In 2023, Maureen, a single mother of three residing in Boston, was diagnosed with uncontrolled diabetes after months of untreated symptoms. She carried more than just a medical condition and faced housing instability, job loss, and daily uncertainty. Without reliable transportation, affordable healthy food, or health insurance, her condition deteriorated. Maureen entered Boston Medical Center for her routine medical appointment and enrolled in the THRIVE Social Determinants of Health Screening & Referral Program. Tears welled up as she shared her struggles—revealing to her care team a complex web of unmet social needs that were just as urgent as her medical ones.

Her story reflects the experiences of millions of Americans. According to the National Academy of Medicine, up to 80% of an individual’s health shapes social and economic factors beyond medical care. These realities reflect the need for a fundamental shift in healthcare delivery modalities. If the US healthcare system is to improve outcomes and meaningfully serve communities, it must integrate social care, prioritize patient-centered approaches, and proactively address social determinants of health.

The US healthcare delivery system is a fragmented network of various public and private entities responsible for providing, financing, and regulating health services. It is not a single unified system, but rather, it reflects a patchwork of models: the Beveridge model seen in the Veterans Affairs (VA) system, where care is government-funded and delivered; the Bismarck model reflects employer-sponsored insurance, financed jointly by employers and employees; traditional Medicare resembles a National Health Insurance model, where the government funds services delivered by private providers, and millions of uninsured Americans fall under an out-of-pocket model, paying directly for care or forgoing it altogether. Core components of the US system include healthcare providers (hospitals, physicians, clinics), payers (private insurers, Medicare, Medicaid), regulators (federal and state agencies), and patients. This complexity creates opportunities and obstacles to achieving equity, access, and quality.

Historically, care focused on acute, episodic issues. Employer-sponsored insurance and government programs like Medicare and Medicaid expanded access, but the system remained reactive. The emphasis on care has transitioned to equity and prevention. Despite 21st century policy advances structural and cultural barriers to care persist.

The core values of the US healthcare system, particularly autonomy, equity, justice, beneficence, and non-maleficence, generate a moral obligation to fulfill the needs of vulnerable populations. Equity demands a fair distribution of resources and services and the elimination of avoidable disparities. Autonomy entails the right of individuals to make informed decisions about their care, requiring systems that are culturally sensitive, linguistically accessible, and free from coercion. Beneficence compels doing good to promote well-being and address medical needs and social conditions that shape health. Non-maleficence, the duty to not harm, requires removing systemic barriers that cause preventable suffering. A commitment to population health means extending care beyond clinic walls to housing, food access, education, and environmental safety.

To effectively attain these goals, healthcare systems must recognize the specific needs of vulnerable populations: racial and ethnic minorities, immigrants, rural residents, low-income individuals, individuals with disabilities, LGBTQ+ individuals, and the elderly. They face health disparities and unjust inequities rooted in structural (social, economic, and political) disadvantage. For example, Black women are three to four times more likely to die from pregnancy-related causes than white women due to clinical and structural racism. Native American communities experience high rates of diabetes and hypertension, which links to limited access to nutritious food and culturally relevant care. Immigrants face language and cultural barriers that reduce their ability to access preventive services or navigate complex systems. These setbacks reflect more than medical needs—they represent fundamental gaps in access to stable housing, nutritious food, transportation, education, safe neighborhoods, and trusted care, all shaped by broader Social Determinants of Health (SDOH).

These SDOHs are deciding factors in shaping health outcomes over life trajectories. For example, food deserts fuel obesity and diabetes. Lack of transportation leads to missed appointments, delayed diagnosis, and avoidable hospitalizations. Poor housing quality can trigger or worsen respiratory conditions. Addressing these factors is vital for improving outcomes and reducing disparities.

While public policy, defined as the formal rules, regulations, and laws enacted by federal, state, or local governments, can powerfully shape health outcomes in the United States, purposeful transformation does not have to wait for legislative action. Although major reforms like the Affordable Care Act have expanded access and funding, US healthcare delivery systems and public health agencies can take independent, proactive steps to address social needs and reduce disparities today. Across the country, innovative models are already emerging. For instance, hospitals in cities like Boston and Camden have implemented programs that integrate community health workers and trusted members of their populations to help patients navigate care, housing, and food resources. Health centers are increasingly co-locating social services inside clinics, such as housing assistance or legal aid—a practice used by Federally Qualified Health Centers (FQHCs) nationwide. Beyond these examples, US health systems can partner with local nonprofits, schools, and faith-based organizations to amplify their reach and engage patients where they live and work. Hospitals and clinics can implement social prescribing programs, where providers “prescribe” non-medical interventions such as exercise, access to social services, or community engagement activities. Kaiser Permanente and Montefiore Health Systems utilize social risk screening tools to collate demographic and neighborhood-level data, allowing for more targeted and equitable care.

Furthermore, US healthcare providers can advance health equity by integrating interdisciplinary team-based care- doctors, social workers, mental health professionals, and community advocates into a cohesive, patient-centered approach. Additionally, training providers to recognize and address bias and discrimination is important. Despite resource limitations, these efforts show that health systems can promote equity without waiting for new policies.

Building on these innovations, one of the most potent strategies health systems can adopt—without waiting for significant policy reform is the widespread implementation of patient-centered care (PCC) and the intentional design of patient-built environments. Together, these approaches hold transformative potential in reducing disparities and improving outcomes, especially for vulnerable populations.

PCC is a healthcare model that emphasizes treating patients with dignity, respect, trust, and compassion while engaging them in decisions about their health. Evidence shows that PCC leads to improved satisfaction, greater adherence to treatment, fewer unnecessary interventions, and ultimately, better health—making it a cost-effective, scalable solution for health systems.

The built environment is the physical design of healthcare facilities. User-friendly entrances, welcoming aesthetics, and flexible layouts can improve the healthcare experience, particularly for those who already feel marginalized. Organizations like the Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), and the Joint Commission have recognized PCC as foundational to healthcare improvement. Their practical guidelines, incentives, and accreditation models increasingly reflect the need to put patients and especially vulnerable populations at the heart of care.

The US healthcare delivery system stands at a crossroads, tasked with treating diseases and actively confronting the social and structural drivers that shape health. The USA’s healthcare systems and public health agencies are already equipped with powerful tools to act now and not rely solely on policy reforms for transformation.

Resource limitations, including tight institutional budgets and reimbursement models that do not support non-clinical interventions, often hinder integrating social services or redesigning care environments. Staffing shortages, particularly in rural or underserved communities, complicate the implementation of patient-centered approaches. The disjointed nature of the US healthcare system and the inadequacy of compatible data systems undermine the seamless coordination for holistic care. Furthermore, cultural and political resistance to addressing social determinants or funding non-traditional services remains a significant barrier. These constraints, however, must not excuse inaction. Instead, they should sharpen our advocacy and drive healthcare leaders to seek strategic, scalable solutions rooted in equity, collaboration, and community. By centering care on patients and embracing the full context of their lives, the US can take meaningful strides toward a system that delivers clinical excellence, justice, compassion, and proper health for all.

Maureen’s story is a riveting reminder that health begins in homes, communities, and relationships. Her unmet social needs ultimately became medical emergencies, like millions of vulnerable Americans each year. However, her story is also a call to action. While structural policy change is critical, we cannot wait for legislation to respond to the urgent realities our patients face. Healthcare systems and public health agencies already hold the tools to lead by integrating social services and patient-centered care, and building strong, local partnerships rooted in trust. When healthcare settings reflect those values, we treat disease, rebuild trust, reduce disparities, and create space for people to thrive. Yes, there are limitations— but these challenges are not excuses. They are calls to innovate boldly, advocate loudly, and lead more bravely. Let us envision a future where no one like Maureen is left behind because their needs do not “fit” the system. A future where healthcare delivery is inseparable from social care and dignity is not earned but guaranteed. That future is not only possible but also necessary. Moreover, it begins with our willingness to act right now with purpose, humility, and unwavering commitment to health justice for all.

References

1. Boston Medical Center. (2023). Addressing social determinants of health: Maureen’s story. https://www.youtube.com/watch?v=VgO7Lishi1I
2. National Academy of Medicine. (2017). Ensuring health equity: From the Institute of Medicine to the National Academy of Medicine. https://nam.edu/ensuring-health-equity-from-the-institute-of-medicine-to-the-national-academy-of-medicine/
3. American Medical Association. (n.d.). Patient-centered care. https://www.ama-assn.org/delivering-care/public-health/patient-centered-care
4. Centers for Medicare & Medicaid Services. (2021). Patient-centered care and quality. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Patient-Centered-Care
5. Institute of Medicine (US). (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.
6. National Academy of Medicine. (2017). Ensuring health equity: From the Institute of Medicine to the National Academy of Medicine. https://nam.edu/ensuring-health-equity-from-the-institute-of-medicine-to-the-national-academy-of-medicine/
7. Pereira, J., & Taylor, R. (2019). Addressing social determinants of health in healthcare systems. Journal of Public Health, 56(3), 212-221. https://doi.org/10.1016/j.jph.2019.02.004
8. Robert Wood Johnson Foundation. (2019). Social determinants of health: What are they, and why do they matter. https://www.rwjf.org/en/how-we-work/grants-explorer/our-grants/2019/05/social-determinants-of-health-what-are-they-and-why-do-they-matter.html
9. World Health Organization. (2020). Social determinants of health.https://www.who.int/social_determinants/en/