Despite considerable scholarly and health care industry agreement that addressing the social determinants of health (SDOH) is essential for improving the population’s health status, there is little agreement on how health care systems and insurers should approach the problem. The growing recognition of the SDOH is driving new efforts to integrate health care and human services, including housing, social services, and nutrition. Developing these initiatives involves working across sectors with different organizational structures, business models, and cultures.

But implementing investments in housing, social services, nutrition, and other areas outside of the health care enterprise to improve the well-being of entire communities has been challenging. For health insurers and health systems, which tend to be focused on the needs of their patients and insured populations, it can be challenging to integrate not only those specific needs, but also those of the community at large. In this post, we explore the limits of these arrangements.

To gain insight into the roles of health insurers and health care organizations in pursuing investments in human services, we studied whether and how written agreements are being used to implement SDOH investments in their surrounding communities. When health care organizations create cross-sector partnerships, we hypothesized that they would use contracts as effective mechanisms for defining the responsibilities of participating organizations, ensuring accountability for results, and scaling investments beyond health care financing and delivery. Because cross sector partners are driven to achieve financial savings while still producing positive changes to the community’s health, we hypothesized that contracts would be an effective tool for defining measurable outcomes through an impact assessment approach.

To find out if we were correct, we interviewed leaders at several health organizations to understand better how they structured partnerships, finances, and programs aimed at improving SDOH. These interviews helped us understand how to approach future integrative efforts.

We first focused on identifying community-wide health initiatives that reach beyond patient populations, then evaluated how these efforts are improving community health, and assessed the potential of each program’s potential scalability. We identified programs of interest by reviewing examples of promising Medicaid waiver programs, community health centers, and nonprofit organizations that address community social factors beyond their patient populations, and speaking to experts in the field. We then conducted pilot interviews with 10 leaders of four separate cross-sector collaborations designed to address SDOH. In these interviews we sought to identify key elements of the arrangements between health insurers and health systems, and the organizations addressing key SDOH in their communities.

Despite the emerging consensus that integration efforts addressing SDOH improve community health outcomes, we found that the cross-sector partners we interviewed are not utilizing contracts or written agreements to formalize community investments in sectors beyond health. Most efforts are only focused on existing patients and insured populations, failing to reach individuals who are not health system patients or otherwise covered by insurance products. The pilot interviews demonstrated that many cross-sector partners engage in frequent and serious dialogue between health systems and community partners, but with much less participation from insurers.

In fact, we did not identify cross-sectoral partnerships that included any investments from health insurers to reach beyond the already insured patient populations. While our interviews identified both discussions and planning aimed at those goals, there appears to be limited forward movement toward implementation through formal agreements. Rather than addressing community-wide needs, the initiatives remain embedded in serving the insured patient population.

Likewise, public health departments seem to play at best a subsidiary role in the process. While health departments are often either involved or consulted, they do not appear to play a central role in how the initiatives are developed and implemented beyond the ACA-required Community Health Needs Assessment activity. While COVID has understandably stretched the capacity of health departments in multiple ways in the past year, it would be unfortunate to forego their deep knowledge and skills in addressing population health issues. Although this aspect is beyond the scope of our interviews, our experience with the process suggests that the reasons may include retaining hospital control of the process, and unfamiliarity with how the two systems could collaborate to improve the community’s health.

We observed several barriers to health insurers and health care systems employing contracts for community investments: uncertainties of working outside their areas of experience; lack of staff and resources to support entering formal agreements; lack of staff trained in population health analysis and interventions; and limited financial incentives for investing in projects that might not provide direct benefits to their patients and insured populations. The interviews also revealed that measurable outcomes are general in nature rather than being specified. For example, partnerships often failed to use specific quantitative measures, i.e., “homelessness was reduced by x percent,” to determine the success of initiatives. Defining measurable metrics is essential to determining the effectiveness of cross-sector partnerships addressing SDOH. Understanding the partnership’s impact on particular social and health problems is necessary to sustaining the partnership and securing long-term funding.


Our interviews, while not dispositive of the varied cross-sector arrangements, show that the partnership efforts underway to improve SDOH could be at risk of stalling out. At a minimum, stakeholders show uncertainty about sustainability of investments in SDOH, the lack of adequate staff and resources, and the complicated nature of developing and implementing contractual arrangements. Cross-sector partners are engaging in a new frontier of health integration efforts and are uncertain of how the efforts outside of health care will affect patient care and revenue, whether programs are designed to produce positive health outcomes, and whether money will be strategically spent. Partners are insufficiently funded to overcome these barriers and lack the staff capacity to adequately understand population health interventions. Equally important, the lack of the public health system’s involvement from the outset exacerbates the staffing capacity concerns. In their efforts to create partnerships addressing SDOH, cross-sector partners, especially health system leaders, recognize and seek to remedy these complex and endemic social problems. However, several interviewees reported that these issues can be overwhelming, making partners feel as if they are tasked with undoing years of an unravelling U.S. safety net.

Public policy changes may help address these barriers. Policy makers should use financial assistance, such as funding for demonstration projects from the Centers for Medicare & Medicaid Services (CMMS) Payments, to incentivize health care enterprises to effectively improve long-term health outcomes through interventions that support individuals beyond their patient population. Doing so may encourage the private health insurance industry to make robust investments in addressing the SDOH.

As an example, CMMS has funded State Innovation Models (SIMs) to support multi-payer health system performance improvements. This funding mechanism encourages state-wide innovation and helps stimulate the formation of community-based backbone organizations. Backbone organizations function as coordinating bodies bringing together several entities to achieve a common goal, by guiding vision and strategy, synchronizing efforts, facilitating effective communication. At least in some instances, such as Washtenaw County, Michigan, the backbone organizations migrated from health system improvement to developing community-wide strategies for improve the community’s health status. Creating community-based backbone organizations may be needed to engage and provide technical capacity to advance cross-sector collaboration, including negotiating and drafting contracts. Contracts or written arrangements could explicitly specify the outcomes to be measured.

Looking Ahead

Our interviews identified several barriers to forming effective, long-term partnerships that invest in community-wide health initiatives. Minimal engagement by public health departments leaves cross-sector partners without the financial resources or subject-matter expertise to invest in complicated community initiatives. The partnerships are uncertain of how efforts outside of health care will affect patient care and revenue and are unwilling to take the risk with little accountability when making community investments. When partnerships do have adequate resources, there is minimal use of binding investment agreements that formalize commitments to serve the broader community in ways seeking to address SDOH. Cross-sector initiatives have the potential to scale, but it is difficult to see how this can happen without mechanisms for clear accountability, especially measurable outcomes.

While we set out to study how these partnerships use contracts to secure and measure the outcomes of community-based investments, it appears that the structural barriers we identified must be addressed before determining whether contracts would be an effective strategy. In short, it seems premature to focus on contractual arrangements as a solution to improving cross-sectoral arrangements. Once the major structural barriers are addressed, contracts may then be a useful way of implementing the resulting SDOH initiatives.

Even though the interviews did not confirm our working hypothesis, other findings support the need to integrate health insurers and public health departments into the design and implementation of the initiatives. Health insurers must play a more prominent role in providing funding for SDOH demonstration projects. After all, a healthy community will result in lower health care costs and more effective health care delivery.

Olivia Backhaus is a 3L at Georgetown University Law Center and a research assistant at the O’Neill Institute.

Peter Jacobson is Professor Emeritus of Health Law and Policy, University of Michigan School of Public Health, Co-Director, Mid-StatesRegion of the Network for Public Health Law, and a senior scholar at the O’Neill Institute.

John Monahan is the senior adviser to the president of Georgetown University, and holds academic appointments as a professor of medicine, senior lecturer in law, and senior fellow at the School of Public Policy.