Unmet social need and how it relates to health care quality and access in the US

Cecille Joan Avila is a Policy Analyst at Boston University School of Public Health. She tweets at @cecilleavila.

Lately, the relationship between unmet social need (e.g., food insecurity) and health care in the United States has been a prominent area of interest. However, much of the existing literature is extremely specific and not easily generalizable. A recent study by Megan B. Cole, PhD, MPH, and Kevin H. Nguyen, MS, takes a broader look at the extent of unmet social needs in low-income US adults and the relationship to health care access and quality. The study is part of the Drivers of Health theme issue.

Cole and Nguyen hypothesized that, as unmet social needs increase, access to and the quality of health care would decrease, even after accounting for confounding characteristics (e.g. income). If true, this has significant implications, considering one survey estimates 90% of people below 138% of the federal poverty line (FPL) have some unmet social need.

New Research

In 2017, the national Behavioral Risk Factor Surveillance System survey included an optional social need module for the first time. Researchers used these responses to classify individuals as having unmet social needs if they answered yes to at least one of seven questions about housing, financial, and food insecurity; chronic stress, and neighborhood safety.

Cole and Nguyen — academics affiliated with Boston University School of Public Health and Brown University School of Public Health, respectively — used data from 12 states to link number of reported unmet social needs to measures of health care access and utilization. They focused on low-income (<200% FPL) adults over 18, and a secondary sub-set with diabetes.

Primary outcome measures included having a check-up or flu vaccine in the last twelve months, having a personal health care provider, and if cost prohibited a health care visit. Among diabetic adults, outcome measures included receiving two or more diabetic tests in the last year, at least one foot or eye examination in the last year, and whether or not diabetes affected their eye health.


Researchers found 54% of individuals in the primary study population reported at least one unmet social need. The most prevalent was food insecurity. They also found those who reported unmet needs were more likely to be under 65, Black, uninsured, <100% FPL, current smokers, or identify as LGBT+.

In the primary population, having two or more unmet social needs was associated with statistically lower levels of health care access and utilization. The magnitude of effect increased with the number of unmet social need. For example, 44% of patients with four or more unmet needs cited a cost barrier to seeing a doctor, compared to only 9% of those without unmet needs.

For low-income diabetic adults, greater unmet need was also associated with lower rates of access to and quality of care with increasing magnitude (except for glucose testing, which was not statistically associated with need). Those with four or more unmet needs were less likely to receive a foot or eye examination in the last twelve months and more likely to have poor eye health than those with fewer unmet needs.


This study adds to the existing literature by analyzing a larger, more generalizable, population than previously studied and empirically showing an association between level of unmet social needs, multiple types of needs, and access to quality health care. There are limitations to this research, however. Data are dependent on participating states from a single year, and findings only show association, likely underestimated. Regardless, these findings expose possible areas for intervention, especially around cost and food insecurity.

Cost-related barriers to care, strongly related to level of unmet social need, are particularly concerning given that patients with significant health needs have limited health care access. Minimizing this burden by partially or wholly absorbing shared costs for low-income individuals could improve their health care access by eliminating the need to prioritize what to pay for. Reaching this group is important, since those with greater unmet social needs were found to be significantly more likely to report poor physical and mental health.

Although research shows up to 90% of health outcomes are explained by outside factors, not all physicians screen for social needs and it is unclear if screenings are truly effective. This suggests more individuals need to be reached in non-clinical settings, especially if identifying and addressing social needs could improve overall quality and access to care. Screening patients upon insurance enrollment could pro-actively link those in need with appropriate services, especially for food insecurity, although this might require a shift in current practices and resources to be successful.

Cole and Nguyen’s study provides important empirical evidence for clinicians and policymakers who wish to improve health care quality and access for low-income, marginalized adults. Anticipating needs and successfully meeting people where they are at is the best approach to improving health outcomes; failure to do so harms both patients and prevents health care systems from providing the best care.

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