Medicaid Researching Social Determinants of Health

It’s no secret that where we live, work, and age has a major impact on our overall health. Over the past decade, public health organizations — including the World Health Organization (WHO) — have emphasized the importance of creating social and physical environments that support good health for all people.

Now, Medicaid officials are expanding efforts to address these “social determinants of health” (SDOH) across a broad population of enrollees, especially seniors, people with disabilities, and low-income families. The goal is simple but profound: improve health outcomes by addressing the non-medical factors that affect well-being every day.

What Are Social Determinants of Health (SDOH)?

Social determinants of health refer to the conditions in which people are born, grow, live, work, and age. These factors affect everything from access to care to quality of life. Common examples include:

Access to safe, affordable housing and nutritious food
Education, literacy, and job opportunities
Transportation options and mobility accessibility
Social connections and support networks
Access to healthcare and technology (Internet, phones)
Environmental quality, including clean air, water, and safe neighborhoods

When these essential elements are missing, individuals are more likely to experience chronic illness, stress, and reduced quality of life.

How SDOH Impact the Elderly and Disabled

Seniors and individuals with disabilities are among the most vulnerable to poor social conditions. Limited income can lead to inadequate housing, food insecurity, or social isolation. Neighborhoods without accessible transportation or safe walkways can make it difficult for older adults to stay engaged or reach healthcare services.

For those living alone or with mobility issues, even minor environmental challenges can lead to major health risks. Addressing these social barriers is crucial to helping older adults live independently and with dignity.

How Medicaid Is Addressing Social Determinants of Health

In recent years, Medicaid has recognized that improving health outcomes requires more than just medical care — it requires addressing social and economic conditions as well. States are increasingly using 1115 waivers and managed care contracts to fund and expand programs that target housing, nutrition, and community engagement.

Key Federal and State Initiatives

Accountable Health Communities Model (CMMI): This program connects Medicaid and Medicare beneficiaries with community services to address health-related social needs. It focuses on screening, referrals, and navigation services to reduce costs and hospitalizations.
State Innovation Models (SIM): Funded by the Centers for Medicare and Medicaid Innovation, SIM helps states develop and test new ways to improve healthcare delivery while reducing costs. States like Ohio, Connecticut, Washington, and Delaware are using these funds to link primary care with community-based organizations and social services.
1115 Waiver Demonstrations: States such as New York, North Carolina, and Rhode Island have used waivers to invest in community-based organizations that provide social services. Others, like Colorado and Oregon, are integrating physical, behavioral, and social services through regional health entities.

Housing and Health: A Critical Connection

Stable housing is one of the strongest predictors of good health. The American Hospital Association reports that nearly 1.5 million people experience homelessness each year, making them more vulnerable to infectious diseases and chronic illness.

While Medicaid cannot pay for room and board directly, it can fund supportive housing services — such as case management, care coordination, and referrals. For example:

New York’s DSRIP initiative helps providers create supportive housing for vulnerable populations.
Louisiana’s Permanent Supportive Housing Program has reduced hospitalizations and Medicaid costs by keeping people stably housed.

These programs show how Medicaid dollars, when used creatively, can reduce emergency care use and improve long-term health outcomes.

Private and Nonprofit Health Sectors Are Joining In

It’s not just Medicaid leading the charge. Private health organizations and nonprofits are investing heavily in social health initiatives:

Humana Foundation has awarded grants to programs improving nutrition, community health, and telehealth access.
UnitedHealthcare (UHC) has invested over $400 million in affordable housing initiatives, funding more than 80 communities nationwide. These investments have led to significant drops in emergency room visits and overall healthcare costs.

Many insurers are also integrating SDOH assessments into clinical workflows, merging census data with patient information to identify needs early and tailor interventions effectively.

Building Health Equity Beyond Healthcare

Improving health outcomes requires collaboration beyond the healthcare system. Public transportation, education, and housing policies all influence community health. Programs that provide early childhood education, access to healthy foods, and safe, walkable neighborhoods help lay the groundwork for healthier lives — especially in underserved communities.

The Future of Medicaid and SDOH Integration

Moving forward, Medicaid and other payers will continue expanding efforts to integrate social services into healthcare delivery. We can expect to see:

More 1115 waivers supporting housing and food programs
Stronger partnerships between healthcare providers and community organizations
Increased data tracking on social needs and health outcomes

Ultimately, addressing social determinants of health is about creating health equity — ensuring everyone has the opportunity to achieve their best possible health, regardless of income or environment.

Medicaid Researching Social Determinants of Health

Medicaid Researching Social Determinants of Health