Health Systems and Social Services—A Bridge Too Far?

Robust evidence shows that social conditions (including housing, food security, education, and transportation) are critical factors in promoting individual and population health. There is also evidence that addressing the social determinants of health can improve health status.¹ It is thus not surprising that, in the past several years, health care systems, policymakers, and researchers have renewed their interest in the role that health care systems and particularly hospitals can play in identifying and responding to the social needs of patients.² Indeed, Horwitz and colleagues identified 57 health systems, including 917 hospitals, that recently have launched programs to address social determinants of health.³

The health systems dedicated $2.5 billion of funding to these programs, of which about two-thirds was specifically committed to housing-focused interventions (other focus areas included employment, education, food security, and transportation). In short, health systems are making sizable investments in the social determinants of health. Proponents argue that these investments are needed not only because of the evidence on the health effects cited above, but also because community-based social service agencies and state social welfare systems are typically inadequately funded to address social needs.

We disagree. Health systems and hospitals should tread warily into the provision of social services and policymakers should not encourage this approach. It has real risks, such as diverting scarce resources to socially less-desirable uses, and few prospects of success. Social determinants of health should be addressed by the social service organizations and governments that specialize in this work. There are fundamental mismatches between the priorities and capabilities of hospitals and health systems and the task of addressing social determinants of health.

One mismatch arises from heterogeneity among hospitals. Investing in social needs is costly and requires managerial attention, but while the health system as a whole spends a great deal of money, the finances of hospitals typically mirror the finances of the communities they serve. Accordingly, the systems where patient needs for social services are greatest are those that are already struggling to meet their core missions around patient safety and quality care. Their patients rely on them to devote their budgets and attention on improving patient care, for example, by maintaining adequate nurse staffing levels. For these institutions where the social needs are greatest, a pivot from the central mission to addressing social needs can be a dangerous distraction.

In better-resourced hospitals, providing social services will always be no more than a grace note to hospitals’ institutional priorities. Social workers, who know the most about how to address these needs, make up only a fraction of the health care labor force at hospitals and within health systems, and typically hold little power in the organizations. The incentives operating within most health system organizations, and particularly those that do not primarily serve safety net populations, mean that funding intended for social services is unlikely to be spent in the ways that are optimal for population health.

Some see collaborative relationships with social service organizations that specialize in this work as a way to address the lack of expertise within hospitals.⁴ But hospitals and health systems do not typically play well with others. They are bigger, stronger, and more politically well-connected than local community social service providers and differ from their erstwhile colleagues in their cultures, leadership styles, and managerial practices. Numerous studies show that lack of alignment on these dimensions bodes poorly for the effectiveness of cross-sector collaboration.⁵

Beyond the internal challenges, hospital and health system engagement in addressing social determinants of health may have negative system-wide consequences. Social service agencies have different and broader priorities than health. Focusing scarce social service resources too tightly on immediate health goals could undermine long-term well-being. For example, allocating limited housing units to poor but healthy children might improve their educational outcomes and ultimately generate more long-term population health than prioritizing housing for sicker, older adults, even if it improves their health outcomes. The goal of incorporating health in all policies risks becoming a strategy of health is all.

In addition, investment in social services for the more financially able and politically powerful health systems and hospitals could have the perverse effect of reducing the amount of funds governments dedicate for other social services. Diversion of funds from social welfare programs to more powerful interests already occurs in other contexts. For example, states continue to use their considerable flexibility under the Temporary Assistance for Needy Families program to divert funds away from income support for families and toward other, often unrelated but more politically salient budget areas.

There does need to be more investment in the social determinants of health, but health systems should not take the lead in these efforts. Alternative strategies exist. For example, instead of attempting to provide social services or to collaborate directly with social service providers, hospitals could donate funds to local community-based organizations that act as trusted entry points into social service systems, as Butler has suggested. Rather than encouraging health system mission creep, advocates for improvements in social determinants of health should use their fundraising capacities, community benefit responsibilities, and lobbying efforts to strengthen independent local social service providers.

Published: August 17, 2023. doi:10.1001/jamahealthforum.2023.3445

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Glied S et al. JAMA Health Forum.

Corresponding Author: Sherry Glied, PhD, Robert F. Wagner Graduate School of Public Service, New York University, 295 Lafayette St, New York, NY 10012 (sherry.glied@nyu.edu).

Conflict of Interest Disclosures: Dr Glied reported serving as a board member for Geisinger. No other disclosures were reported.