Health Policy$ense

Health Systems and Social Determinants

New Administration, Same Challenges

The election of Donald Trump has ushered in an uncertain future for the Affordable Care Act (ACA), from modification to total repeal. While many policy experts are concerned about people losing the coverage they gained through the ACA, other aspects of the ACA are also under threat: specifically, provisions that address the social determinants of health.

Although they draw far less attention than the coverage expansions, the incentive models built into the ACA push health systems towards addressing the social and environmental needs of their patients. We know that health is determined by social circumstance just as much as it is by health care. Though the health sector has traditionally focused on improving health care, what patients want is better health.

My colleagues and I recently described three ACA-based policies that affect how health systems integrate social determinants into their overall approach:  the community benefit standard for non-profit tax exemption, new payment models, and CMS’ Accountable Health Communities Model. Though they use different mechanisms, these policies use a common lever that resonates with health systems: money. Whether through taxes, reimbursement, or grants, these policies have begun to encourage hospitals to play a more significant role in addressing social determinants.

Yet these policies have fallen short to the extent that they encourage passive reactions from health systems, rather than active engagement:

  • The new community benefit standard requires a Community Health Needs Assessments (CHNA) to document the hospital’s surrounding community needs and outline an action plan to address them. However, the IRS does not require hospitals to implement these plans—a critical step in achieving the goal of better health.
  • New payment models such as shared savings programs, intentionally or unintentionally, insert social determinants into the financial equation for health systems. In the Hospital Readmissions Reduction Program, for example, risk-adjusting for 30-day readmission rates may avoid disproportionately punishing hospitals in poor areas. But beyond risk-adjusting, funds could be reapplied to help safety net hospitals address the social determinants that lead to higher readmission rates.
  • CMS’ Accountable Health Communities Model evaluates the impact of stronger linkages between the health sector and public health, but does not directly reward health systems for providing or funding social services.

With the ACA’s future in question, the path forward is less clear but the goal should not change – improving the health of Americans. The parts of the ACA that put social determinants into the financial equation for health care providers was an important step. These provisions could be retained and strengthened. Alternately, any replacement plan should take on the social determinants of health directly and earnestly.

Despite the campaign rhetoric surrounding the ACA and the health insurance exchanges, the Trump administration can still shape health care in ways that address social determinants. If addressing social needs reduces overall costs and improves health, it’s a win for all Americans, whether they voted for Trump or not.