COUNCIL OF THE DISTRICT OF COLUMBIA
The John A. Wilson Building
1350 Pennsylvania Avenue, nw
Washington, D.C. 20004
Christina Henderson Committee Member
Councilmember, At-Large Hospital and Health Equity
Chairperson, Committee on Health Judiciary and Public Safety
Transportation and the Environment
Statement of Introduction on the
Social Determinants of Health Spending
Amendment Act of 2024
November 8, 2024
Today I am introducing the Social Determinants of Health Spending Amendment Act of 2024.
This bill will allow private insurers and Medicaid Managed Care Organizations to allow
spending on select social determinants of health to count towards their medical loss ratio, thus
encouraging insurers to invest in the non-medical needs that we know significantly affect health
outcomes.
The conditions in which people are born, grow, work, live, and age greatly influence a person’s
health.1 Those conditions, also known as social determinants of health (SDOH), are the non-
clinical factors that have an outsized influence on health outcomes. Medical care is estimated to
account for only about 20% of contributors to a person’s health outcomes and SDOH account for
the other 80%.2 These determinants are also key drivers of health inequities; a lack of equal
access to social and economic benefits, including adequate nutrition, community-based
programming, and housing, put people, especially the District’s Black residents and other People
of Color, at higher risk of poor health and premature mortality. This is especially apparent in the
District of Columbia, where Ward 7 and 8 residents have disproportionately lower access to both
social services and medical care, and a significantly shorter life expectancy compared to
residents of other Wards.3
One strategy the District has to address these non-clinical health outcomes is to involve the
Health insurers. Health insurance companies are required by federal and District law to spend at
least 80% of their premiums on medical care and quality improvement, as calculated by a
Medical Loss Ratio (MLR). The MLR is the percentage of health insurance premiums that an
insurer spends on patient care and quality improvement, over what they keep for administrative
costs and profits. However, the way the District law is currently written, spending on SDOH for
beneficiaries is generally counted as an administrative expense, and thus doesn’t count towards
the 80%.4 Medicaid managed care organizations can individually request to count SDOH
services as a “value-added service” to their MLR numerator, but this process is not widely used
and complex. With this legislation, the District would join several other states to expand their
1
https://www.cms.gov/priorities/innovation/key-concepts/social-drivers-health-and-health-related-social-needs
2
https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/
3
https://disb.dc.gov/sites/default/files/dc/sites/disb/publication/attachments/her_summary_report_final_with_letter_and_table_02_08_2019.pdf
4
https://www.commonwealthfund.org/publications/issue-briefs/2017/nov/addressing-social-determinants-health-through-medicaid-
managed#:~:text=Social%20Determinants%20and%20the%20Medical,as%20opposed%20to%20administrative%20costs.
 COUNCIL OF THE DISTRICT OF COLUMBIA
The John A. Wilson Building
1350 Pennsylvania Avenue, nw
Washington, D.C. 20004
medical loss ratio framework to include both medical and select social determinants of health
services. Including both private and Medicaid managed care organizations would mean parity for
insurers and more equitable access to services for residents. This legislation is timely as the
Department of Health Care Finance is considering the framework for the District’s 1115
Medicaid Waiver to address SDOH, and the SDOH named in this bill are intended to mirror
those in the 1115 waiver., including health services and case management for justice-involved
populations in their reentry process, housing support, and a variety of nutrition services.
I look forward to working with my Council colleagues and other stakeholders to advance and
pass this legislation which will help improve health care outcomes in the District.
 1
2 ______________________________
3 Councilmember Christina Henderson
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5
6 A BILL
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8 _____________________
9
10
11 IN THE COUNCIL OF THE DISTRICT OF COLUMBIA
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13 ________________________________
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15
16 To amend the Reasonable Health Insurance Health Insurance Ratemaking and Health Care
17 Reform Act of 2010 to allow private insurers and Medicaid managed care organizations
18 to include expenditures for certain social determinants of health services in their medical
19 loss ratio.
20
21 BE IT ENACTED BY THE COUNCIL OF THE DISTRICT OF COLUMBIA, That this
22 act may be cited as the “Social Determinants of Health Spending Amendment Act of 2024”.
23 Sec. 2. Section 103 of the Reasonable Health Insurance Ratemaking and Health Care
24 Reform Act of 2010, effective April 8, 2011 (D.C. Law 18-360; DC Official Code § 31–
25 3311.02), is amended as follows:
26 (a) A new subsection (a-1) is added to read as follows:
27 “(a-1) An insurer may include specific evidence-based expenditures related to initiatives
28 that address social determinants of health in the numerator of their medical loss ratio calculation
29 when the initiative is designed to improve the health of District residents and to reduce health
30 disparities. Eligible expenditures shall include:
31 “(1) Initiatives addressing food insecurity and nutrition education;
32 “(2) Services promoting access to community-based programs for justice-involved
33 individuals upon reentry; and
34 “(3) Supporting continuity of care for populations experiencing housing instability.”.
35 (b) A new subsection (g) is added to read as follows:
36 “(g) For purposes of this section, the term “social determinants of health” (SDOH) means
37 the conditions in the environments where people are born, live, learn, work, play, worship, and
38 age that affect a wide range of health, functioning, and quality-of-life outcomes and risks; SDOH
39 refers to community-level factors, as defined by the Centers for Medicare and Medicaid
40 Services, as adapted from the Centers for Disease Control and Prevention Healthy People 2030
41 definition.”.
42 Sec. 3. Fiscal impact statement.
43 The Council adopts the fiscal impact statement in the committee report as the fiscal
44 impact statement required by section 4a of the General Legislative Procedures Act of 1975,
45 approved October 16, 2006 (120 Stat. 2038; D.C. Official Code § 1-301.47a).
46 Sec. 4. Effective date.
47 This act shall take effect following approval by the Mayor (or in the event of veto by the
48 Mayor, action by the Council to override the veto), a 30-day period of congressional review as
49 provided in section 602(c)(1) of the District of Columbia Home Rule Act, approved December
50 24, 1973 (87 Stat. 813; D.C. Official Code § 1-206.02(c)(1)), and publication in the District of
51 Columbia Register.