Uncertainty After Ending Medicaid Social Needs Guidance

It may be surprising to learn that health is more affected by social factors, like housing and nutrition, than by clinical care. In fact, health systems are increasingly recognizing these types of factors as “health-related social needs,” because they can worsen health outcomes, increase mortality, and drive costly health care use when unmet. This year, changes by the Trump Administration will make it harder for states to address social needs through Medicaid.

In 2022 and 2023, the Centers for Medicare and Medicaid Services published guidance for states looking to improve population health and reduce health disparities by addressing social needs. The Biden Administration also released a “call to action” to address health-related social needs in communities across the nation. This guidance led to an explosion of states pursuing Medicaid demonstration projects, which allow states to use Medicaid funds to test new strategies to improve health.

By 2024, 25 states had approved projects with social supports, a sharp increase from previous years. However, in March 2025, the second Trump Administration revoked this guidance, saying that applications to cover such supports would instead be considered on a “case-by-case” basis. We anticipate that new opportunities will be limited, and existing programs may be scaled back or shuttered. Massachusetts and North Carolina—two of the early adopters—provide useful illustrations of the risk to these social support programs.

Although Medicaid programs are not a substitute for comprehensive social supports, they can serve as a bridge to essential resources that would otherwise be inaccessible.

Our study, published in Health Affairs Scholar earlier this year, analyzed cuts to a Massachusetts program that used Medicaid funds to provide patients with nutrition and housing supports. Federal requirements shifted more financial risk to the state, which caused Massachusetts to impose stricter eligibility criteria for the program to reduce costs. Limiting eligibility will exclude many people in need.

The 2025 cuts restricted supports for people who are experiencing homelessness to those aged 55 and older. They also redefined homelessness more narrowly, required more documentation to prove housing instability, and instituted a minimum threshold of past-year emergency department and hospital visits. We found that at least 68% of those receiving support from 2021 to 2024 would no longer qualify under the new criteria. Although this shift occurred before the federal social need guidance changes, it illustrates the impact reduced federal support can have on these programs.

Another example is the recent termination of the North Carolina Healthy Opportunities Pilot. This first-of-its-kind state Medicaid program was approved in 2018 and provided housing and nutrition supports to over 30,000 patients from 2022 to 2025. Even though it was associated with decreased health care costs, the program was shuttered in July 2025, citing budgetary concerns.

Limiting how health systems can address social needs will further erode the social safety net.

Medicaid demonstration projects have existed since the creation of Medicaid in 1965. They were originally intended as ways for states to test interventions and generate evidence to inform future policy changes. However, in reality, they are vulnerable to swings in political priorities. While resource constraints are inevitable, program changes driven by budget constraints without evidence-informed strategies to minimize unintended consequences are troubling.

Although Medicaid programs are not a substitute for comprehensive social supports, they can serve as a bridge to essential resources that would otherwise be inaccessible. Currently, the federal government is implementing cuts to nutrition assistance, imposing Medicaid work reporting requirements, and proposing cuts to the Department of Housing and Urban Development. Limiting how health systems can address social needs will further erode the social safety net.

This post is in partnership with the Medicaid Policy Lab at Boston University School of Public Health.