Caught Between Compliance & Care: Examining the Policy Paradox of SDOH, Payor Obligations, and Population Health Outcomes

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Presentation

Presentation Date

7-15-2026

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Presentation: 26:56

Abstract

The American healthcare system has undergone a significant transformation. The governing reimbursement model has shifted from fee-for-service, originally designed to safeguard against fraud, waste, and abuse, to a value-based care model that emphasizes improving population health, enhancing quality of care, and addressing social determinants of health (Zolotor & Yorkery, 2019; Magarino et al., 2022). Social determinants of health was defined by the World Health Organization as the conditions in which people are born, grow, live, work, and age (Office of Disease Prevention and Health Promotion, n.d.) and has since influenced and become the central pillar of the federal compliance frameworks affecting Medicare Advantage plans, Medicaid managed care organizations, Commercial, the Affordable Care Act Exchange plans, and self-insured employer plans (Donohue et al., 2022; Kominski et al., 2017). This rapid review analyzes the policy paradox currently confronting payor organizations. The federal mandates social determinants of health screenings, health equity reporting, and community-based programs that payors must adhere to, while legislation such as the H.R. 1 Act threatens to reduce funding, impose Medicaid eligibility restrictions, and create compliance contradictions established by federal agencies. This review utilizes peer-reviewed publications, federal regulatory documents, guidance from the Centers for Medicare & Medicaid Services, and policy analyses published between 2021 and 2026. The primary outcome of this review was that compliance requirements for social determinants of health vary across health plan types, resulting in an inconsistent compliance framework. The mandatory social determinants of health screening requirement set forth by the 2024 CMS final rule faces reversal under the H.R. 1 Act, creating confusion amongst payors. This review concludes that without clear and sustainable federal policy alignment, payor organizations face compliance risks as they try to address mandated social determinants of health requirements while being defunded of the resources needed to successfully meet their contractual obligations.

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English

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