In a remarkably short period, attention to social determinants of health—nonmedical factors influencing health, such as housing, adequate nutrition,1 and transportation—has become a central feature of efforts to improve health and health equity. In just the last 10 years, the term’s annual frequency in journal articles has increased 7-fold. More recently, COVID-19 has underscored the link between social factors and inequities in health care. It is now common to have screening questions about social conditions during patient intake and for referrals to be made.2 And there are calls for Z codes identifying social needs to be used more extensively in the health system to improve care.
However, despite this growing focus on social determinants, the health care system is far from able to effectively address these influencers of health. There has been progress, but several challenges require attention.
Limited Evidence on the Effects of the Interventions
One significant challenge is that rigorous research evidence on the health effects of social determinants of health interventions is limited and mixed.3 Some studies do suggest that attending to social determinants—such as addressing housing and the social services needs of older adults and children’s families—can lead to health improvements, such as reductions in hospital admissions and possible savings. But it is often unclear which specific interventions matter and to what degree. For instance, a recent assessment of 35 peer-reviewed studies of social screening and referral programs found most studies had limitations that could bias the conclusions.4 Another recent analysis of randomized trials of social interventions also found bias.5
The mixed findings from this research do not mean we should deemphasize social determinants of health screening and interventions. But it does mean more experimentation and better study designs to understand social determinants of health are needed. We also need to be cautious before committing to large and expensive changes in care patterns until better evidence is available. Meanwhile, it is helpful that some professional advisory bodies, such as the US Preventive Services Task Force, are providing careful guidance on how to address social risk during care.6
Need for Better Data Sharing
Barriers to sharing data are another obstacle. Different data systems, privacy rules, and sharing protocols often make it difficult for community-based organizations in nonmedical sectors to work in concert with health care organizations. Fortunately, the growth of intermediary networks, such as the company Unite Us, is creating a data infrastructure to help social service organizations and health systems coordinate person-centered care. Also, community initiatives such as the San Diego–based Community Information Exchange, assemble partners to create integrated data systems to enable multiple sectors to provide holistic care. The federal government can help by offering greater clarification and guidance on privacy rules and grants for local initiatives. Meanwhile, Congress is considering legislation, known as the LINC Act, that would provide grants to states to help increase data sharing among local health and community organizations (as well as other steps to improve collaboration). In addition, a recent report to the Office of the Assistant Secretary for Planning and Evaluation at the US Department of Health and Human Services on data sharing at the community level includes several steps the federal government could take to improve the sharing of information.
Determining Who Should Pay
Another nettlesome issue concerns who should pay to address social determinants. Legislative and administrative rules often limit or prohibit health programs from using funds for nonmedical services, even if doing so would lead to better outcomes or lower total costs. However, at the federal level the §1115 Medicaid waiver process has permitted some flexibility for state social determinants of health pilot programs to proceed. In 2019, for instance, the Trump administration authorized North Carolina to use a Medicaid managed care model to combine nonmedical and medical services for certain populations with complex and chronic illness. In addition, changes in Medicare Advantage rules now allow plans to include more nonmedical services related to food insecurity, transportation, and housing instability within their benefits. During 2021, more than 900 plans offered such benefits. Still, much more needs to be done to permit health sector programs and plans to invest in social determinants of health.
A related payment issue is how to address the reluctance of different sectors to share the initial cost to obtain health quality improvements or future cost savings. The problem is that in many cases, one sector foots the bill while another reaps the savings—the so-called wrong pockets problem. For example, a housing department might be urged to spend resources on bathroom safety for older adults to reduce falls, but the subsequent savings would accrue to Medicare or Medicaid, not the housing department. Even when each sector would gain from a collaboration if they shared the upfront cost, it can be difficult to find a commitment formula that each would consider fair.
Some models of cooperation suggest possible solutions to this problem. One promising example is CommonSpirit Health’s “Connected Community Network.” This network uses a trusted community convener, together with a technology platform for referrals and coordination, to connect multiple health plans with community-based organizations providing a range of social services. The neutral convener is the key to this unusual example of “co-opetition” between competing health plans that jointly shoulder the cost of creating an infrastructure for their mutual benefit. Meanwhile a series of pilot programs being undertaken in several locations by the Collaborative Approach to Public Goods Investments is exploring a variety of ways to achieve cooperation by using a trusted neutral convener combined with a formula for allocating costs and benefits to each partner.
Governments are also developing ways to encourage departments to work together for a common goal. The expansion of “children’s cabinets” to more than half the states is an example of one approach creating a special executive-level body to coordinate cross-department planning and budgeting for such areas as health, transportation, education, and social services to advance the health and welfare of a targeted population. There have been proposals for a White House–based children’s cabinet to achieve similar collaboration at the federal level.
The federal government is encouraging such local collaboration. For instance, the Administration for Community Living, which supports services for aging populations and those with disabilities, recently announced grants for 12 community-based organizations to function as an integrated network that helps bolster local activities that focus on social determinants of health. In addition, the US Centers for Disease Control and Prevention is providing funds to address social determinants of health by encouraging state, local, territorial, and tribal jurisdictions to launch multisector plans for people experiencing health disparities and inequities.
Efforts at the state and local level to foster cross-sector collaboration could expand if the Social Determinants Accelerator Act were to become law. This legislation would create a technical advisory council and provide grants to states and communities to coordinate medical and nonmedical social services for targeted groups of high-need Medicaid patients. Such federal actions to explore ways to achieve this and other aspects of social determinants of health are likely to get a significant boost with the recent creation of the bipartisan Congressional Social Determinants of Health Caucus.
A focus on social determinants is important and necessary. But to address these influences on health successfully and efficiently, we still need to understand much more about the connections between investing in social services and health outcomes. And we need many more experiments to find innovative ways to achieve greater and more effective collaboration between health care and other sectors.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Butler SM. JAMA Health Forum.
Corresponding Author: Stuart M. Butler, PhD, Brookings Institution, 1775 Massachusetts Ave NW, Washington, DC 20036 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Butler reported he is the unpaid advisory board chair of the Collaborative Approach to Public Goods Investments.
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Butler SM. What is the Outlook for Addressing Social Determinants of Health? JAMA Health Forum. 2021;2(9):e213639. doi:10.1001/jamahealthforum.2021.3639