A person’s health is shaped by their surroundings long before they ever reach a doctor’s office. For our most vulnerable neighbors, daily hurdles like poverty, lack of transportation, and unstable housing (i.e., social determinants of health) create a “health gap” that is difficult to bridge.
As the United States works to lower the rising costs of Medicaid and Medicare, it faces a critical challenge: finding the budget to address these root causes without weakening the clinics and hospitals that provide essential care. Policymakers must manage a delicate balance—if they shift too much funding away from medical services to pay for social support, they risk overstretching an already strained healthcare system.
The Accountable Health Communities Model
The Accountable Health Communities (AHC) model was designed to solve this puzzle. It explores whether investing in social needs can actually lower overall healthcare spending while helping people live healthier, more stable lives.
In partnership with 28 bridge organizations, the AHC model screened more than 1 million Medicaid and Medicare beneficiaries to identify and address core needs.
AHC Navigation Services Were Associated with Lower Healthcare Costs
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The Assistance Track led to a 3% cost reduction for Medicaid and 4% cost reduction for Medicare beneficiaries.
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The Alignment Track resulted in a 7% reduction in expenditures for Medicaid beneficiaries.
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Measurable reductions in unplanned admissions, avoidable ED visits, and Primary Care Provider (PCP) visits were found across both tracks.
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This decrease in utilization resulted in more than $200 million in healthcare cost savings.
These results suggest that addressing the root causes of poor health is a smart way to keep people out of the hospital over the long term. As federal, state, and municipal policymakers design their next round of programs, the takeaway is clear: when leaders invest funds to solve social hurdles today, they save on massive healthcare bills tomorrow by preventing emergencies before they start.
Complex Needs and Transportation Needs for Seniors
Medicaid beneficiaries often face more than one challenge at once—struggling with food, housing, and transportation all at the same time. While this may seem overwhelming, the data show something hopeful: people with the most complex needs saw the greatest health improvements when they received navigation support. For these individuals, having a “navigator”—someone to help them find resources and schedule appointments—is a life-changing service that bridges the gap between a crisis and a healthy life.
For many seniors using traditional Medicare, transportation was a significant need. Because Medicare typically doesn’t cover the cost of a ride to the doctor, many seniors skip preventive check-ups simply because they have no way to get there. The AHC model stepped in to solve this. By helping these seniors arrange transportation, they were able to access preventive care and avoid the emergency room.
The Results are Positive, but the Mechanisms Remain Unclear.
The AHC Model demonstrates that interventions that address health-related social needs can reduce healthcare expenditures and improve the quality of care for beneficiaries who struggle to navigate the system.
However, the AHC research is unclear about why the intervention worked. The report posits several explanations:
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Partial need resolution: Though only 28% of beneficiaries reported complete need resolution, partial resolution could explain improved health outcomes. For example, transportation to medical appointments facilitates access to quality care. Although these populations still have a core need, this partial resolution may lead to better interactions with the healthcare system.
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Differences among subpopulations: Subpopulations, such as those with multiple needs or chronic illness, were more likely to have their needs met and showed greater cost reductions. In this case, navigation services may drive part of the overall impact.
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Impacts of Navigators: Navigators act as brokers between the healthcare system and beneficiaries. They leverage client relationships to ensure beneficiaries have access to quality healthcare. At the same time, they build trusting relationships with beneficiaries, helping them trust the health care system overall.
More research is needed to investigate these alternative explanations and to offer clear design guidance for policy implementation.
The Bottom-Line
Closing the “health gap” in U.S. communities isn’t just a task for doctors—it’s a mission for all of us. The AHC model demonstrates that investing in addressing social needs, such as stable housing and reliable transportation, is not just about addressing social needs; it’s practicing smarter healthcare. By supporting the “Navigators” who build trust and bridge the gap between social needs and medical care, policymakers can move away from a reactive system that only waits for a crisis. As the saying goes, an ounce of prevention is worth a pound of cure.
Read the full AHC report here.
Written By: Jade Young Class of ’27