A Survey of Integrated Social and Health Care through Medicaid Public Insurance Program in the USA

Background: The Medicaid public insurance program provides health coverage for low-income Americans. As a joint federal and state program, Medicaid programs vary by U.S. state. States may opt to use Section 1115 Demonstration waivers, a federal authority under Medicaid, to pilot new approaches that meet Medicaid objectives. Following the release of a federal Health-Related Social Needs (HRSNs) framework in 2021, states have increasingly used the 1115 Demonstration authority to cover housing, nutrition and other unmet HRSNs. The aim of this study is to examine how states are leveraging the 1115 Demonstration to cover HRSN services and support integrated health care and social services within the context of a non-universal healthcare system.

 

Approach: A systematic analysis was conducted on state Medicaid Section 1115 Demonstration waivers through March 4 2025. Each U.S. state’s most recently approved Medicaid Section 1115 Demonstration, along with relevant supplemental filings was reviewed using data available on the Medicaid.gov State Waivers List and each state’s Medicaid website.

 

The following data were extracted and recorded for each state: (1) Health care delivery system; (2) Types of allowable HRSN services; (3) Target population for HRSN services; (4) HRSN payment methodologies; (5) Entity responsible for administering HRSN services and determining eligibility; and (6) Roles of community-based organizations (CBOs).

 

Results: Out of 50 US states, 18 states have received approval to use the 1115 Demonstration to provide HRSN services. Massachusetts, New York and Hawaiʻi are the only states that cover all allowable housing and nutrition-related HRSN interventions, while six states provide only housing interventions. In terms of health care delivery system, three states use Accountable Care Organizations (ACOs) or similar models, while the majority rely on traditional managed care organizations (MCOs).

Two states operate HRSN services as regional pilots, while New Mexico restricts services to pregnant women and West Virginia limits them to individuals with substance use disorders (SUDs). Only five states offer HRSN services to the broader Medicaid population. Most states use a non-risk, fee-for-services model to reimburse HRSN services. Nearly half of the states rely on an ACO or MCOs to administer services and determine eligibility. Only three states authorize community-based organizations (CBOs) to play this role. Three states have established, and four more are proposing, community care hubs composed of HRSN services providers.

 

Implications: Despite some shared elements, HRSN implementation under the 1115 Demonstration varies significantly across states. This variation likely reflects differences in political climate, levels of experience in addressing social needs, and state-specific population health priorities. The fragmented nature of the US healthcare system likely hinders the adoption of value-based payment models for HRSN services. Efforts to address HRSNs has largely been reactive, led by health insurers or providers, and focused on individuals with more severe health needs. Existing infrastructure was built for healthcare organizations, creating barriers for social services providers to participate fully in integrated care. While the 1115 Demonstration permits investment in HRSN infrastructure, the absence of clear federal guidelines and selection criteria may prevent qualified social services providers or CBOs from accessing funding.