How U.S. Health Care Providers Are Addressing the Drivers of Health

Introduction

Our health is affected by the complex social and economic conditions in which we live, even more so than the quality of health care or our access to clinical services. The drivers of health — among them food and housing security, access to utilities and transportation, and interpersonal safety — directly and indirectly influence our individual and collective well-being. Often, they reflect underlying structural inequities in our society: people who have been socially or economically marginalized are more likely to experience adverse health outcomes from unmet social needs. People with low income, for example, are less likely to have access to affordable and safe housing, which can worsen quality of life and compromise health.¹

Health care providers respond to the negative downstream effects that patients experience as a result of these unmet social and economic needs through the delivery of emergency care, chronic condition management, and more. For example, people who are food insecure are more likely to develop diabetes and hypertension — chronic conditions that require continual management with the help of providers.²

With evidence suggesting that meeting patients’ social and economic needs can reduce the demand for costly or avoidable health care and generate savings, payers, providers, and policymakers are trying to do more to address the drivers of health in clinical settings.³ Their efforts include screening patients for social and economic needs in health care settings, referring patients to community-based organizations, and more.

However, addressing patients’ lack of securing housing, regular employment, or other social and economic needs can be a difficult task for many practices, requiring additional resources that may not be reimbursable. Others argue that health systems should not focus on attempting to address the nonmedical needs of patients because it strays from their main goals.⁴

In this brief, we describe the extent to which people in the United States struggle to meet their social and economic needs, and how payers, physicians, and policymakers are attempting to support them. We use U.S.-specific data from the Commonwealth Fund 2023 International Health Policy Survey of adults 18 years and older; U.S.-specific data from the Fund’s 2022 International Health Survey of Primary Care Physicians; and information from state Medicaid programs. (For more details, see “How We Conducted This Study.”)

Findings

While over half of surveyed adults reported always, usually, or sometimes worrying about any social or economic needs, more adults reported worrying about their income and ability to pay housing bills than about having a clean or safe place to sleep.

Adults with incomes below the national household average, $62,000 at the time of the survey, were at least twice as likely as those with average or above-average incomes to report worrying about having enough money to pay their housing bills, enough food to eat, or a safe place to sleep.

Prior research has highlighted the ways that both income and social needs can affect health outcomes — developing certain chronic conditions, including obesity and diabetes, is associated with both lower income and certain drivers of health, like food insecurity.⁵

Over 70 percent of adults with incomes below the national average reported worrying about their social and economic needs, a significantly higher share than adults with average or above average incomes (see the first exhibit). Among low-income adults, those without insurance were significantly more likely to report worrying about their social or economic needs than those with insurance.

Prior research has found that unmet social and economic needs among adults with low income is associated with worse health outcomes and lower use of health care services. One potential reason is the financial trade-offs they may need to make between paying for health care services or other bills and necessities.⁶

The first step providers often take in tailoring care to a patient’s needs is screening, whether through a standardized instrument or informal conversations initiated by clinicians, social workers, or care coordinators.⁷ Primary care providers, who serve as the “front door” to health care for most people, may be well positioned to screen patients.

The majority of primary care physicians in the U.S. reported screening their patients for the drivers of health. But there is a mismatch between what needs are screened for and what needs patients worry about. Physicians reported screening for financial security at slightly lower rates than other needs, yet patients reported worrying about financial needs more so than those related to food or housing (see the first exhibit). While it’s important that providers screen for a range of needs, they may sometimes need to be more targeted in their approach.

Three-quarters of primary care physicians working in community health centers (CHCs), where 90 percent of patients have low income, reported screening their patients for unmet social or economic needs.⁸ Other research has found that CHCs use screening data to inform care delivery and develop new community partnerships to address emerging needs within their patient population.⁹

Social services and health care services have historically operated independently, with little to no coordination of patients’ care. Through referrals, health care organizations are beginning to coordinate care with local social service organizations to address the unmet needs of patients, which may improve their health outcomes.

Our survey reveals physicians with at least half of their patients enrolled in Medicare were significantly more likely to coordinate their care with social services than physicians with a majority of patients enrolled in private insurance. In recent years, the Centers for Medicare and Medicaid Services (CMS) have taken several regulatory steps to make it easier for providers to identify their Medicare patients’ social and economic needs and take actions to address them. These include requiring providers to ask their patients about at least one social need in their health assessment.¹⁰

Effective care coordination to address patients’ unmet drivers of health needs often consists of developing partnerships between health and social service organizations, maintaining accurate directories of available services, establishing feedback loops to confirm that patients receive services, and being aware of the partner organization’s capacity.¹¹ Our survey reveals this may be easier said than done, as physicians report facing several coordination challenges.

Physicians in solo practices and at CHCs reported staffing and paperwork posed a challenge to coordination at similar rates. Physicians in solo practices were significantly more likely to report that lack of information about community organizations was a challenge, compared to CHCs. Prior research has found that, nationally, CHCs employ hundreds of community health workers, case managers, outreach workers, and eligibility assistance workers, who likely maintain an awareness of available resources in their communities.¹²

CMS has created state pathways for addressing drivers of health-related needs, which offer a learning opportunity for other payers on how to address the drivers of health. In addition to regulatory efforts to support addressing social needs in Medicare, CMS has created several avenues to provide nonclinical but medically appropriate services to Medicaid beneficiaries, including through home and community-based service (HCBS) programs for older adults and patients with disabilities, Section 1115 waivers that allow states to use federal funds to develop targeted initiatives, and “in lieu of services” that allow managed care plans to address needs through Medicaid benefits. Over half of state Medicaid programs are engaged in such programs.

Minnesota’s HCBS program offers housing stabilization and transition services for older adults and those with disabilities to access reliable, stable housing.¹³ Through their 1115 waivers, North Carolina offers enhanced case management and nonclinical services, like housing modifications and transportation vouchers via community partners, and Massachusetts provides nutrition counseling and medically tailored meals.¹⁴ California has 14 in-lieu-of services, including housing modifications, housing deposits, and medically tailored meals.¹⁵

Beyond these efforts targeting individual patient needs, several Medicaid programs are investing in their communities. In Arizona, Medicaid managed care organizations are required to invest 6 percent of their profits into communities, while California and Ohio are planning to implement similar requirements in the future.¹⁶

Discussion

Our survey data revealed that many U.S. adults, especially people with lower incomes and those who are uninsured, are regularly concerned about meeting their social and economic needs, something research shows significantly affects our health and well-being. Evidence suggests that if left unaddressed, these drivers of health can cause new health problems to develop, complicate existing health conditions, and undermine access to care.¹⁷

In response, providers and health care organizations are attempting to mitigate these downstream health effects by screening patients and coordinating care with local organizations. While we found high rates of physicians screening their patients for issues like food and housing insecurity, there was a disconnect between the needs patients most worried about and what they screened for. As payers and policymakers encourage physicians to screen patients through data reporting and quality measurement efforts, there is an opportunity to better align screening to patients’ needs.¹⁸

Three-quarters of physicians in community health centers screened their patients and nearly two-thirds reported coordinating their care with local organizations. CHCs were designed expressly to offer comprehensive and accessible health care for underserved populations, and they often employ members of the community.¹⁹ Their patients’ needs, strong community ties, and mission-driven operations likely enable them to address unmet social and economic needs. CHCs may offer a learning opportunity for policymakers and practices looking to increase screening and coordination in other care contexts.

Fewer than half of physicians in solo practices coordinated their care with social service organizations. They reported challenges to coordination like too much paperwork and inadequate staffing. Prior research has found that lack of infrastructure for screening and coordination, including insufficient staff time and financial support, and the need to change workflows, can deter practices from identifying the unmet needs of their patients.²⁰ Policymakers and payers may consider opportunities to better support solo practices, like providing technical assistance to help streamline coordination and referrals, as well as additional funding to hire case managers or care coordinators.

As efforts to address patients’ social needs become more common in clinical settings, some experts warn that practices should avoid assuming that their patients are not already aware of available services, or that organizations within the community have the capacity to take on referrals.²¹ Instead, health care organizations can engage patients and local organizations throughout the process, from developing a screening methodology to using their resources to invest in their communities and local services. This also may help ensure that practices are screening for needs that their patients are more likely to face.

Through Medicaid, states have several options to address people’s economic and social needs, but not all states are leveraging these opportunities. Many states, particularly in the Midwest and South, have yet to offer nonmedical services through CMS’s waivers and other programs. Through reporting changes, guidance documentation, and more, CMS is making it easier to apply for and use these programs, which could encourage additional states to participate.²²