Policies to Address Adverse Social Health Factors (2025)

The US Healthy People 2030 vision is “a society in which all people can achieve their full potential for health and well-being across the lifespan,”¹ yet the US health care system and its financial underpinnings are not designed to meet the medical and social needs of patients and communities.² Using 2021 Medical Expenditure Panel Survey data, Mohan et al³ found that social determinants of health (SDOH) were associated with health care expenditures by insurer. Lower educational attainment, economic insecurity, medical discrimination, and lower availability of parks were associated with higher expenditures. Mohan et al³ conclude SDOH could be used by health insurers and policymakers to identify and control health care expenditures and advance health equity.

Why, then, have health care industry efforts to address adverse SDOH been so limited? What policies could support and incentivize the health care industry to address SDOH sustainably at scale?

Addressing adverse SDOH has great societal value for our nation’s health and economic future, but the health care system’s financing structure is not designed to maximize everyone’s health.¹ The case for the health care industry addressing adverse SDOH is premised on 2 assumptions: that the health care system’s goal is to maximize patient and community health and well-being and that the nation and health care system care about the health and well-being of all persons. Unfortunately, too often that is not the case.

We would all be better served by a comprehensive paradigm, akin to the Indigenous approach, viewing health and well-being more holistically and incorporating SDOH and our relationship with land, sea, climate, and ecosystem.¹ Today’s business case for payers, health insurance plans, and health care delivery organizations to address adverse SDOH is too weak.¹ Most health care systems work under rules and incentives that reward generating revenue from patients covered by higher-paying insurers, rather than caring for the entire community. When outcomes and quality of care are considered, institutions usually concentrate on traditional clinical performance metrics rewarded by payers, such as childhood immunization rates or diabetes control, rather than more holistic measures of community health and well-being, such as healthy days at school and work.

Troyen Brennan, MD, JD, Executive Vice-President and Chief Medical Officer of CVS Caremark Corporation, stated: “As a hospital executive, your key strategy, perhaps your only strategy, has been to increase in size, gain leverage with insurers, bargain for better fee-for-service rates, and do more procedures.”⁴ While in theory the value in value-based care represents a ratio of overall benefit to cost, in practice, health care institutions’ organizational behavior emphasizes the financial cost denominator, a phenomenon exacerbated by health care’s financialization and rise of private equity.⁵

The second incorrect assumption is that the nation and health care system care about every person’s health and well-being, including those in marginalized communities. While polls show that two-thirds of the public agree that “our society should do whatever is necessary to make sure that everyone has an equal opportunity to be healthy,”² supporting policies have not followed. Health care delivery organizations that would like to advance health equity view the incentives to do so as weak. A foundational problem is that we tolerate a multitiered health care system where some persons are uninsured or underinsured, creating perverse incentives for health care delivery organizations to limit care for underresourced, marginalized, and racially and ethnically minoritized populations, such as patients with Medicaid insurance.⁶

We must change the rules to enable addressing SDOH, and implement regulations and incentives that create a business case for each industry stakeholder, including payers, health plans, and health care delivery organizations, to maximize health and well-being of all patients and communities.^1,2,6,7 A mission-driven business case would reward social return on investment (SROI), which emphasizes a holistic vision of community health and well-being, rather than narrow financial ROI. Stakeholder priorities should include caring for overall geographic populations and managing total cost of care to incentivize providing high-value care and eliminating waste.^1,4 Yet, many health care delivery organizations caring for underinsured patients and those with more social risk prioritize shifting costs to more highly reimbursing payers or increasing the percentage of highly-reimbursed patients in their payer mix. Moreover, business time horizons must shift from short-term financial gains for themselves to medium- and long-term value to the community.

Payment reforms to create the business case require expanding access to health insurance and resourcing the Medicaid program to support care that can adequately address medical and social needs.⁶ All-payer rate systems such as in Maryland, where reimbursement rates are the same across payers, reduce perverse incentives to avoid caring for underinsured and complex patients.

Additionally, payment and policy levers can work synergistically to support the business case, including^1,2,6,7 (1) paying for reducing disparities and advancing health equity, like what private payers such as Blue Cross Blue Shield Massachusetts and some state Medicaid Accountable Care Organization (ACO) programs do; (2) flexible funding to address adverse SDOH (eg, 1115 waivers in Oregon, California, and North Carolina allow Medicaid funds to pay for community navigators, community-based organizations that address SDOH, and enabling services such as transportation); (3) risk adjusting payment for social risk to provide additional resources to care for patients with more health-related social needs, such as in the Medicaid ACO programs of Massachusetts and Minnesota; and (4) total cost of care systems, such as in Maryland, which hold health care systems responsible for the total cost and quality of care of a defined population; this creates much stronger incentives to address health-related social needs and invest in structural SDOH interventions to decrease costly health care visits and hospitalizations.

These financing and payment reforms are designed to support and incentivize activities that holistically address patient and community health and advance health equity. Activities can focus on health care, unmet health-related social needs (eg, screen individual patient for economic insecurity), and systemic, structural adverse SDOH (eg, partner with broad coalitions to tackle problem of economic insecurity in communities).² The health care industry should address all 3 collaboratively with cross-sector partners, including community-based organizations, to maximize community health and well-being.

The Centers for Medicare and Medicaid Services (CMS) States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model addresses adverse SDOH, drawing upon these 4 payment and policy levers, especially as operationalized in the Maryland Total Cost of Care, Vermont All-Payer ACO, and Pennsylvania Rural Health Models.⁴ While promising, AHEAD has limitations. Challenges include getting private payers to participate if they believe they can financially profit more from opportunities in other parts of the market that do not prioritize SROI, competing diametrically opposed incentives from fee-for-service in many markets, and limited state experience in population health management and cost control needed for successful implementation.⁴

Wider public and political support for maximizing community health and well-being and advancing health equity is essential.² Multisectoral national and state initiatives are aligning payment and care transformation with SROI and health equity. For example, the CMS Health Care Payment Learning and Action Network Health Equity Advisory Team and Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation program are developing, implementing, and evaluating such efforts. To succeed, we must all affirm that the purpose of the health care system must be, first and foremost, to maximize health and well-being for all, and align the business case for the health care industry with this national imperative.

Published: October 23, 2024. doi:10.1001/jamanetworkopen.2024.40439

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Chin MH et al. JAMA Network Open.

Corresponding Author: Marshall H. Chin, MD, MPH, Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC2007, Chicago, IL 60637 ([emailprotected]).

Conflict of Interest Disclosures: Dr Chin reported receiving grants from the Agency for Healthcare Research and Quality, California Health Care Foundation, Health Resources and Services Administration, Kaiser Foundation Health Plan, and Merck Foundation; personal fees from the Patient-Centered Outcomes Research Institute, Health Equity Advisory Team for the Centers for Medicare & Medicaid Services Health Care Payment Learning and Action Network, Bristol-Myers Squibb Health Equity Advisory Board, Blue Cross Blue Shield Health Equity Advisory Panel, US Centers for Disease Control and Prevention, and American College of Physicians Advisory Committee (I Raise the Rates: Promotion of Influenza Immunization through Interprofessional Partnership), Institute for Healthcare Improvement Health Equity Alliance Accelerator (through support of Sutter Health in part with funding provided by Genentech), America’s Health Insurance Plans (support for attending meetings and travel), Robert Wood Johnson Foundation, and National Institute of Diabetes and Digestive and Kidney Diseases; serving on various committees including the Essential Hospitals Institute Innovation Committee, Institute for Healthcare Improvement and American Medical Association National Initiative for Health Equity Steering Committee for Measurement, National Committee for Quality Assurance Expert Work Group on role of social determinants of health data in health care quality measurement; and being a member of the National Advisory Council of the National Institute on Minority Health and Health Disparities, the Health Disparities and Health Equity Working Group of the National Institute of Diabetes and Digestive and Kidney Diseases, Families USA Equity and Value Task Force Advisory Council, National Academy of Medicine Council, and The Joint Commission Health Care Equity Certification Technical Advisory Panel outside the submitted work. Ms Dale reported being an employee of a Medicaid managed care plan, AmeriHealth Caritas (Washington, DC); serving as cochair of the Health Equity Advisory Team for the Centers for Medicare & Medicaid Services Health Care Payment Learning and Action Network; being a member of the National Advisory Committee of the Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation Program and being a board member of CRISP DC, Institute for Medicaid Innovation, and Volunteers of America outside the submitted work. Ms Hernández-Cancio reported receiving grants from Arnold Ventures, California Health Care Foundation, Commonwealth Foundation, Fundación Dune, WK Kellogg Foundation, Merck for Mothers, Packard Foundation, Robert Wood Johnson Foundation, and Skyline Foundation; personal fees and travel support from Robert Wood Johnson Foundation Advancing Health Equity, Robert Wood Johnson Foundation Intersection Advisory Council, National Institutes of Health Office of Research on Women’s Health Technical Advisory Group (for their Understudied, Underrepresented, and Under Reported fifth edition of the Health of Women of U3 Populations Data Book), AcademyHealth, America's Health Insurance Plans, Association of Health Care Journalists, Council of State Governments, Robert Wood Johnson Foundation Medicaid Leadership Institute, National Committee for Quality Assurance, National Family Planning & Reproductive Health Association; nonfinancial and travel support from the Agency for Healthcare Research and Quality National Advisory Council and Stanford University Maternal and Child Health Institute; serving as Chair for Consumer Advisory Committee of the National Committee for Quality Assurance and Cochair of the Health Task Force of the Leadership Conference for Civil and Human Rights; being a current member of the Health Equity Advisory Team for the Centers for Medicare & Medicaid Services (CMS) Health Care Payment Learning and Action Network (HCP-LAN), Engage for Equity PLUS External Governance Board, Partners for Advancing Health Equity National Advisory Committee, Change Lab Solutions Board of Directors, Primary Care Collaborative Board of Directors, Health Care Transformation Task Force Executive Board; and being a former cochair of National Academy of Medicine Assessing Meaningful Community Engagement Organizing Committee outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grants from the Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation National Program Office (to Dr Chin) and the Chicago Center for Diabetes Translation Research (grant No. NIDDK P30 DK092949 to Dr Chin).

Role of the Funder/Sponsor: The sponsors had no role in the analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The thoughts and ideas expressed in this article are those of the authors and do not necessarily represent the views or policies of their employers or other organizations associated with the authors.