The U.S. healthcare system struggles to deliver better health outcomes, yet we spend more per capita on healthcare than any other country. Medicaid, a lifeline for one out of five Americans, is under immense pressure, with rising costs and a potential wave of funding cuts in 2025. These challenges demand that we rethink how we care for the most vulnerable who often face significant health-related social needs and are often disconnected from traditional healthcare pathways.
I propose a “Three-C Strategy” built around Care, Community, and Cost. This model addresses systemic barriers and helps Medicaid and dual-eligible members to take control of their lives and their health. It’s a proven model that our company has developed and has continually refined over the last decade for the top 3-5% of healthcare users, including children.
The keys to success of this multi-pronged strategy are deep engagement, trust building, and addressing the whole person. And yes, in many ways, it’s the exact opposite of today’s traditional healthcare model.
Care: Knocking Down Personal, Social and Medical Roadblocks
At its core, the Three-C strategy is about care. Holistic care. It starts with Health Risk Assessments to identify each person’s needs and develop customized care plans.
The goal is to help individuals re-engage with the healthcare system and address their underlying social determinants of health, such as housing instability, food insecurity, and transportation challenges—often the root cause of healthcare inequities. This high-touch care model shifts the dynamic from reactive, episodic treatment to proactive, personalized care by meeting members where they are. Further, by reconnecting unengaged members with their primary care physician and attending visits with them, members have an advocate in the room to help them interpret what they are being told while strengthening the bond between provider and patient.
This full-court press can be life-changing for people in the top 3-5% of healthcare users. Many of these folks face multiple chronic conditions or live in places that make their health challenges worse. Through interventions that focus on the whole person, care teams help members understand and manage their needs on an ongoing basis, reducing their need for costly emergency services and inpatient care.
Community: It’s All About Leveraging Local Knowledge and Relationships
The success of the Three-C Strategy hinges on the fieldwork of locally based Community Health Navigators (CHNs). These navigators are hired directly from the communities they serve. They bring first-hand knowledge of local challenges, resources, and cultural nuances. Their familiarity allows them to build trust quickly and engage with the highest-risk, hardest-to-reach people to build genuine relationships that they can count on. Simply put, CHNs “get” the problems their members are facing—and know how to tackle them.
Because of their dedication and passion—along with intensive training and a robust support system of nurses, licensed clinical social workers, and streamlined scheduling and routing—CHNs excel at reaching members who have fallen through the cracks. From knocking on doors to coordinating with local organizations and healthcare providers, they leave no one behind. The impact is profound. CHNs successfully enroll more than 40% of referred members, a stark contrast to traditional outreach efforts that often struggle to connect with this population.
At the heart of this model’s success is paving the way for CHNs to do what they do best:
build trust and transform lives. CHNs provide hands-on support, from coordinating care across providers to connecting members with essential community resources and assisting them with all administrative tasks. They serve as trusted guides, navigating a complex healthcare system and advocating for their members’ needs. This personalized, one-on-one support and education empower individuals to take ownership of their health, and it creates a ripple effect throughout the community. CHNs coach and empower their members to overcome their unique barriers to care and improve and manage their health and well-being.
Cost: Reducing Financial Strain on the Entire System
Beyond improving individual health outcomes, this model delivers tangible cost savings for the entire healthcare system. By addressing root causes and preventing unnecessary utilization, the program significantly reduces avoidable emergency department visits and hospital admissions. Between 2015 and 2023, MedZed’s field teams implementing this model achieved remarkable results for Medicaid members, including:
• 40% enrollment rate among referred members.
• 38% reduction in emergency department visits.
• 54% decrease in inpatient admissions.
• 54% decrease in total medical costs.
This pioneering model creates a virtuous cycle of improved health and lower costs by reinvesting savings into preventive and community-oriented care. And it’s not just MedZed. Others using community-based approaches like ours are seeing similar results, so we know that the model works.
A Blueprint to Promote Health Equity
The challenges facing Medicaid are daunting, but they’re not impossible. Focusing on proactive, community-driven care can improve outcomes for the most vulnerable individuals while alleviating the financial strain on the healthcare system.
Programs like MedZed demonstrate this approach’s transformative potential. By addressing social determinants of health, leveraging local knowledge, reconnecting individuals with their primary care physicians, and prioritizing personalized care, this model delivers better outcomes for people and financial sustainability for the system.
In 2025, Medicaid has an opportunity to embrace this community-based outreach model as a powerful solution to its most pressing challenges—offering a path to a healthier, more equitable future for all.

Scott Schnell
Scott H. Schnell is founder and chief executive officer of MedZed, provider of community-basedservices to address the Health-Related Social Needs of high-risk, high-need Medicaid and dual-eligible members who are disengaged from primary healthcare. He built the company to find, engage and care specifically for these complex and hardest-to-reach members. With the mission of “inspiring and enabling better health,” Schnelldeveloped MedZed’s business model, technology platform and member acquisition plan to partner with managed health plans to improve member health outcomes, lower utilization rates and reduce costs.An entrepreneur, Schnell has started, grown, led and sold several companies.