To Work and To Love—Health in Theory and Practice

Sigmund Freud said, “Love and work are the cornerstones of our humanness.” That insight—that productive labor and positive human relationships improve one’s physical and mental health—is part of the increased interest in health care’s role in addressing the social determinants of health. The absence of these factors—such as economic stability, safe neighborhoods, access to education and healthy foods, and social connectedness—are commonly considered to be the cause of 20% to 40% of premature deaths in the country. A steady job can positively influence a number of these factors in readily apparent ways.

While the role of health care providers in helping their unemployed patients gain and retain work is attracting more attention, recent personal experience has shown me that, for some, the leap to work and health can be wide and is only bridged with hard work and passionate commitment by others.

Freud’s analysis was probably not the driving force for the five state Medicaid agencies that received permission from the Center for Medicaid and CHIP Services (CMCS) in the last 18 months to add work requirements as a condition for eligibility for selected Medicaid beneficiaries nor for the 10 other states with similar requests in the queue at CMCS. But even if only 6% of adult Medicaid recipients nationally are either not working or not eligible for a medical exemption—the targeted population for work requirements—the current Medicaid work requirements discussion has cast a light on the positive contributions work can make to a sense of civic engagement and commitment.

In response to this heightened interest in the relationship between work and the health of individuals and communities, CMCS has clarified that Medicaid funds cannot be used to pay beneficiaries’ wages, but can pay for employment counseling as an optional benefit—to help people get jobs. Years of experience with work requirements for the Supplemental Nutrition Assistance Program, Aid to Families with Dependent Children, and populations with disabilities have developed the evidence for what is needed to help different populations find and keep jobs.

So will states that are thoughtfully implementing a work requirement—and those committed to addressing the social determinants of health—take up Medicaid’s guidance? Perhaps, but it will still take years of experience and experimentation as well.

It turns out that the daughter of a friend is experiencing that first hand. Newly graduated from college, Ruth is working in a community health center (CHC) in Washington State as an employment counselor.  Her CHC is a provider of supported housing and employment services in the state’s Foundational Community Supports program, one of three parts of its five-year Medicaid Transformation Demonstration.

While supported housing and employment services are not new optional Medicaid benefits, there is a growing interest in Washington and other states in assessing their effectiveness for broader patient populations and in new delivery settings. If patients whose medical needs are costly can gain employment and improve their health, Medicaid programs and local communities both benefit.

To receive employment counseling in Foundational Community Supports, a Medicaid beneficiary must meet medical necessity criteria, and have a disabling condition, a behavioral health diagnosis, or already be receiving long-term services and supports through Medicaid.  Under the benefit, recipients are counseled using the Individual Placement and Support (IPS) model, a widely-tested intervention for people with serious mental illness.

Ruth was trained in the IPS model, paired with more experienced staff, and started seeing clients. With the CHC billing for her services, she books appointments, screens people for eligibility for the program, and obtains prior authorization to provide services.  “My daughter is now a Medicaid provider,” my friend chuckled.

As clients embark on a job search, Ruth helps them identify barriers to employment—like missing identification, housing and legal issues, and transportation—and addresses them, often with the help of others on staff. She administers health screening questionnaires and sets clients up with medical services at the center. She helps them identify and apply for jobs, facilitates interviews, and works with employers. Mostly, it seems, she gives them hope.

So how is it working? “These aren’t happily ever after stories,” she says ruefully.  Even in a strong economy and with access to a local program that uses private funds to pay people to work up to 100 hours at one of several welcoming local employers, getting permanent jobs is tough, and Ruth reports few full-blown successes.

Early data from the Washington State Health Care Authority says 96% of the 1,400 people receiving supported employment services so far have indicated a need for behavioral health services in the last two years and 49% report a need for substance use disorder services in the same period.

As a result, it should not be surprising that many clients are unable to keep appointments. Others are seen in several different settings, and case managers struggle to coordinate services.  One client was so upset at his regular appointment that all Ruth could do was alert his therapist who was seeing him later that day. Another client found work, but then was laid off because of a health problem. The seasonal and temporary nature of much of the available work triggers bouts of depression even in some of her most motivated clients.

Foundational Community Supports has been in operation across the state for less than a year and will continue for three more years. The state and providers will learn more from one another and from experience with “implementation fidelity”—how to hew to the IPS model. As required by the Feds, a third party with evaluate all components of Washington’s Medicaid transformation efforts.

These evaluations are essential to the waiver experiments and there is evidence  CMCS is relaxing its standards for them. Perhaps Washington will be able to point to an objective number of “happily ever after stories” as a result of this work to justify providing supportive employment counseling as an ongoing benefit for all or a subset of Medicaid beneficiaries in the program. Maybe some types of providers will prove more effective in delivering this service than others: Will locating supportive employment services in health care settings coordinate other services or will it limit access? Perhaps the real lessons will be about the adverse events that created the disabling conditions that make some people so hard to employ and how these events can be prevented.

To keep us healthy, a paycheck is better than a prescription pad. But helping some people find employment and build healthy relationships takes hard work and passion on the part of others—policymakers, administrators, and service providers, like Ruth and her colleagues. This cycle of experimentation and evaluation must continue. If we want to help those who are hard to employ find work—either to fulfill Freud’s dictum for individuals or public desires for merit and civic engagement—we will have to keep learning from the work—and the love—in places like Washington State.