Social Safety Net and The ACA

Social barriers to accessing health care negatively impact health outcomes for low-income families contributing to the rise of health care costs in America.  According to the University of Wisconsin Public Health Institute (UWPHI; 2013), working in partnership with the Robert Wood Johnson Foundation (RWJF; 2012), four health factors influence health outcomes as measured by morbidity (quality of life) and mortality (length of life).

While health care services are universally available through the public health system, low-income and disadvantaged populations face greater personal and financial challenges to accessing health care (Gulliford, et al., 2002). America’s network of public assistance programs, or social safety net, offers services to address these social barriers in addition to supporting vulnerable populations with chronic or critical care needs. This assistance enables disadvantaged populations access healthcare and/or families with critical or chronic care needs stay at home or in the community for as long as possible.  However, continued funding cuts (both federal and state) and increased demand (brought on by the Recession) threatens the viability and sustainability of the social safety net itself. This threat creates the need to quantify the positive impact of the social safety net in addressing social barriers to accessing healthcare leading to reduced but related costs overall and the foundation for policy and payment reform.


The connection between social determinants of health and the services offered through the social safety net remains to be quantified.  At the same time, funding for the social safety net continues to be reduced. The funding challenges will continue until a uniform process for quantifying the outcomes of social services and establishing the link between these services and health outcomes as a one element to address social determinants of health. The benefits of the social service programs on poor and disadvantaged populations remain important despite the lack of quantifiable documentation. Without a concerted effort to develop common methods for evaluating the outcomes as well as payment reform, the social safety net and its benefits remains at risk. Programs focused on overcoming social determinants of health seek to provide community interventions that couple health education and prevention. With the recent implementation of the Affordable Care Act (ACA), the availability of health care, including preventive services, has increased for all populations including those who are unemployed or underemployed and/or not offered insurance through their employer (Centers for Medicare and Medicaid Services, 2014). With a goal of enhance the quality of care for all Americans as well as lower health care costs, the ACA outlines options for increase access to health care for all populations, including vulnerable populations, which reduces the negative impact of social determinants of health. The ACA makes a significant step in reducing the social determinants of health.  Developing and applying common evaluation criteria and adopting payment reform to sustain the social safety net represent the next logical steps.

According to the World Health Organization (WHO; 2008), the term social determinants of health describes the circumstances in which people live, work and age as well as the systems through which they seek care. External factors, such as policy, politics and funding, influence these circumstances (WHO, 2008). For example, low-income neighborhoods rely heavily on public assistance programs such as public transportation, free and reduced childcare, utility assistance and rental assistance programs. These programs, and several more, comprise the social safety net. Policy changes that reduce funding for these programs as form of budget relief actually limit healthcare access points for low-income or disadvantaged populations and will inversely impact health outcomes and health costs.


Centers for Medicare and Medicaid Services. (2014, January 1). Affordable Care Act. Retrieved January 7, 2014, from Centers for Medicare and Medicaid Services:

DeNavas-Walt, C., Proctor, B., & Smith, J. (2011). Income, poverty, and health insurance coverage in the United States: 2011. United States Department of Commerce, Economics and Statistics Administration, United States Census Bureau. Washington: United States Census Bureau.

Gulliford, M., Figueroa-Munoz, J., Myfanwy, M., Hughes, D., GIbson, B., Beech, R., et al. (2002). What does ‘access to health care’ mean? Journal of Health Service Research & Policy , 7 (3), 186-188.

National Research Council. (2004). Understanding Racial and Ethnic Differences in Health. Washington, DC: National Academies Press.

Robert Wood Johnson Foundation. (2012). Overcoming obstacles to health. Robert Wood Johnson Foundation. Princeton: Robert Wood Johnson Foundation.

University of Wisconsin Public Health Institute. (2013, January). County Health Rankings and Roadmaps. Retrieved January 11, 2014, from Rankings Background:

World Health Organization. (2008). Social Determinants of Health. Retrieved February 15, 2014, from World Health Organization:

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