to aim hundreds of millions of dollars at very narrow set of predetermined services. They will not be healthy, if the money just triggers computer-directed interventions at people with no names living on streets with no names. Social.

This bold—and noble—social experiment is taking place very early in the field of social determinants. We’ve discovered that you can put social indicators in our computers and spit out lists of things that are missing in hopes that people will cost less and do better. People are not things who just need things. We humans need, above all, to have other humans in our lives when we enter a time of dependency, on our friends, family and the kindness of strangers, such as insurance companies. Wires fool us into thinking we are doing social when we are just doing wires.

Most human phenomenon are more complicated then they seem at first touch. Our current phase of engaging “social determinants” –healthy opportunities—is rather like adolescent sexual opportunities, which are experimental and clumsy. It gets better when the relationship does.

Salem Lake is ringed by a wooded seven-mile trail because when the citizens needed water, they built a dam and let the forest grow. In early spring you can see the wounded and down trees amid the tall ones. The loam through which the rainfall moves to the lake is from oaks long past. The trees are why the lake is clean. There is another way: you can clean all the crap out of the water with machines and chemicals rather like a hospital does with ill populations. That mind would see the trees as 2×4’s standing as a poorly organized lumber-yard.

James C. Scott, writing about the German Black Forest, described this as “seeing like a state,” which are usually not smart about how living systems produce trees and healthy humans. Citizens and neighbors have to be smarter.

Nobody in the room behaved normally, beginning with Mayor Joines who was the one to guide the leadership of the pilot toward the Piedmont Triad Council of Governments where Blair Percival flipped his skills honed with senior programs toward the moms and kids of Medicaid. All three health directors were involved even though Medicaid is not theirs. Tim Gallagher, a former Deloitte consultant now working through the NC Association of Free Clinics under Randy Jordan (who is helping the free clinics understand their stake in Medicaid transformation). Jamilla Pinder opening with a personal story that turned all the professionals into humans. Hospital folks saying “we.”

The piedmont of North Carolina has been integrating medicine into social and vice versa since the Moravians came South on the great wagon road a quarter millennia ago. One of those 14 men was a physician smart and humble enough to learn herbal wisdom from the Cherokee. The Greensboro Quakers and High Point Methodists had their own way. It is now a crazy quilt of government, schools, industry with layers of immigrants finding how to blend into the old neighbors. The forest of assets mingle and dance with possibilities.

The Medicaid pilot is an invitation to think to the limits of what works and then reach beyond. It would be silly to expect one five-year pilot to heal all the wounds of poverty and race with only $200 million. It won’t do that. For one thing, the members of Medicaid don’t stay in the program very long. Four out of five “churn” in and out every year. Any one of them is a moving target. But while the individuals move, the phenomenon of poverty does not—it pretty much stays in the same, obvious, known neighborhoods. Medicaid, which is still tied paying for services to its members, can’t break the cycle of poverty, because that phenomenon is social. It happens to types of people living in neighborhoods. The current Medicaid challenges are the best our system can do at this time, but not tuned to the real drivers of cost and care.

We should be grateful for what we have to work with, but not expect this one program to do all we hope for. It doesn’t need to. Dr. Kevin Barnett, who keynoted at Salem Lake suggested that if we get the relationships right, we could unleash way more to weave with. Getting the social, governmental, health and faith systems into alignment would all by itself free up another $200 million worth through efficiencies and synergies currently trapped in our siloes. Then, we might be able to see the neighborhoods as places ripe for investment in affordable housing and economic development.

Hospitals are required to have hundreds of millions of dollars in the bank to guarantee their reliable operations. They can’t give it away with current thin margins. But Wake Baptist, Novant and Cone’s could put 2% of their required investment corpus into community-smart development corporations focused on the neighborhoods that matter most. That would put another $200M in motion—a healthy opportunity, indeed. Forward thinking banks and corporations, of which the Piedmont has many, could see the opportunity to add to the momentum with employment and training.

This is thinking like citizens, not merely professionals trapped in our disciplines and jobs. Seeing like free citizens, we can realize how much we have to work with.

I’ve had enough birthdays (and another one Saturday) to know what is likely to happen. Expensive water disappearing into hot sand. On Saturday we watched Camelot with one eye and the Mueller report with the other. The people in Raleigh who opened the possibilities of Medicaid also seem to see our neighborhoods less than potential 2×4’; more like mulch for their golf courses. But you may remember that Camelot ends with Arthur claiming victory because one young boy ran free from the cynicism to tell of a time when it was possible to do the right thing and the right people did.

I’m uploading this on Easter, which reminds me that we believe even stranger things have happened.

This is just us citizens, choosing to be more than professionals trapped in our disciplines and jobs. Seeing like free citizens, we can realize how much we have to work with.