Executive Summary

Efforts to improve health in the U.S. have traditionally looked to the health care system as the key driver of health and health outcomes. However, there is broad recognition that improving health and achieving health equity will require approaches that address the social, economic, and environmental factors influencing health. [1] For example, education can influence health in many ways. People who have a higher level of education are more likely to practice health-promoting behaviors such as exercising regularly, refraining from smoking, and obtaining timely checkups and screenings. Accordingly, they have longer life expectancies and are likely to experience better health outcomes.[2]

This report focuses on education and workforce development, two of the six areas of the social determinants of health outlined by the Kaiser Family Foundation.[3] It describes the health impacts faced by Medicaid enrollees who are unable to obtain a job due to a lack of education or job skills and provides an overview of federal policies in education, labor, and Medicaid targeted at individuals with low incomes. Finally, it highlights the work of four Association for Community Affiliated Plans (ACAP)-member Safety Net Health Plans (SNHP) that have helped members in obtaining their GED, a job, or both.

SNHPs have invested in interventions that support educational attainment and meaningful employment among Medicaid enrollees. Interventions operated by SNHPs are directed at the very populations also served by other critical, federally-operated programs focused on labor and education, but often are developed and run separately. Medicaid plans are building an evidence base demonstrating that these interventions, if done in a meaningful manner, positively impact the health of Medicaid beneficiaries, but find that intersections between health coverage, education, and labor policy, as well as funding that could facilitate useful programming, often do not exist.[4]

The health plans featured in this report, along with their local health and education departments, local governments, and community-based organizations, have taken it upon themselves to create innovative programs to assist Medicaid beneficiaries in obtaining employment or furthering their education.


“Education is the single most important modifiable social determinant of health…income and education correlate most strongly with life expectancy and most health status measures.”

Education’s power as a social determinant of health is resident in the doors it unlocks to future well-being.[5] Educational attainment not only can predict employment and income, but also can influence where someone lives—and whether they can afford health care. For example, the health of people who leave high school without a diploma can be adversely affected by their inability to get a job that offers health benefits, putting them at higher risk for a number of health-damaging conditions, such as high blood pressure, diabetes, asthma, and heart disease.[6],[7]

Education is linked with health through three interrelated pathways: health knowledge and behaviors, employment and income, and social and psychological factors.[8] Education can increase people’s knowledge and cognitive skills, enabling them to make better-informed choices among the health-related options available to themselves and their families. Higher educational attainment is linked with higher-paying jobs, which allow individuals to live in environments encouraging and enabling healthy behaviors. Additionally, better-paying jobs offer greater economic security and increased ability to accumulate wealth, enabling individuals to obtain health care when needed.

One in four American adults without a high school diploma is enrolled in Medicaid.[9] Despite rising high school graduation rates, disparities in such rates persist among racial and ethnic groups. Although the U.S. high school graduation rate was 84 percent in 2016[10], Latinos, African Americans, and American Indian and Alaska Natives lag behind Caucasian students. According to Terri Wright, Director of American Public Health Association’s Center for School, Health and Education, “We know those who drop out of high school are most likely to practice risky behaviors as adults and are most likely to have multiple health issues as adults.” Therefore, federal health officials made high school graduation rates a priority in Healthy People 2020, outlining goals to increase education and quality of instruction for children.

This report briefly outlines how some education and labor policies focus on populations similar to the covered Medicaid population, explores how SNHPs provide support for education and employment activities for Medicaid enrollees, and provides policy recommendations to address the issue.


Federal Medicaid, Education, and Labor Policy Targeting Low-Income Individuals

The Medicaid program was initially designated as a federal-state program to cover medical expenses for the aged, blind, and disabled individuals, parents and dependent children receiving public assistance. Medicaid beneficiaries include many of the most disadvantaged individuals in the United States in terms of poverty, poor physical and mental health, disability, and lack of social supports.[11] According to the Kaiser Family Foundation, in 2013, the majority of beneficiaries covered were women and children. When Medicaid was expanded to cover individuals ages 18-64 with incomes at or below 138 percent of the Federal Poverty Level in 2014, 1 in 5 Medicaid beneficiaries qualified for the program via its expansion.

Federal Medicaid law sets broad requirements for states, mandating coverage of some populations and benefits, leaving many others optional. States then make policy and operational decisions needed to determine eligibility, covered services, and payment settings. This is all captured in the state plan, which requires approval from the Centers for Medicare & Medicaid Services (CMS) as a condition of federal funding.

Medicaid demonstrations allow the federal government to approve state approaches to financing and delivering Medicaid coverage that fall outside existing statutory requirements.[12] States have used 1115 demonstrations to provide targeted benefits to individuals with HIV/AIDS, mandate enrollment in a specific capitated managed care plan, and implement cost sharing for certain populations. Section 1115 authority is also used to negotiate program parameters rather than to create experiments focused on answering specific research questions.[13] Recent research shows that states use Section 1115 demonstrations to incentivize or require Medicaid health plans to provide supports to individuals, including assistance related to education and employment.[14]

The Trump Administration has approved Section 1115 demonstrations in several states that restrict eligibility and enrollment for expansion adults, including conditioning eligibility on meeting work or “community engagement” requirements. CMS maintains that employment leads to improved health outcomes, and policies that condition Medicaid eligibility on meeting a work requirement will further this objective. Though the structure of Medicaid work requirements is similar to those used in other programs, such as Temporary Assistance for Needy Families (TANF), the Administration’s stated goal of improving health through Medicaid work requirements is different from the goals of welfare reform work requirements in the past, which were to strengthen self-esteem and provide a ladder to economic progress.[15]

Certain federal Department of Labor and Department of Education policies target populations similar to those Medicaid serves.[16] The Carl Perkins Vocational and Technical Education Act, first enacted in 1984, has evolved with the goal of matching student needs with the current and emerging needs of the economy.[17] Perkins V, the Strengthening Career and Technical Education for the 21st Century Act, became law in 2018. Notably, it includes provisions for helping special populations – individuals with disabilities, individuals from economically disadvantaged families, including low-income youth and adults, single parents (including pregnant women), homeless individuals, and youth who are in or have aged out of the foster care system, individuals who are likely also to be served by Medicaid.[18] Similarly, federal workforce development programs have served as a policy solution for many of the same populations, addressing unemployed individuals’ needs in obtaining jobs.[19] The Workforce Innovation and Opportunity Act of 2014 (WIOA), iterations of which have existed under varying federal statutes and titles for several decades, is a collaboration between the U.S. Departments of Labor and Education, prioritizing low-income people who meet a number of conditions, some of which are parallel to Medicaid eligibility parameters.[20],[21]

ACAP raises these policies to observe that there potentially is fertile ground for intersections of policy and funding for Medicaid, education, and labor, particularly as more Medicaid programs and Medicaid health plans develop interventions focusing on employment and educational attainment. However, as we describe on the following pages, SNHPs serving the Medicaid program often operate and fund educational and labor support interventions at their own cost, motivated by an observed need among covered enrollees, independent of direction from these policies and funding sources.


Case Studies

Throughout the last few years and especially in post-recession years, SNHPs have heard from their members about the importance of being employed. Between 2007 and 2009, the national poverty rate rose from 13 percent to 14.3 percent, and the number of people below the poverty line jumped by 4.9 million. [22] Although the Great Recession technically ended in 2009, its effects on some segments of the population have lasted, with unemployment levels and household incomes slow to return to pre-recession levels.[23] In large part due to this environment, Medicaid enrollment increased rapidly between federal fiscal years 2007 and 2012, from 42.3 million to 54.1 million. Spending on medical services (excluding administrative and other non-service spending) rose from $292.7 billion to $383.6 billion during the same period – an average annual increase of 5.6 percent.[24] Consequently, SNHPs have been working with community partners to aid their members in obtaining work.

For example, Kern Health Systems (KHS), the local Medi-Cal health plan and largest plan in Kern County, California, serving approximately 251,000 enrollees, provides resources and referrals to its members based on their needs through a care management team. KHS staff provides referrals to members regarding employment, job training, appropriate job interview attire, adult school, and English as a Second Language (ESL) courses. To facilitate a warm hand-off for members, KHS has developed close working relationships with various community partners such as family resource centers, community colleges, county departments, and American Job Centers.

In addition to providing resources and referrals, health plans have developed innovative education and vocational support programs to aid their members in obtaining employment. The following case studies highlight programs that have been implemented by four SNHPs across the nation. Their work shows how health plans not only play their traditional role of providing health coverage, but also provide additional services well beyond the scope of traditional health care.


Community Health Choice

Community Health Choice (Community) is a local, not-for-profit managed care organization in Houston which serves more than 400,000 members across Southeast Texas.

In 2017, Community established a new Life Services team within the Community Affairs Department to create initiatives surrounding social determinants of health. The team identified three priority initiatives that focus on social factors greatly influencing its membership: early childhood development, job training, and education.

Community laid a foundation for its career program by creating a scholarship program that covers all tuition, books, and supplies for eligible members to attend Houston Community College with the goal of completing a job certification program, such as a certified nurse assistant, medical scribe, or occupational therapy assistant. The objective of this program, CareerReady, is to help members achieve economic independence through furthering their education and career trajectory.

CareerReady’s mission is to open opportunities for educational advancement for certain Community members, including high school seniors and pregnant women between the ages of 18 and 30. Community hopes to help these participants succeed through addressing the social needs that may influence employment and academic performance.

CareerReady participants are assigned a life coach who helps members by:

  • Providing assistance to overcome any hurdles faced while applying for college;
  • Making connections to community resources to address social needs such as food, clothing, housing, and transportation;
  • Build program participants’ soft skills including conducting mock interviews and resume editing;
  • Assisting with the employment search; and
  • Providing participants support during their enrollment in school and their first years of employment.

In its pilot year, Community partnered with the Association of the Advancement of Mexican Americans (AAMA) Sanchez Charter School, a local charter school. Community worked with high school counselors and career advisors to recruit students eligible for the scholarship. To engage pregnant women for CareerReady, Community promoted the scholarship opportunity via email, postal mail, and social media to eligible members. During the program’s pilot year, Community accepted 35 people, 12 high school seniors and 23 pregnant women. Thirty-two members remain in the program at the time of this report.

For the coming year, funding to accept 40 CareerReady scholars has been provided by Community using its surplus.


CareSource, one of the fastest growing not-for-profit managed care plans in the United States, serves nearly 2 million members in Georgia, Indiana, Kentucky, Ohio, and West Virginia. CareSource currently serves Medicaid, Medicare Advantage, dual-eligible, and Marketplace consumers with a member-centered and integrated approach to care.

CareSource’s underlying mission to make a lasting difference in the health and well-being of those it serves prompted leadership to expand the scope of what that truly means given the reality of members’ everyday lives. After holding a series of focus groups aimed at identifying the greatest needs of its members, education and employment surfaced as two of the greatest obstacles in members’ lives, preventing them from focusing on health and other aspects of well-being. In response, CareSource in 2015 launched Life Services with a renewed mission to make a difference with a proactive socioeconomic focus and strategy to remove barriers to care.

JobConnect, a key component of Life Services, operates in Ohio, Indiana, and Georgia, and was the first step toward building a comprehensive population health model. Through intrinsic community and employer partnerships, Life Services builds a coordinated network of supports around individuals with financial, education and employment needs. Specifically targeting education and employment needs, JobConnect focuses on developing members’ job readiness skills and secure connections to long-term employment.

JobConnect is a voluntary program for CareSource members. Members who opt in to the program are assigned life coaches who come from the communities they serve and who have built partnerships with local agencies. Life coaches help members identify strengths and prioritize areas that need reinforcing, including emotional support, food stability, child care, or physical health. Once needs are identified, life coaches coordinate and connect members with community services such as food banks or transportation vouchers. Life coaches may also assist members eligible for public assistance with managing state and federal resources such as TANF or the Supplemental Nutrition Assistance program.

Once immediate needs have been met, members are connected with education or employment opportunities to help them increase skills and obtain connections to long-term employment. Life coaches seek to understand the job needs and preferences of members to better prepare them for employment and work with members for up to 24 months to help them navigate the work world and educational resources such as free computer classes and enrollment programs. Life coaches also prepare the member for their loss of government subsidies, increase their financial literacy, and map out future career steps.[25]

Notably, CareSource serves parents or guardians of child-only cases who are not themselves enrolled in Medicaid. Children in lower-income families have an increased likelihood of developing a variety of serious chronic health problems, and poor children typically experience worse health outcomes than other children with chronic health conditions. Disparities in health status between richer and poorer children increase throughout childhood; poorer children tend to enter adulthood with the disadvantage of worse health.[26] CareSource has found that offering JobConnect services to parents in need of employment services, even if they are not members of CareSource – is beneficial to entire families, not just the adults. For every parent that earns a high school diploma or GED, their annual earnings increase 37 percent; on average, from about $27,000 to $37,000 per year.[27]

Observing that many of its Medicaid enrollees in Georgia do not have a high school degree, CareSource initiated a program to help members obtain either a diploma or GED. JobConnect in Georgia refers members to specific GED training programs via partnerships with local agencies and higher education institutions, and not only pays for the cost of taking the exam, but provides additional non-emergency medical transportation benefits for members to attend the test preparation course. This enhancement to the GED benefit directly addresses common transportation barriers found across rural Georgia, reinforcing the power of simultaneously providing GED availability and transportation access.

CareSource members learn about Life Services and JobConnect through the CareSource website, referrals made through community partnerships, clinical providers, community events and career fairs, and internal referrals through the CareSource case management team.

One of the factors driving the success of the JobConnect program is the direct feedback CareSource obtains from their Consumer Advisory Council, comprising former CareSource members who completed the program and successfully gained employment. The Advisory Council provides recommendations to the Life Services leadership on the program and offers suggestions for program improvements.

Since the inception of the program, 2,870 members have enrolled in JobConnect. As of this report’s publication, 441 CareSource members actively work with a life coach in Ohio, along with 178 in Indiana and 175 in Georgia.

The program is 90 percent funded by CareSource; the rest comes from outside grants for all three markets. The goal is to make the program fully sustainable with external funding.

The success of Life Services’ direct impact in individual lives speaks for itself: in 2017, CareSource observed a 20 percent decrease in emergency department visits among JobConnect participants, a 27 percent decrease in inpatient stays, an increased number of wellness visits, and an increase in pharmacy spend by members participating in the program. The program measurably demonstrates that by addressing the socioeconomic needs of individuals first, you open the door to greater improvements for health and well-being.

Amida Care

Amida Care is a not-for-profit community health plan that specializes in providing comprehensive health coverage and coordinated care to Medicaid members with chronic conditions, such as HIV/AIDS and behavioral health disorders. Amida Care currently serves approximately 7,000 members throughout the five boroughs of New York City, including people living with HIV/AIDS; people who are experiencing homelessness, regardless of HIV status; and people of transgender experience, regardless of HIV status.[28] Amida Care currently operates two employment support programs for its members.

Workforce Initiative Network. In 2014, the Workforce Initiative Network (WIN) was launched in partnership with two community organizations, Housing Works and The Alliance for Positive Change. Amida Care entered into two pilot partnership programs for vocational training services for Amida Care members. Amida Care’s WIN was designed to give Amida Care members marketable job skills by completing a six- to seven-week training program at either Housing Works or The Alliance.

Both curricula were designed by their partnering organizations in collaboration with Amida Care, and include the following trainings:

  • HIV/AIDS education;
  • Resume building;
  • Basic computer skills.

Upon completion of the vocational training program, Amida Care members graduate with basic job readiness skills that will enable them to gain employment in part-time Community Health Outreach Worker positions at HIV community-based organizations. WIN aims to help lay the foundation for individuals to return to the job world by providing skills, training, recovery education and support services. Upon program completion, graduates return to the workforce equipped with the skills to fulfill the roles of health navigators, administrative assistants or community health outreach workers. While the Alliance, Housing Works, and Amida Care assist in job searching and resume building, placement is not guaranteed after the completion of WIN for all program graduates. Graduates are encouraged to take the new skills they have learned and apply to jobs on their own.

To be eligible for WIN training, individuals must be enrolled in Amida Care and must have been actively engaged in care with a primary care provider or HIV specialist for at least six months. All candidates are required to complete an application, an interview, or an orientation session with The Alliance, Housing Works or Amida Care staff.

Currently, Amida Care hires individuals trained through the WIN program as Community Health Outreach Workers (CHOW) and Health Navigators. Each CHOW works 19 hours or fewer weekly, to ensure that their social service benefits are not interrupted for the first year of employment. CHOWs conduct an array of services: they perform intensive outreach for 30 days to members who have been deemed lost to care or tenuously engaged in care, conduct needs assessments including new member orientations and HIV risk assessments for Transgender and Gender Non-Conforming members, refer and connect members to appropriate providers or provider sites, schedule initial appointments with identified providers, escort members to initial appointments as indicated, facilitate transportation access assessments and assistance when needed, follow up with members to assure their engagement in services and the appropriateness of service sites, participate in biweekly case conferences and departmental meetings to identify barriers to care and assist with the development of interventions as appropriate. CHOWs are supervised by the Manager of Outreach Programs, a Master’s Degree or Licensed Social Work position. Amida Care currently employs seven CHOWs.

Since its inception, 340 Amida Care members have been referred to the WIN program, 90 individuals have graduated, and 38 have received placement at Amida Care, The Alliance, Housing Works, and other community-based organizations in Community Health Outreach Worker work positions. Amida Care pays for WIN with plan administrative funding.

The Consumer Workforce Innovator Project. Amida Care’s second employment support program aims to help consumers – regardless of their enrollment in Amida Care  – to gain livable wage employment in New York City. The Consumer Workforce Innovator Project is supported by funds from New York City Council and contributes to New York State’s Ending the HIV/AIDS Epidemic 2020 initiative. Funding has been renewed for the past three years. The project harnesses the skills and life experiences of consumers and builds the capacity of community-based safety-net health care providers. It provides ongoing fiscal and technical support to the hired members and to contracted community providers that employ them. The program’s ultimate goal is to move consumers towards livable wage employment and private health insurance coverage. To support this goal, the program works with community safety net providers to create lasting consumer positions within the community that add significant value to patients.

All workers have a shared experience of living with HIV/AIDS, living with Hepatitis C, or accessing harm reduction services. They have obtained or are working toward NYS Department of Health AIDS Institute’s employment readiness certification, the CHOW Certification. These workers possess a unique understanding of the challenges faced by health care consumers living with chronic conditions. They can translate their own experiences into strategies to help patients engage with health care providers and take actions to improve their health.

Each hiring agency selects which consumer workers to hire and decides in what capacity to employ them, depending on the needs of their clients. Health care providers benefit when consumers use their lived experience to link other Medicaid recipients – including those living with HIV – to care. Providers can bill for Medicaid-covered outpatient services accessed by individuals who would otherwise remain out of care. This also helps avoid more intensive, more expensive care, such as emergency room visits and hospitalizations, potentially resulting in cost savings to the Medicaid program. As of this report’s publication, 31 CHOWs participate in this program.

Amida Care reimburses provider sites for 50 percent of the total cost of consumer workers’ employment for the first year and 25 percent in the second year. After the second year, the workers’ positions are fully funded by the provider sites through increased revenues.

AmeriHealth Caritas

AmeriHealth Caritas was founded in 1983 at a West Philadelphia hospital and has grown into one of the largest Medicaid managed care organizations in the U.S. Today, AmeriHealth Caritas ACAP member plans serve more than 600,000 Medicaid enrollees in Florida, Louisiana, and Pennsylvania.

AmeriHealth Caritas’ mission to build strong, healthy communities goes beyond health care. For several years, AmeriHealth Caritas has developed initiatives to address social determinants of health for its members, recognizing that education is a major component to addressing social disparities and correlates with health status. AmeriHealth Caritas observed that a major barrier for its members in obtaining employment related to educational attainment: people who lack a high school diploma or equivalency have a harder time obtaining a job. More than 1 in 5 of Medicaid enrollees enrolled in AmeriHealth Caritas ACAP plans lacks a high school diploma or its equivalent.

In 2014, AmeriHealth Caritas launched its Mission GED program to help members who do not have a high school diploma earn a high school equivalency certificate by passing the GED or HiSET exams. The Mission GED program offers members the tools and support they need to earn their certificate to further their education and reach their goals. AmeriHealth Caritas has partnered with local adult literacy agencies who provide exam preparatory classes. AmeriHealth Caritas provides vouchers to members to cover the cost of the pre-test and GED or HiSET exams.

The path to obtaining a high school equivalency is long, with multiple exams in reading, writing, math, science, and social studies required to earn a high school equivalency certificate. Once members are enrolled in classes, they are connected to an AmeriHealth Caritas program coach who works with members through graduation. The program coach provides ongoing support to help members continue their coursework, serving as a source of encouragement and a resource to help members navigate barriers.

The Mission GED program is open to all enrolled AmeriHealth Caritas members over age 18 who do not have a high school diploma or equivalent. Members learn about the program through AmeriHealth Caritas member outreach activities and referrals from community organizations. More than 1,000 members have participated in the program to date.

The Mission GED program is solely financed by AmeriHealth Caritas.


Policy Recommendations

A central theme throughout the case studies is that because these interventions do not meet Medicaid definitions of “medical services,” SNHPs invest in employment and educational supports out of plan administrative funds or seek support from private investors, local governments, and community organizations. Whether future sustained use of plan administrative funding for these interventions is possible is unclear, given the countercyclical nature of Medicaid and other pressures on health plan finances. In addition, common types of external funding such as grants are not assured, particularly over the long term. Ensuring the longevity of employment and educational supports by Medicaid health plans will require an exploration of sustainable funding sources, including

  • Flexibility under Section 1115 demonstrations,
  • Outcomes-based payment for social determinants of health interventions, and
  • Agency collaboration at the federal level.

CMS may consider approving demonstrations that increase investment in and access to targeted social determinants of health interventions and work- and education-related supportive services. This focus is consistent with the general push toward value-based payments, upstream prevention, and cross-sector collaboration.[29] States could work with their contracted Medicaid managed care plans to come up with a meaningful innovation model that meets their residents’ needs, which could be piloted via a Section 1115 as shown in the case studies.

Pay for Success (PFS) is one tool that can be used to finance initiatives aimed at addressing the social determinants of health. Today, governments bear all risk for programs intended to serve the public interest. PFS allows private entities to pay for the outcomes associated with social determinants of health interventions, rather than paying for actual encounters.[30] The model establishes outcomes-driven contracts between government and service providers, with up-front capital from private funders.[31] The funded entity or entities repay the private investor if a rigorous evaluation shows that the intervention has successfully improved some predefined outcomes.[32] PFS is an example of how evidence-based policymaking and strategic thinking within government systems could help deliver better health outcomes and contain rising costs.


A 2017 national survey of Medicaid managed care organizations conducted by the Kaiser Family Foundation demonstrates that over 90 percent of plans operate some type of social determinants of health intervention for their enrollees. Many such interventions, such as the employment and educational supports described in this paper, are not defined as “medical services” in Medicaid statute or regulation. Accordingly, health plans, states, and the federal government have not used traditional Medicaid reimbursement to fund educational and employment interventions, despite what in these early stages appears to be efficacy in containing health care costs and improving health outcomes. It has often fallen to SNHPs to fund these types of services on their own, or to seek funding from external grants or local governments to operate these programs. It is incumbent on the Medicaid policy community to evaluate efforts to support employment and educational attainment among Medicaid enrollees, as well as other social determinants of health interventions, determine which are effective and why, and work toward a plan to ensure programmatic and financial sustainability.