A substantial number of research demonstrates that social factors (such as stable housing, access to nutritious food, educational opportunities, and reliable transportation) play a decisive role in shaping both individual and the general population’s health. Evidence also shows that interventions targeting these social determinants can lead to measurable improvements in health outcomes. As a result, recent years have seen renewed attention from health care organizations, policymakers, and researchers on whether health systems, particularly hospitals, should take a more active role in identifying and addressing patients’ social needs. In fact, Horwitz and colleagues documented 57 health systems, along with 917 hospitals, that have recently implemented initiatives aimed at tackling social determinants of health.
Collectively, these health systems committed approximately $2.5 billion to such efforts, with roughly two-thirds of that funding directed toward housing-related interventions. Other areas of focus included employment, education, food access, and transportation. In essence, health systems are making significant financial investments in addressing social determinants of health. Supporters contend that these investments are justified not only by the growing evidence linking social conditions to health outcomes, but also by the chronic underfunding of community-based social service organizations and state social welfare systems.
We take a different view. Health systems and hospitals should approach the provision of social services with caution, and policymakers should resist promoting this strategy. The risks are substantial, including the misallocation of limited resources toward less effective uses, with little likelihood of achieving meaningful success. Addressing social determinants of health is best left to the social service agencies and government institutions designed specifically for that purpose. There are deep structural and operational misalignments between the missions and capacities of hospitals and the work required to address social needs effectively.
Drawing from more than a decade of work in residential mental health care, Megan Fischer emphasizes that the article’s caution is especially relevant in behavioral health settings. She argues that while social determinants like housing stability, family systems, and food security undeniably shape mental health outcomes, hospitals and inpatient facilities are not structurally designed to resolve those issues at scale. In her experience, when clinical environments attempt to absorb responsibilities better suited to community agencies, the result is often diluted care on both sides—clinicians are pulled away from trauma-informed treatment, and social needs are addressed superficially rather than sustainably. Fischer notes that effective mental health recovery depends on coordination, not substitution: health systems should focus on delivering high-quality, evidence-based clinical care while intentionally building referral pipelines and financial support mechanisms that strengthen external social service providers. This division of labor, she argues, preserves clinical integrity, respects professional expertise across sectors, and ultimately leads to better long-term outcomes for patients and families navigating complex social and psychological challenges.
One key mismatch lies in the uneven financial realities across hospitals. Addressing social needs demands significant funding and sustained leadership focus. Although health systems in aggregate command vast resources, individual hospitals’ financial health often reflects the economic conditions of the communities they serve. Consequently, hospitals serving populations with the greatest social needs are frequently those already under strain to meet their fundamental obligations related to patient safety and quality of care. These institutions must prioritize core responsibilities, such as maintaining adequate nurse staffing and delivering reliable clinical services. Redirecting attention and funding toward social services in such settings risks undermining their primary mission and may prove counterproductive.
In hospitals with stronger financial footing, social service initiatives tend to remain peripheral rather than central to institutional priorities. Social workers, who possess the greatest expertise in navigating social needs, represent only a small portion of the hospital workforce and typically have limited organizational influence. Moreover, the incentive structures within most health systems, particularly those not focused on safety-net populations, make it unlikely that resources earmarked for social services will be deployed in ways that maximize population-level health benefits.
Some proponents argue that partnerships with established social service organizations could help compensate for hospitals’ lack of expertise in this area. However, hospitals and health systems often struggle to function effectively in collaborative arrangements. Compared with community-based social service providers, they are larger, more powerful, and more politically connected. Their organizational cultures, leadership approaches, and management styles frequently differ sharply from those of their potential partners. A body of research suggests that such misalignment significantly weakens the effectiveness of cross-sector collaborations.
Beyond internal limitations, hospital-led efforts to address social determinants of health may produce unintended consequences at the broader system level. Social service organizations operate with priorities that extend well beyond immediate health outcomes. Narrowly directing limited social service resources toward short-term health objectives may undermine longer-term societal well-being. For instance, allocating scarce housing resources to low-income but otherwise healthy children could yield greater long-term benefits through improved educational attainment and future health outcomes than prioritizing housing for older, sicker adults—even if the latter group experiences more immediate health gains. In this context, the aspiration of embedding health considerations into all policies risks morphing into a framework where health concerns dominate all policy decisions.
Additionally, the involvement of well-funded and politically influential health systems in social service delivery could unintentionally reduce public investment in traditional social welfare programs. Governments may view hospital-based initiatives as a substitute for direct funding of social services. Similar patterns have already emerged elsewhere; for example, states routinely use the flexibility of the Temporary Assistance for Needy Families program to redirect funds away from direct income support and toward other budgetary priorities that carry greater political appeal.
There is no question that increased investment in the social determinants of health is necessary. However, health systems should not be positioned as the primary drivers of these efforts. Viable alternatives exist. Rather than directly delivering social services or attempting to manage complex partnerships, hospitals could provide financial support to trusted, community-based organizations that already serve as effective gateways to social service systems, therefore, as Butler has proposed. Instead of encouraging an expansion of health system mandates, advocates for social determinant improvements should leverage hospitals’ fundraising capabilities, community benefit obligations, and political influence to strengthen independent local social service providers.
