States Develop New Approaches to Improve Population Health Through Accountable Health Models

In this time of changing federal health priorities, state health policymakers play a crucial role in breaking the cycle of poverty and inequity so everyone can live healthy, prosperous lives. Many state leaders, with federal support, are implementing community-wide prevention initiatives that acknowledge that health is affected by factors that extend beyond clinical care. Policymakers are also fostering innovative strategies to promote community engagement so low-income, disadvantaged individuals and families help define community health priorities so all may achieve and maintain health.

In Brief :

  • Accountable health structures are community-based entities that invest in, or are accountable for, population health improvement.
  • This brief highlights policy levers, performance measurement strategies, and sustainable financing options that states can use to support accountable health structures.
  • State accountable health entities are often built into health system transformation efforts and provide a strategic framework for states seeking to integrate health-related social needs into their health systems.
  • These states work across agencies and sectors to improve population health, advance prevention, and reduce health disparities.
  • State accountable health entities can take a range of forms. Some — such as Health Equity Zones — focus only on community-based interventions, while others — such as accountable care and coordinated care organizations — contract with Medicaid to provide direct clinical care.

To improve population health and health equity, states are working across Medicaid, public health, and other agencies to develop accountable health structures. State accountable health models — both currently operating and those in development — fall along a continuum. All of them promote healthy communities through community partnerships, but some contract with Medicaid agencies to provide health care services directly to individual Medicaid beneficiaries, while others focus only on community-based interventions.

In October 2017, the National Academy for State Health Policy (NASHP) convened state health officials representing 10 state accountable health models to discuss strategies for using accountable health structures to promote population health. Participants also discussed strategies to assess these structures’ impact on health, determine their return on investment, and develop sustainable funding approaches. The following are some of the key strategies that they identified:

  • Use states’ policy and contracting levers to address prevention and health-related social needs in payment and delivery reform. States can leverage Medicaid managed care contracting, build on the flexibility available through Section 1115 demonstration waivers, and maximize State Innovation Model (SIM) investment in population health to focus efforts to improve health.
  • Align population health goals, agendas, and, where possible, metrics across communities, payers, and stakeholders. Accountable health structures are most effective in reaching their goals and engaging stakeholders across sectors when they work toward shared goals.
  • Use data and measurement to raise the bar on performance, and consider financial incentives to address prevention and health-related social needs. Some policymakers suggest identifying a unified, small set of metrics that can be used across various systems and are tied to payment and accountability and based on community outcomes as well as provider outcomes.
  • Work across sectors and agencies to develop a range of financial strategies to support investment in prevention and community health. Identify any gaps and duplication in funding streams. States can bolster the resilience of their accountable health structures by braiding and blending funds across agencies and seeking private sector investment. Cross-sector financial mapping of health-related programs and services can ensure that federal funds support activities that align with state priorities.
  • Learn from other states’ value-based payment roadmaps and lessons learned. Instead of reinventing the wheel, state policymakers can adopt and adapt other states’ tools to fit their state’s needs.

Next Steps
As state and federal policymakers seek opportunities to promote good health and its associated benefits, initiatives that enable communities to set public health priorities and maximize resources will be critical. States with active accountable health structures will continue using available policy levers to advance their goals, from improved health and equity to lower medical costs and economic sustainability. Information about the viable strategies and experiences of these states will help policymakers use available funding and policy levers to craft their own sustainable accountable health entities that achieve measurable long-term success to improve population health. NASHP will continue to convene these states, drill down into their experiences, and share lessons so other states may develop accountable health models in the future.

Related Resources
To read NASHP’s in-depth reports on accountable communities for health that explore initiatives in states including California, Minnesota, Vermont, and Washington, please visit:

Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.