Over the past decade, the United States quietly built something real. A growing set of programs now connects health care to the housing, food, transportation, and support that actually determine whether people stay well. The evidence that this work improves outcomes is strong and getting stronger. And in 2025, we learned how quickly it can all be switched off.
I have spent most of that decade working alongside the state agencies, health systems, payers, funders, and community organizations doing this work, including its setbacks. What follows is where I have landed on what we built, why it will not hold, and what comes next. It is the argument I make at greater length in our new brief, Integrating Health and Social Care in the United States: From Fragmented Pilots to Universal Community Infrastructure.
Two Problems: Structure and Durability
Start with a premise that should be uncontroversial. You cannot improve population health inside the medical system alone. Clinical care accounts for roughly 20 percent of what determines health. The other 80 percent is social, economic, and behavioral. We have organized our single largest sector around the smaller share of the problem, and the results show up in nearly every measure of how Americans fare.
The models we built to close that gap share two flaws.
The first is structural. Every one of them is gated. They reach people through a payer, a health system's catchment area, a waiver region, or a qualifying diagnosis. The uninsured, the undocumented, the near-poor, rural and tribal residents, moderate-income working families, and the family caregiver who needs a knowledgeable navigator all receive integration only by accident, if at all.
The second is durability. What we built is reversible within a single budget cycle or a change of administration. In 2025 alone, CMS rescinded its Health-Related Social Needs Framework guidance, ended the federal match for Designated State Health Programs, and Congress enacted OBBBA, which tightened Section 1115 budget neutrality and set nationwide Medicaid work requirements for January 2027.
The Chain That Stops Before Delivery
Think of the work as a four-link chain: identify the need, refer, coordinate, and deliver the service. Each link has to be paid for, and delivery is the one most often missing.
Here is the pattern that runs through every model. Where a model can serve every resident, it does not fund delivery. Where it funds delivery, it cannot serve every resident. No existing U.S. model does both. That empty space, universal access plus funded delivery, is the missing layer.
North Carolina Is the Cautionary Tale
If you want to understand structural fragility, look at the Healthy Opportunities Pilots (HOP), the most rigorously evaluated state Medicaid social care program in the country. The 2026 Sheps Center evaluation found net Medicaid medical savings of roughly $164 per member per month across 31,597 enrollees, driven by fewer emergency visits and hospital admissions.
And it still went dark. North Carolina suspended HOP on July 1, 2025 after a budget impasse, less than seven months after CMS approved a five-year federal renewal that runs through December 2029. HOP did not fail because the federal government withdrew. It failed because a single state legislature, in a single budget cycle, declined to appropriate the matching funds. The state's first full budget since 2023 restored the program at just $25 million in nonrecurring money, roughly a third of what the Network Leads had requested. A year of suspension had already degraded the delivery network. Drivers left for other work. Participating farms scaled back.
If a program with documented per-member savings can be frozen for a year, no gated, budget-cycle-financed program is safe.
The Missing Layer
So what would durable actually look like? A universal, residency-based Social Care Network, built on a few principles. Access that is blind to insurance status and immigration status. A service chain that is funded through delivery, not just through referral. And financing diversified enough that Medicaid becomes one of several revenue sources rather than the single point of failure.
The right analogy is public infrastructure. Public libraries, public health departments, 911, and public transit are residency-based, they are durable, and they are not gated by who pays. Most people encounter them as part of community membership, not as benefits earned through eligibility. We built those systems because we decided, at some point, that they were too important to leave to administrative discretion or market forces. We are at that same threshold now.
Someone Is Already Building It
This is not theoretical. In New Hanover County, North Carolina, Community Care of the Lower Cape Fear (CCLCF) is doing exactly this: pivoting from a Medicaid-anchored HOP Network Lead into a universal, residency-based Social Care Network open to every resident regardless of payer or background. The transition is anchored by the New Hanover Community Endowment, which committed $2.5 million to launch the network in June 2026, building on an earlier planning grant. The funder has described it as potentially the first Social Care Network of its kind in the United States, structured across four revenue streams: medical payer reimbursements, employer contributions, philanthropic investment, and public funding.
If it succeeds, it will be the first working proof that the gated-to-universal transition is not only defensible in theory but feasible at a regional scale, with philanthropy as a bridge rather than a permanent subsidy. In the interest of transparency: Atrómitos has supported CCLCF across multiple initiatives over the past decade, and the brief documents that relationship in full.
Don't Wait for Washington
The lesson of 2025 is not that federal and state authorities are irrelevant. Every layer of public financing still flows through one or the other. The lesson is that anchoring durability solely on federal and state action is the strategy that just failed.
So the path forward runs through four moves. Build the infrastructure first and let financing follow. Aggregate demand across every payer and private pay, so no single waiver can switch the network off. Pursue public-utility status for regional networks at the state level. And federate horizontally rather than wait for a federal program to appear. Federal and state authorities have a real role here, but as accommodators and partial financiers, not as the leaders of the build. The legal and financing tools already exist.
The Bottom Line
The choice is no longer whether to integrate health and social care. That work is already underway nationwide, much of it carried by community-based organizations on a shoestring. The choice is how. We can keep reassembling integration from time-limited fragments every five years, or we can build the missing layer as durable public infrastructure, owned and governed at the community level and financed by enough independent sources to survive the loss of any one.
I think the second path is not only necessary. As New Hanover County is beginning to show, it is already possible.
Read the full policy brief, along with our related analysis, in the full brief and the Atrómitos Knowledge Hub.