Who's Responsible for What?

Aligning Health Systems, Grassroots Action, and Government Policy to Tackle Social Determinants of Health: Don’t Let Them Tell You We Can’t Do Anything.

Jun 23, 2025

(Upstream- addressing SDOH before they get downstream)

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“If a patient keeps showing up in the ER with asthma attacks, and we’re only giving them an inhaler, we’re not doing our jobs.” - your local hospital administrator

I talk a lot about the social determinants of health (SDOH): the non-medical factors that shape our well-being—things like housing, food access, transportation, and economic stability. For some reason, when it comes to solving these problems, the conversation gets fuzzy.

Who’s actually responsible for addressing SDOH? I think every stakeholder is responsible but not in the same way.

Today, I want to talk about how hospital systems, local communities, and government entities can each uniquely address SDOH, and how they can do it without going broke.

Hospitals: The Economic and Moral Case for Addressing SDOH

Hospitals are increasingly being held accountable for population health, especially in value-based payment models. Beyond financial incentives, hospitals can’t improve outcomes without addressing what happens outside their walls.

What Hospitals Can Do:

Screen patients for social needs.
Example: Implement universal screening for food insecurity, transportation, and housing instability during intake.
Build medical-legal partnerships.
Example: Boston Medical Center co-locates legal aid within clinics to help patients fight evictions or access SNAP benefits.
Invest in housing.
Example: Bon Secours in Baltimore invested in renovating nearby low-income housing, improving health outcomes and neighborhood safety.
Create community health worker (CHW) programs.
Example: CHWs can connect discharged patients with food pantries, utilities assistance, and transportation to follow-up care.

Financial Viability:

Community Benefit Requirements: Nonprofit hospitals must provide community benefit activities—SDOH programs often count.
Reduced Readmissions & ED Visits: Fewer preventable readmissions mean avoiding CMS penalties.
Tax credits & grants: Many programs are eligible for federal/state funds or local development tax incentives.
Return on Investment: For example, Kaiser Permanente’s housing investments are expected to reduce healthcare costs by stabilizing high-need patient populations.

Communities: Local Wisdom, Grassroots Power

Local community organizations, faith groups, and neighborhood leaders are the eyes and ears on the ground. They understand the cultural, linguistic, and structural barriers residents face daily.

What Communities Can Do:

Run food distribution programs tailored to cultural needs.
Example: Community-led pantries that offer halal, gluten-free, or culturally relevant ingredients.
Start transportation collaboratives.
Example: A rural community center partners with Uber Health and local churches to offer rides to medical appointments.
Host health literacy workshops.
Example: Peer-led sessions about Medicaid enrollment, managing diabetes, or navigating insurance paperwork.
Build trusted relationships with vulnerable populations.
Example: LGBTQ+ centers offering gender-affirming health navigation or refugee centers with multilingual caseworkers.

Financial Viability:

Grants and philanthropic funding: Many community-based organizations (CBOs) operate with federal, state, or foundation grants.
Partnerships with health systems: Hospitals can contract with CBOs for navigation and outreach services.
Low overhead: These groups are nimble and often volunteer-driven, stretching limited resources for maximum impact.

Government (Federal & State): Policy, Infrastructure, and Scale

Government is the only sector with the power to shift entire systems- by changing policy, reallocating funding, and setting standards.

What the Federal Government Can Do:

Expand Medicaid and protect CHIP funding.
Example: Medicaid expansion has been linked to improved housing stability and reduced food insecurity.
Fund housing and transportation infrastructure.
Example: HUD-VASH program (VA + HUD) provides housing vouchers and case management for homeless veterans.
Incentivize SDOH interventions in Medicare and Medicaid.
Example: The ACO REACH model includes health equity benchmarks and lets providers bill for addressing social needs.
Support rural broadband and telehealth.
Example: The FCC’s Rural Digital Opportunity Fund expands internet access, critical for telehealth and job access.

What State Governments Can Do:

Use Medicaid waivers to fund SDOH.
Example: North Carolina’s Healthy Opportunities Pilots allow Medicaid dollars to pay for housing support, food, and transportation.
Support public health departments and local initiatives.
Example: California’s Whole Person Care program brings together health, behavioral health, and social services.
Fund workforce pipelines for CHWs and social workers.
Example: State-funded programs to train and certify community health workers, especially from underserved backgrounds.

Financial Viability:

Budget-neutral waivers: States can get CMS approval for innovative Medicaid programs that don’t increase federal spending.
Economic ripple effects: Investments in stable housing and jobs reduce downstream spending on emergency care, incarceration, and unemployment.
Blended funding streams: Governments can combine health, education, and housing dollars to address complex needs.

Putting It All Together: Collaboration Isn’t Optional

No one sector can do this alone. Addressing SDOH is a team sport, and shared impact requires shared investment.

Example Collaborative Models:

Anchor Institution Models: Hospitals work with city officials, schools, and housing agencies to improve a whole neighborhood.
Health Equity Zones: Rhode Island’s model funds local collaboratives to tackle SDOH with community-defined goals.
Accountable Communities of Health (ACHs): Seen in Washington State and elsewhere, these cross-sector collaboratives align funding and goals across healthcare and social services.

Everyone Has a Role, But It's Not the Same Role

When we try to solve every problem with one tool, it seems like we either overreach or underperform. Hospitals are not housing authorities. Community groups can’t change Medicaid policy. However, there is a way we can work together. Each sector can move the needle on what makes people healthy long before they ever enter a clinic.

I think we need to stop asking, “Who’s in charge?” and start asking, “How can we each do our part and do it well?”

Let’s Chat

How is your organization tackling social determinants of health? Are you seeing more collaboration?

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