The Intersection of Social Factors and Health Policy: A Deep Dive into the U.S. Government’s Approach

Today, the conversation around healthcare has expanded beyond traditional medical treatments to include a broader understanding of the social circumstances that significantly impact health outcomes – also known as the social determinants of health (SDOH). According to the U.S. Department of Health and Human Services, the SDOH are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH accounts for up to 50% of health outcomes at the county level, with socioeconomic factors such as poverty, job availability, and education access exerting the most potent influence.

Recognizing the rising importance of SDOH, The White House released the first-ever U.S. Playbook to Address Social Determinants of Health with a vision to “enable every American to lead a full and healthy life within their community.” The Playbook first details four key issues that emphasize the links between social circumstances and health and then outlines a series of federal measures implemented to address them. The focus of this publication is to offer a guiding framework to tackle SDOH, which consists of three pillars: 

  1. Expand data gathering and sharing: Enhance the accumulation and compatibility of data among healthcare, public health, social care services, and various data systems to tackle SDOH with federal, state, local, tribal, and territorial backing.
  2. Support flexible funding to address social needs: Promote adaptable utilization of funds across sectors to provide community-tailored grants and enable resource coordination to address health-related social needs (HRSNs).
  3. Support backbone organizations: Facilitate the establishment of community backbone organizations and additional infrastructure to connect healthcare systems with community-based organizations, especially those focused on SDOH.

Through the actions mentioned above, the Biden-Harris administration aims to promote innovation across sectors to devise practical solutions that equitably augment social circumstances, thereby creating improved health outcomes. In this blog article, we will delve into the first two sections of the Playbook, providing an overview of the socioeconomic issues related to SDOH. Then, we will turn to how federal agencies are addressing the SDOH. 

Socioeconomic Factors Impacting Health Outcomes

1. Housing Security

One of the most significant SDOH is the security and quality of housing, yet many Americans still grapple with housing-related challenges, especially those identifying as racial minorities. The Department of Housing and Urban Development estimates that 8.53 million households who do not receive federal housing assistance either live in extremely inadequate rental conditions, spend over half of their income toward rent, or both. The lack of secure housing makes individuals more susceptible to unsanitary environments, subpar air quality, climate-related hazards, and many other variables that might negatively impact their health and wellness. As a result, there is a strong correlation between housing insecurity and mental health challenges, adverse birth outcomes for pregnant women, and mortality from any cause. Most notably, homelessness is associated with high rates of dangerous diseases like tuberculosis, HIV infection, and substance use disorder. Housing support can lower a person’s chance of developing these detrimental health conditions.

2. Food Security

Up to 33.8 million Americans face food insecurity, with 1 in 8 U.S. households with children encountering this challenge. Despite a slow decline in these numbers, it must be acknowledged that food insecurity is more prevalent among racial minorities: 20% of Black households and 16% of Hispanic households are food insecure compared to 7% of White households. Many factors, including geographic proximity, financial constraints, and inadequate transportation, can limit individuals’ access to nutritious food. Moreover, most Americans fail to consume enough fruit and vegetables in their diet, and less than 25% can meet recommended physical activity goals. Lack of nutritious foods increases the risk of hunger and causes serious health conditions such as obesity, diabetes, and heart disease, all of which can lead to premature death. Consequently, expanding access to nutritious food can serve the dual purpose of promoting a healthy lifestyle and lowering healthcare costs.

3. Education Access

Several studies indicate that an individual’s level of educational attainment is positively correlated with their health and well-being. Early childhood education can be a preventive measure against disease and disability, further supporting and enhancing health and health behaviors. Meanwhile, pursuing additional levels of education increases the likelihood of getting jobs with higher incomes, which tend to provide health insurance and improve health outcomes. Recent research has identified a substantial difference in mortality rates based on educational achievement. For those born after 1950, each additional level of schooling is associated with at least an 18% lower all-cause mortality rate. This compelling finding suggests that the benefits of education extend beyond immediate health improvements and permeate throughout one’s lifespan. Therefore, government initiatives that prioritize educational accessibility and attainment have the potential to contribute significantly to addressing SDOH, fostering a population with enhanced health behaviors and prolonged life expectancy.

4. Healthy Environment

Environmental factors strongly influence health and wellness. Yet, many American communities still struggle to gain access to a healthy environment due to historical racial discrimination, redlining, exclusionary zoning, and other biased land use decisions. As a result, they are forced to endure poor circumstances like water pollution, hazardous waste, and toxic exposures, which tremendously reduce health outcomes and quality of life. This situation is particularly concerning for communities already faced with other SDOH like food insecurity, educational obstacles, and disinvestment. Besides, it should be recognized that limited access to clean water, safe living conditions, and proper waste management jeopardizes immediate personal well-being and perpetuates long-term health inequities. The cumulative effect of these challenges underscores the intricate linkages between environmental justice and community health, emphasizing the pressing need for comprehensive and equitable interventions on both federal and regional levels.

Federal Actions to Address SDOH by Agency

1. Department of Health and Human Services (HHS)

The HHS has introduced a Strategic Approach to Addressing Social Determinants of Health to foster more equitable health outcomes to Advance Health Equity. This document addresses underlying systemic and environmental factors that affect individual and community well-being, closely aligning with the White House Playbook. Furthermore, the Centers for Medicare & Medicaid Services (CMS), under the purview of HHS, delivers health insurance to over 150 million Americans and has plans to expand coverage to many more. Recently, the CMS has offered states several new options to tackle HRSNs, mainly through clarifying in-lieu-of-service opportunities and approving 1115 demonstration waivers. These alternatives would allow state health officials to create and implement SDOH initiatives targeted towards high-need populations, for example, medically tailored meals or housing transition guidance. Besides, to improve screening for HRSNs, the CMS adds two new SDOH measures to its Hospital Inpatient Quality Reporting program and mandates Medicare Advantage Special Needs Plans to ask enrollees about food insecurity, housing instability, and transportation problems as part of annual health risk assessments. The HHS has played a significant role in recognizing and managing SDOH, contributing to a more inclusive and responsive healthcare landscape

2. Department of Veterans Affairs (VA)

The VA plays its part in tackling SDOH by adopting a Whole Health approach, which entails identifying individual and community-level unmet social needs and delivering evidence-based health and social care services. To put this strategy into action, the department launched a National Social Work Program with a workforce of over 18,500 Master’s trained social workers who are dedicated to providing SDOH-focused services and assessments for veterans nationwide. Particularly concerned about homelessness, the VA also launched a pilot housing model to help ease veterans’ transition from being housed to unhoused. Before moving to permanent housing, veterans are assigned a small unit on the Los Angeles VA campus where they can adapt to their new housing situation while still getting full access to essential services. Another successful VA-led initiative is the Transition Assistance Program, which connects veterans to VA benefits, mitigating the risks of housing and food insecurity during their reintegration into civilian life. Besides, the VA has also participated in the Sync for Social Needs coalition, whose purpose is to ensure consistency in the exchange of patient HRSN data, aligning with the Whole Health approach. Through implementing these programs and beyond, the Department will continue its steadfast commitment to enhancing the health outcomes of veterans.

3. Department of Agriculture (USDA) 

As a critical player in the Biden-Harris Administration’s National Strategy on Hunger, Nutrition, and Health, the USDA has an instrumental role in managing SDOH, particularly food security. The Department actively implements initiatives such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Program for Women, Infants, and Children (WIC), regularly updating food offerings and access as necessary. Most importantly, the USDA has also reexamined the Thrifty Food Plan to align with the cost of a budget-conscious, healthy diet, leading to a 21% rise in the maximum SNAP benefit amounts for a family of four. Furthermore, the USDA is actively collaborating with federal partners, such as CMS, with a dual focus on enhancing data services for benefits delivery and assisting states in streamlining access to benefits. The end goal is to simplify enrollment and recertification procedures for nutrition assistance programs, reducing the burdens on participants to the greatest extent possible. These partnerships aim to utilize data-matching strategies to promote cross-enrollment in USDA- and CMS-led programs to maximize positive impacts on health outcomes. With these comprehensive efforts, the Department is at the forefront of combating food and nutrition insecurity, significantly enhancing Americans’ health status.

4. Department of Education (ED)

Recognizing the importance of education in addressing SDOH and enhancing health status, the ED works to augment the quality of public instruction from pre-kindergarten through post-secondary levels and beyond. Through its Raise the Bar program in collaboration with various states, districts, and schools, the ED aims to expedite learning for students, especially those belonging to underserved communities who require extra support to catch up to pre-pandemic trends. In addition to an academic focus, this initiative also prioritizes the overall well-being of every student while ensuring that they have a well-defined path to college and career success. Furthermore, leveraging substantial funds from the American Rescue Plan and the Bipartisan Safer Communities Act, the ED directs investments toward high-quality tutoring, afterschool, and summer learning programs. For example, the Department has brought more than 20 organizations together in the Engage Every Student Initiative to guarantee availability in out-of-school programs for any child who demonstrates sufficient interest. Through these concerted efforts, the ED is actively shaping a future where students have the support and resources necessary for educational achievement and long-term success, allowing them to experience improved health outcomes.

At the Network for Nonprofit and Social Impact, we are dedicated to discovering how non-profit organizations can better work together to move the needle on social issues. However, federal agencies like the HHS, VA, USDA, and ED operate in separate silos, lacking the cohesion needed to address complex SDOH matters comprehensively. Despite the successful implementation of individual measures, these institutions continue to encounter challenges in fostering effective collaboration, which results in a fragmented approach. Through research, advocacy, and capacity-building programs, the NNSI aims to establish a knowledge exchange platform for SDOH and other pressing issues, thus empowering federal agencies to cooperate more seamlessly. By promoting a regulatory environment that fosters joint initiatives and resource-sharing, we can overcome existing communication barriers and better resolve HRSNs among Americans. Click here to find out more about our approach to SDOH and systems of care.