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Top Insurers Invested Fraction of Income on SDOH

Analysis  |  By Jay Asser  
   November 18, 2022

Housing and food security programs led the way for spending on social determinants of health (SDOH) by payers between 2017 and 2021.

SDOH have been identified as worthwhile investments by health organizations, but insurers are not putting their money where their mouth is, according to a study published in the Journal of General Internal Medicine.

The research, which examines social spending by the top 20 payers in the nation based on market share rankings by the National Association of Insurance Commissioners, found miniscule investment on SDOH by insurers relative to their net income.

Between January 1, 2017, and December 31, 2021, the total spending for the top 20 insurers was at least $1.87 billion, with the top six payers by market share making up 72%. The top six, on average, spent 0.11% of their net income on SDOH in 2017 and 0.67% in 2021. Spending in 2020 peaked at 1.6%, which the researchers attribute to the COVID-19 pandemic.

To quantify social spending, researchers searched news articles and press releases that included insurer name and terms "social determinants of health" or "community health." Social spending was categorized into housing, food security, employment, education, social and community context, transportation, and "general SDOH" for ambiguous reporting.

The researchers acknowledged their method could have blind spots with missed investments by insurers not publicly posted. They also recognize they may have misclassified investments depending on when they were publicized.

Investments in mental health, substance use, domestic violence, natural disaster relief, technological infrastructure, community health workers, and racial equity initiatives without specifically mentioning SDOH were excluded from the study.

The majority of payers' spending was on housing ($1.2 billion) and food security ($238 million) programs, while $247 million was classified as general SDOH.

The areas that saw the least investment were transportation ($13.4 million), social and community context ($49.7 million), education ($57.2 million), and employment ($58.6 million).

The spike in SDOH spending in 2020 coincided with significant profit for insurers, but the researchers posit that the uptick in investment was due to urgency around the pandemic and not necessarily based on an increase in net income.

Regardless, the study suggests that payers have the capability to put more money into SDOH initiatives, though investing more in other areas may be more of a priority.

"Whether insurers should spend more on these programs is unclear considering that these dollars may be instead used to lower patient premiums and cost-sharing," the authors wrote. "The impact of insurer social spending remains equivocal, though practice patterns, such as considering SDoH in hypertension guidelines, will continue to change as payers and providers make more investments."

Jay Asser is an associate editor for HealthLeaders.


A study of social spending by major insurers found that payers invested less than one percent of their net income on SDOH in 2021.

SDOH investments spiked in 2020, when insurers spent 1.6% on their net income due to circumstances around the COVID-19 pandemic.

The areas that saw the most investment were housing ($1.2 billion) and food security ($238 million) programs, while transportation ($13.4 million) received the least attention.

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