Efforts to improve health in the U.S. have traditionally looked to the health care system as the key driver of health and health outcomes. However, there has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health. This brief provides an overview of these social determinants of health and discusses emerging initiatives to address them.
Social determinants of health are the conditions in which people are born, grow, live, work and age.1 They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care (Figure 1).
A growing number of initiatives are emerging to address social determinants of health. Some of these initiatives seek to increase the focus on health in non-health sectors, while others focus on having the health care system address broader social and environmental factors that influence health.
Policies and practices in non-health sectors have impacts on health and health equity. For example, the availability and accessibility of public transportation affects access to employment, affordable healthy foods, health care, and other important drivers of health and wellness. Nutrition programs and policies can also promote health, for example, by supporting healthier corner stores in low-income communities,7 farm to school programs8 and community and school gardens, and through broader efforts to support the production and consumption of healthy foods.9 The provision of early childhood education to children in low-income families and communities of color helps to reduce achievement gaps, improve the health of low-income students, and promote health equity.10
In addition to the growing movement to incorporate health impact/outcome considerations into non-health policy areas, there are also emerging efforts to address non-medical, social determinants of health within the context of the health care delivery system. These include multi-payer federal and state initiatives, Medicaid initiatives led by states or by health plans, as well as provider-level activities focused on identifying and addressing the non-medical, social needs of their patients.
Through the CMMI State Innovation Models Initiative (SIM), a number of states are engaged in multi-payer delivery and payment reforms that include a focus on population health and recognize the role of social determinants. SIM is a CMMI initiative that provides financial and technical support to states for the development and testing of state-led, multi-payer health care payment and service delivery models that aim to improve health system performance, increase quality of care, and decrease costs. To date, the SIM initiative has awarded nearly $950 million in grants to over half of states to design and/or test innovative payment and delivery models. As part of the second round of SIM grant awards, states are required to develop a statewide plan to improve population health. States that received Round 2 grants are pursuing a variety of approaches to identify and prioritize population health needs; link clinical, public health, and community-based resources; and address social determinants of health.
A number of delivery and payment reform initiatives within Medicaid include a focus on linking health care and social needs. In many cases, these efforts are part of the larger multi-payer SIM models noted above and may be part of Section 1115 Medicaid demonstration waivers.20 For example, Colorado and Oregon are implementing Medicaid payment and delivery models that provide care through regional entities that focus on integration of physical, behavioral, and social services as well as community engagement and collaboration.
Several other state Medicaid programs have launched Accountable Care Organization (ACO) models that often include population-based payments or total cost of care formulas, which may provide incentives for providers to address the broad needs of Medicaid beneficiaries, including the social determinants of health.29
Medicaid programs also are providing broader services to support health through the health homes option established by the ACA. Under this option, states can establish health homes to coordinate care for people who have chronic conditions. Health home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support, as well as referrals to community and social support services. Health home providers can be a designated provider, a team of health professionals linked to a designated provider, or a community health team. A total of 21 states report that health homes were in place in fiscal year 2017.34 A federally-funded evaluation of the health homes model found that most providers reported significant growth in their ability to connect patients to nonclinical social services and supports under the model, but that lack of stable housing and transportation were common problems for many enrollees that were difficult for providers to address with insufficient affordable housing and rent support resources.35
The ACA provided a key opportunity to help improve access to care and reduce longstanding disparities faced by historically underserved populations through both its coverage expansions and provisions to help bridge health care and community health. To date, millions of Americans have gained coverage through the coverage expansions, but coverage alone is not enough to improve health outcomes and achieve health equity. With growing recognition of the importance of social factors to health outcomes, an increasing number of initiatives have emerged to address social determinants of health by bringing a greater focus on health within non-health sectors and increasingly recognizing and addressing health-related social needs through the health care system.
Although there has been significant progress recognizing and addressing social determinants of health, many challenges remain. Notably, these efforts require working across siloed sectors with separate funding streams, where investments in one sector may accrue savings in another. Moreover, communities may not always have sufficient service capacity or supply to meet identified needs. Further, there remain gaps and inconsistencies in data on social determinants of health that limit the ability to aggregate data across settings or to use data to inform policy and operations, guide quality improvement, or evaluate interventions.48 Within Medicaid, the growing focus on social determinants of health raises new questions about the appropriate role Medicaid should play in addressing non-medical determinants of health and how to incentivize and engage Medicaid MCOs in addressing social determinants of health.49
This is of particular concern to states. Unlike the federal government, states must balance their budgets. The more dollars that get spent on health care, the less there is for other priorities such as education and transportation. Additionally, there is growing concern from constituents, who are facing greater premiums and out-of-pocket costs as spending increases.
To this end, many states have expressed interest in reducing the rate of growth in health care spending. To do so, states, by definition, must change the behavior of health care providers and payers. This presents two core challenges. The first is to identify the components of spending that should change. For example, one strategy may be to lower, or constrain the growth of, health care prices. Another may be to reduce the utilization of low-value care. The second challenge is designing a system that encourages, or forces, those changes. States have a wide variety of legislative and regulatory tools at their disposal, such as sharing data analytics, regulating prices, or preventing mergers and consolidation, which often lead to an increase in prices.
Health policy commissions also can play an important part in helping states achieve their health spending goals. Massachusetts and Maryland, for example, rely on a state commission to support their policy goals. In some cases, commissions may support strategies implemented through existing state agencies. In other cases, they may have the authority to directly implement strategies to constrain health care spending.
Health care spending is determined by prices and utilization and both of those, in turn, reflect a wide range of market features, such as the extent of provider and insurer competition and local practice patterns. Premiums reflect that spending and any insurer markup, which also reflects insurer competition (Exhibit 1). For this reason, one strategy to control spending focuses on improving either provider or insurer competition. More proximate, yet narrow strategies target high prices or utilization of health care services. The broadest direct strategies focus on spending itself. In each case, policy tools may range from soft encouragement to incentives and regulations with varying degrees of enforcement.
State commissions can be useful in supporting procompetitive policies. While existing agencies can support competition through policy and antitrust regulation, state commissions can serve as a venue for hearings on anticompetitive practices, such as all-or-nothing contracting, where a health care organization requires an insurer to keep all its facilities in-network instead of only those that are considered high-value.8 Commissions can then suggest remedies to such anticompetitive behavior. They also can be a hub for information and strategies to promote the diffusion of insurance plans that encourage consumer shopping and competition.
Later, in 1977, Maryland received a waiver from the Centers for Medicare and Medicaid Services that allows the state to pay HSCRC-approved rates, which were set prospectively, to both Medicare and Medicaid. This waiver gave the state significant regulatory authority over health care spending. 2b1af7f3a8