The emergency department (ED) has long been described as the, “safety net of the safety net,” providing care to anyone, for anything at any time, including the most vulnerable of populations. Emergency physicians have long seen the impact of social factors such as food scarcity, housing instability, and discrimination (including systemic racism) have on the health and well-being of our patients—issues that are pervasive regardless of one’s location or practice setting.

I disagree with those who assert that addressing social needs is outside the purview of the field of medicine. The COVID-19 pandemic is an extreme, but excellent, example of the interconnections between public policy and public health. As Dr. Rudolph Virchow famously stated, “medicine is a social science,” indicating that physicians cannot practice in a vacuum and ignore the social context of our patients’ (and our own) lives and experiences.

While the first step in creating change is to identify the problem, much more is needed to make a meaningful difference. Much scholarly work has been done identifying social needs among patients in the ED and elsewhere, and multiple pilot programs have been created to identify and address some of these needs in select populations. Be that as it may, numerous gaps remain, especially among ED populations, as described in the 2021 Society for Academic Medicine Consensus Conference which served to identify further research priorities within this arena. 

Outside of the academic arena, changes can also be made to address these needs. The implementation of the Affordable Care Act in 2010, which incentivized many health care organizations to prioritize ‘value-based care’ and patient outcomes, may have provided some of the impetus for organizational changes. Currently, federal Medicaid rules do not allow for non-medical (i.e., social) expenditures, though this is not the case at the state level, and in January of 2021, the Center for Medicaid and Medicare Services (CMS) issued guidance educating states on how they may use allocations to “support states with designing programs, benefits, and services that can more effectively improve population health, reduce disability, and lower overall health care costs in the Medicaid and CHIP programs by addressing [social determinants of health].”

Of course, for a truly public-health centered approach, one must ensure solutions are evidence-based. The data from pilot studies to date are mixed, with some projects showing improvements in ED utilization and decreased inpatient hospitalizations, while others fail to show significant benefit. Indeed, the article reviewed in a recent Health Policy Journal Club column had similarly mixed results. Does this mean that efforts within health care to address social needs are untenable? I argue no. But rather, we must continue to study the problem and potential solutions (with an eye towards patient-centered outcomes) and encourage policy makers to ease the barriers to change. This will necessarily involve bringing our patients and our communities to the table, as the most important stakeholders in these efforts and as the reason we joined the profession in the first place. As Dr. Halloran mentions in her column, only five percent of health care dollars go towards population health improvement—an area ripe for growth if we are to improve the health and well-being of the patients we serve.

Dr. Eswaran is an emergency physician and managing editor for PolicyRx.