Funder: The Commonwealth Fund

Author: Anna Spencer, Bianca Freda, and Tricia McGinnis, Center for Health Care Strategies, and Laura Gottlieb, MD, University of California, San Francisco

December 2016 | Brief


Newer payment and care models aimed at improving health outcomes and lowering costs of Medicaid beneficiaries are leading providers and health plans to address the root causes of poor health and high health care costs, some of which relate back to underlying social needs, such as housing and nutrition. Collecting and using data to understand the health-related social needs of patients can help guide state Medicaid agencies in supporting such innovative interventions. Little is known, however, about state-based efforts to collect and use social determinants of health (SDOH) data, including what data health plans and providers are required to collect.

This brief, made possible by The Commonwealth Fund, explores strategies that states are using to capture SDOH information on Medicaid beneficiaries. The insights gleaned from interviews with early state innovators can help policymakers drive greater and more consistent collection of individual-level SDOH information, which can inform patient-level interventions, population health management, research and evaluation, and broader delivery system reform. As federal and state policymakers determine how to structure publicly financed health care for low-income Americans, they should be armed with information about how to measure the social determinants of health and facilitate stronger linkages between health and social service agencies.