Despite great strides in biomedical innovation—as evidenced by the timely development and emergency use authorization of COVID-19 vaccines—there were tremendous inequities in infection, hospitalization, mortality, and vaccination rates during the pandemic among Black, Latinx, Indigenous, and other historically marginalized populations. The pandemic thus put a spotlight on the considerable research connecting upstream systemic structural racism to downstream disparities in health and the unmet social needs that contribute to poor health.
The stark disparities seen during the early months of the COVID-19 pandemic led to new health policy funding and interventions focused on addressing social needs and social determinants of health with the aim of improving health equity. The health care system is well-positioned to identify and address some social determinants of health and unmet social needs—and in recent years, much progress (often bipartisan) has been made in this area. But policy changes must go beyond acute responses to the pandemic to sustainably address both urgent social needs and the underlying systemic issues causing them.
This brief focuses on early research and practical evidence about health policy–led programs and policies that address social needs as a way to mitigate health disparities magnified during the pandemic. There are open questions about which of these policies should continue, and in what form. What lessons do they impart for broader health equity interventions? What policies can lead to the widespread and sustainable change needed to address structural factors creating social marginalization and poor health? Supplementing lessons from these pandemic policies with prepandemic health policies, this brief provides recommendations for policy makers seeking to create or expand policies to address social needs and health inequity. We draw on literature review, policy analysis, and perspectives from a multidisciplinary team of authors.
A Framework For This Brief
The COVID-19 pandemic led to disproportionately devastating health, social, and economic conditions for historically marginalized populations. The consequences of this once-in-a-century public health emergency affect all sectors of society. Accordingly, interventions to mitigate its effects spanned the full range of public policies and programs. To be useful to policy makers seeking to build or sustain health policy–driven interventions to address social needs and improve healthy equity, we focus on programs and policies that meet two criteria. First we focus on US pandemic-related interventions that either were led by health policy makers or are cross-sectoral interventions in which health policy makers played a critical role. We exclude interventions outside of the health sector and without significant health policy involvement. This focus highlights the significant political window of opportunity and financing that is open now for addressing social needs through health policy and health care transformation.
Second, we focus on such interventions that target “downstream” and intermediary social determinants of health or social needs and exclude those that are more upstream. Our reasoning is that interventions targeting “upstream” structural social determinants of health are typically outside of the health sector (our first exclusion criteria). To be specific and consistent, throughout this brief we use concepts and terms from the World Health Organization’s social determinants of health framework. See supplemental exhibit 1 for more information.
We acknowledge that reducing health inequities and addressing social determinants of health necessitates looking beyond health systems to upstream policies led by sectors such as housing, education, child care, and labor. Within the context of the pandemic, a key example outside the scope of this brief is the Pandemic Electronic Benefits Transfer expansion, which substantially reduced food insecurity for families with children. A prepandemic example is the Department of Housing and Urban Development’s Moving to Opportunity for Fair Housing, in which providing vouchers to low-income families with children to move to low-poverty neighborhoods improved both social and health outcomes. Many such non-health-sector interventions with large downstream health impacts are the topics of other policy briefs in this series.
Health Policy–Led Interventions Targeting Social Determinants Of Health And Social Needs
We highlight illustrative examples of health policy–led interventions targeting social determinants of health below. These policies are neither the only ones that attempted to address social needs nor the only ones to advance health equity, although they are innovative exemplars from which to draw preliminary lessons and recommendations.
Until January 2021 there was no unified executive branch health policy approach to addressing social determinants of health and social needs resulting from COVID-19. Instead there was a patchwork of federal policies and actions, mostly legislative, temporary, and outside the scope of health policy. In 2021 the Biden administration began to coordinate efforts to improve COVID-19-related response and recovery. Some of these efforts were temporary, rolled into the American Rescue Plan Act of 2021 passed in March 2021. Notably, the executive effort included a government-wide pandemic health inequities task force with a focus on underlying social vulnerabilities. The task force’s final report recommended federal prioritization of government efforts related to elevating community expertise, accurate data representation, ensuring health care access, and prioritizing equity in policies and practices.
In addition to the task force recommendations, the Biden administration announced $785 million in American Rescue Plan Act funding, much of which provided support for community health workers, school nurses, and community-based organizations in underserved communities. Other relevant executive actions include an executive order establishing the COVID-19 Special Enrollment Period for health insurance exchanges and the Centers for Disease Control and Prevention (CDC), for the first time ever, declaring racism a public health threat. Supplemental exhibit 2 summarizes these and other federal interventions.
Our scans of peer-reviewed literature, grey literature, and state-based or state stakeholder websites (for example, the National Governors’ Association) identified several states that developed more comprehensive health policy–led interventions to emergently address social determinants of health and social needs earlier in the pandemic than did the federal government. We identified three exemplar strategies from states with different contexts; see supplemental exhibit 3 for additional details and early results.
Use Of CARES Act Funding To Address Multiple Social Determinants Of Health And Social Needs:
Significant new federal funding for state and local governments enabled the establishment of expansive and innovative programs. An exemplar is the North Carolina Department of Health and Human Services decentralized COVID-19 Support Services Program for quarantine-related social isolation, supported by Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and state funds. The program supported four regional grantees to provide transportation to and from medical services and housing shelters; home-delivered food, medications, and COVID-19 supplies; and financial relief for housing, child care, and living expenses. The COVID-19 Support Services Program had an equity-focused design in two ways. First, the application process favored organizations run by and serving historically marginalized populations heavily burdened by COVID-19. Second, the program leveraged an expanded community health worker program (partly funded by CARES Act, CDC, and state funds), in which trained community health workers supported grantees as resource navigators and client identifiers.
Focused Programs Targeting Specific Pandemic-Related Social Determinants Of Health And Social Needs:
Several state and city governments launched targeted efforts to address a particular social need related to COVID-19, such as housing. For example, Arizona’s Medicaid agency partnered with Maricopa County, housing authorities, and community providers to use the Homeless Management Information System to identify those who are experiencing or are at risk for experiencing homelessness who test positive for COVID-19 and connect them with social and medical services. California expanded its existing Whole Person Care pilot program to offer social services and care coordination to any Medicaid enrollee who tests positive for or is at high risk for COVID-19.
Equity Task Forces For Cross-government Collaboration:
Some states used executive authority to establish expansive task forces specifically focused on inequities and social determinants of health. One example is the Ohio Department of Health’s Minority Health Strike Force, which launched a statewide campaign on COVID-19 inequities including culturally appropriate exposure notifications and increased testing capacity. The task force also prioritized assessing and addressing social determinants of health among historically marginalized populations as next steps (such as improving access to high-quality education, decreasing incarceration rates, and increasing affordable housing).
North Carolina used COVID-19 relief funding to create the Andrea Harris Social, Economic, Environmental, and Health Equity Task Force to provide recommendations to the state’s governor every six months addressing social, environmental, economic, and health disparities in historically marginalized populations that are disproportionately affected by COVID-19. Most recently, the task force outlined how to achieve these goals through the governor’s proposed fiscal year 2021–23 budget, use of state American Rescue Plan dollars, and other funds, legislation, or agency action.
Building On Pandemic Progress: Recommendations For Policy Makers
We synthesized lessons and preliminary evidence from the policies and programs in this brief into recommendations for policy makers who want to move beyond acute responses to crises to implement sustainable approaches to addressing social determinants of health and health equity. We also embedded lessons from similar exemplar health policies created before the pandemic. See supplemental exhibit 4 for a summary of our recommendations.
Leverage Government Executive Leadership To Establish Cross-sectoral Agency Collaboration
Leadership-championed mechanisms for cross-sectoral collaboration can jump-start work on health equity. As such efforts leverage executive authority and need minimal funding, they can be formed rapidly as a first step. Commonly, states used health equity task forces during COVID-19. Examples we reviewed—including the North Carolina and Ohio task forces described here—focused on a variety of intermediary social determinants of health (for example, employment opportunities, educational quality, food availability, and health system expansion or reform). This cross-sectoral model can be useful, as social determinants of health do not fit neatly into any single agency or department. However, task forces run the risk of burying an issue in recommendations, so they must maintain focus on vision and have accountability measures. Further, it should be noted at the outset that task forces are not the end goal—they are a quick and powerful way to organize cross-sectoral human capital around a policy problem, but the ultimate goal should be sustained collaboration.
Looking to past and current exemplars unrelated to COVID-19, two states took different task force approaches to addressing intermediary social determinants of health. One approach is Maryland’s Children’s Cabinet, a governor-established task force with executive branch department heads and state leaders focused on coordinating child and family social services to improve child well-being. The program achieves success by focusing on four intermediary social determinants of health domains: incarceration, employment, nutrition, and housing.
In comparison, Tennessee established Building Strong Brains, a collaboration among all three branches of state government that focuses on mitigating violence, abuse, neglect, substance use, and mental illness underlying adverse childhood experiences. The collaboration coordinates dozens of policies and programs, such as training teachers and parents in social-emotional learning programs and placing mental health liaisons in public schools. Factors in the success of Tennessee’s task force include partnership with public relations experts to frame social and scientific issues in understandable, actionable terms; a focus on evidence of the problem and effectiveness of interventions instead of politics; and a prominent kickoff event covered by media.
Expand Health Insurance Coverage
Although the uninsurance rate has decreased since implementation of the Affordable Care Act (ACA; and further dropped during the pandemic), there remain significant disparities in coverage and millions of people without coverage. During the pandemic, there were some health insurance expansions such as the ACA Marketplace Special Enrollment Period for COVID-19 and President Biden’s executive order on strengthening Medicaid and the ACA. The latter directed federal agencies to reexamine Centers for Medicare and Medicare Services (CMS) demonstrations and waivers that reduce coverage. Coverage expansion, an intermediary determinant of health in the World Health Organization framework, is linked to health equity. People without coverage have limited access to health care services and poorer health outcomes, and limited coverage is a driver of disparities. Older adults have higher COVID-19 mortality risk, but the higher rates of insurance coverage in older adults (because they are eligible for Medicare) may explain reduced COVID-19 excess mortality among older adults relative to younger populations.
The link between coverage expansion and social outcomes is also documented. Medicaid expansion under the ACA generated economic stimulus, increased financial security, and reduced poverty rates. However, simply expanding access to a fee-for-service health system is problematic, as fee-for-service does not provide health systems with flexibility to address patients’ social needs. The links among coverage expansion, payment and delivery models, and health equity require further research, but we discuss here potential models that can be used in conjunction with coverage expansion to accountably address social needs.
Leverage Value-Based Payment To Sustainably And Directly Address Social Needs
Value-based payment models are a potential way to flexibly and accountably address (and fund) social needs on a large scale. Three states with contrasting political and demographic contexts—New York, North Carolina, and Oregon—are taking major steps to address social needs through value-based payment in Medicaid. North Carolina launched the Healthy Opportunities Pilots using a Medicaid Section 1115 demonstration waiver. The waiver provides $650 million in funding for Medicaid managed care to work with networks of community-based organizations to address a large list of health-related social needs. The program will begin service provision in early 2022.
Oregon developed the coordinated care organization program through state legislation to provide “health-related services” such as food and housing supports to Medicaid recipients. Coordinated care organizations are similar to accountable care organizations (ACOs) but provide prospective global budgets instead of retrospectively assessed benchmarks, involve community oversight, and require some savings to be spent on interventions addressing social determinants of health and equity.
New York announced in August 2021 its intent to submit a Section 1115 waiver requesting $17 billion to pay for and integrate social care into health care to address health inequities exacerbated by COVID-19. The state proposes building on its prior value-based payment Medicaid initiative to create Health Equity Regional Organizations—coalitions of managed care organizations, hospitals, health systems, ACOs, behavioral health providers, community-based organizations, and others. Incentives for improving health equity will be built into the value-based payment arrangements.
However, research on the use of value-based payment to address social needs is nascent. There remain challenges, including limited data collection on social needs, constrained cross-sectoral data sharing, and limited techniques for ensuring that health systems are judged fairly, depending on social risk factors. In addition, clinical and human service organizations must develop significant new competencies to deliver new services.
Design factors also affect whether value-based payment models reduce health disparities, such as whether quality measures incorporate equity or the model adequately supports providers that focus on historically marginalized populations. CMS and the Center for Medicare and Medicaid Innovation recently released their vision for the next decade, with plans to work on these issues, but could solicit and fund state value-based payment initiatives focused on social needs and health equity.
Use Cross-sector Data Partnerships To Automatically Identify People Eligible For Programs
Policy makers can facilitate and automate service referral through public-private technology partnerships designed for cross-sectoral linkages and robust program data reporting. For example, North Carolina created NCCARE360, a statewide technology platform connecting clinicians and community-based organizations to securely share information and help community health workers refer people for services. The system follows up on referrals to see whether unmet social needs were addressed. As noted previously, Arizona Medicaid partners with community providers with access to Homeless Management Information System data to facilitate outreach for care coordination and services for those who are experiencing or are at risk for experiencing homelessness. New York received funding from the federal Administration for Community Living to establish the New York eHealth Collaborative—a social care data exchange—to help integrate social and health providers and interventions. Colorado similarly proposed a Social-Health Information Exchange to coordinate referrals between health and social services agencies.
Meaningfully Engage Communities And Historically Marginalized Populations In Policy Implementation And Design
Policy implementation and design must meaningfully engage communities and historically marginalized populations to build trust, respect, and cultural competency. North Carolina’s COVID-19 Support Services Program offers such lessons. The state partnered with trusted community-based organizations to provide necessary social supports—prioritizing contracts with organizations run by and serving historically marginalized populations heavily burdened by COVID-19. For COVID-19 therapeutics, vaccine planning, and rollout, partnership and representation from local leaders and public health authorities was key in state plans to address disparities in access and built trust.
Formally Recognize Health Equity As The Goal And Structural Racism As A Root Cause Of Health, Economic, And Social Inequities
No matter the policy mechanism, leaders from government and health payers should explicitly recognize health equity as the goal and systemic structural racism as a fundamental cause of racial inequities in health, economic, and social outcomes. In April 2021 the CDC, for the first time, declared racism a public health threat. Leaders must establish and continually reaffirm such messages, especially during moments of significant racial and civil tension, as Health and Human Services Secretary Xavier Becerra did after the Derek Chauvin verdict in April 2021. Such recognition helps incorporate equity into the vision of policies so focus does not deviate over time, and holds policy makers accountable to structural considerations when designing system-wide interventions.
The public health emergency elucidated ways that systemic structural racism and inequities in social determinants of health manifest disparities in health and unmet social needs. Structural and intermediary issues will take time to solve as they, by definition, need to address systemic roots and require actions by many stakeholders. In the meantime, policies to sustainably address social determinants of health and unmet social needs beyond the acute phase are urgently needed. This brief supports these changes by reviewing exemplar policies and outlining short-term and long-term steps for policy makers to sustainably address urgent social needs while tackling structural and intermediary social determinants of health—ultimately to increase health equity.
Acknowledgments And Disclosures
The authors thank Hemi Tewarson and Elaine Hall Chhean for helping to inform this work. William Bleser has previously received consulting fees from Merck for research for vaccine litigation unrelated to this work; from BioMedical Insights, Inc., for subject matter expertise on value-based cardiovascular research unrelated to this work; from Gerson Lehrman Group, Inc., on health policy subject matter expertise unrelated to this work; and from StollenWerks LLC on health policy delivery system change unrelated to this work. He also serves as board vice president (uncompensated) for Shepherd’s Clinic, a clinic providing free health care to the uninsured in Baltimore, Maryland. Robert Saunders has a consulting agreement with Yale-New Haven Health System for the development of measures and development of quality measurement strategies for Center for Medicare and Medicaid Innovation Alternative Payment Models under CMS Contract No. 75FCMC18D0042 and Task Order No. 75FCMC19F0003, “Quality Measure Development and Analytic Support,” option year 2. The Duke-Margolis Center for Health Policy values academic freedom and research independence, and its policies on research independence and conflict of interest are available at: https://healthpolicy.duke.edu/research-independence-and-conflict-interest. The mission of the Duke-Margolis Center for Health Policy at Duke University is to improve health, health equity, and the value of health care through practical, innovative, and evidence-based policy solutions.