Health insurance opens the door to medical care. But having coverage does not guarantee that patients can walk through it. Food insecurity, unstable housing, and financial hardship can prevent people from getting the care they need. These barriers affect people with Medicaid, Medicare, and private insurance, although their effects differ.
A new study in Medical Care, “Health-Related Social Needs and Health Care Access and Use by Payer Type,” examines these differences. Wang et al. analyzed more than 126,000 adults to explore how social needs relate to health care access.
The findings revisit a familiar question in health services research: Why does having insurance sometimes fail to translate into receiving care?
An Old Question in Health Services Research
More than two decades ago, the Andersen-Gelberg Behavioral Model for Vulnerable Populations offered a framework for understanding this problem. The model explains health care use through three broad sets of factors: predisposing characteristics, enabling resources, and health needs. It expands traditional models by including challenges faced by socially vulnerable populations. Predisposing factors include characteristics and experiences that influence how people seek care. Enabling resources include insurance, income, transportation, and access to providers. Health needs include illness, disability, and other reasons someone might require treatment. For vulnerable populations, homelessness, substance use, trauma, and competing daily priorities can also shape care-seeking behavior.
The central lesson is simple: Need, access, and use are not the same thing. Someone with serious illness may receive little care because they cannot reach a clinic. Another person may frequently use emergency services because routine care remains inaccessible.
Insurance matters, but it represents only one piece of a much larger framework.
What a New Study in Medical Care Found
Wang et al. examined survey data collected from 126,490 participants in the NIH All of Us Research Program. The data covered 2017 through 2023. The researchers compared three groups: adults ages 18–64 with Medicaid or private insurance, and Medicare beneficiaries ages 65 and older.
They examined two health-related social needs: food insecurity and housing instability. Housing instability included concerns about losing housing and problems with housing conditions, such as mold or inadequate heating. The researchers then examined three outcomes: having a usual source of care, receiving care during the past year, and forgoing care because of cost.
Social Needs Differ Sharply by Payer
The study found striking differences across insurance groups. Nearly half of Medicaid participants reported food insecurity, while more than half reported housing instability. Medicaid participants also reported the lowest rate of having a usual source of care, at 76.1%. Private insurance participants reported 82.0%, compared with 93.5% among Medicare beneficiaries. Even more concerning, 21.2% of Medicaid participants reported forgoing needed care because of cost. That compared with 12.0% of privately insured participants and 3.9% of Medicare beneficiaries.
These differences reflect more than insurance coverage alone. The groups also differed in age, income, health status, and disability. Still, they reveal important gaps between having insurance and accessing care.
The Relationship Between Social Needs and Care Also Differs
The researchers found that food insecurity was associated with lower odds of having a usual source of care. This relationship appeared among Medicaid and privately insured adults. After statistical adjustment, food-insecure Medicaid participants had 32% lower odds of having a usual source of care. Privately insured participants had 23% lower odds. Food insecurity was also linked to greater odds of forgoing care because of cost across all three insurance groups.
Housing instability showed a similar pattern. It was associated with lower odds of having a usual source of care and greater odds of forgoing care. However, neither social need showed a statistically significant association with past-year care use among Medicaid participants.
This distinction deserves attention. Medicaid’s limited cost-sharing may help patients continue using care despite major social challenges. Yet many still reported unmet needs and financial barriers. Insurance may support use without ensuring that patients receive enough appropriate care.
When Insurance Type Becomes Part of the Risk
Other research illustrates why payer differences deserve closer attention. A 2023 study examined persistent opioid use following surgery among more than 40,000 patients. Persistent use occurred in 11.5% of Medicaid patients, compared with 5.6% of privately insured patients. After adjustment for patient and procedure characteristics, Medicaid coverage remained associated with higher risk. These findings do not establish that Medicaid coverage caused persistent opioid use. Rather, they suggest that payer type may help identify populations needing more tailored postoperative support. Pain management, social conditions, follow-up access, and treatment resources may all shape recovery.
Homelessness offers an especially clear example of the gap between need and care. A 2025 JAMA Health Forum study examined 3,200 adults experiencing homelessness in California. Although 82.6% reported having insurance, only 50.7% had a regular source of care. Nearly 40% had received no ambulatory care during the previous year.
The study also found high levels of unmet medical needs, emergency department visits, and hospitalizations. Unsheltered homelessness and functional impairments were important factors in these patterns. These findings fit closely with the Andersen-Gelberg model. When people struggle to find food, housing, or safety, scheduled medical appointments may become less urgent than immediate survival.
An insurance card cannot solve those competing demands.
What Should Payers Do Differently?
The new Medical Care study offers several lessons for health plans and policymakers. First, payers should treat social needs as important information about access, not simply as predictors of spending. Medicaid programs may need stronger partnerships with food programs, housing services, community health workers, and care navigators. Private insurers should examine how deductibles, provider networks, and financial pressures interact with social needs. Medicare plans should consider how food insecurity and housing problems affect older adults with complex medical conditions.
Second, screening must lead to meaningful support. The Centers for Medicare & Medicaid Services tested screening, referrals, and community navigation through its Accountable Health Communities Model. However, evidence about social-needs interventions remains mixed. A systematic review found improvements in resource connections, but inconsistent effects on health care use and costs. Promising programs are beginning to offer stronger evidence. A 2025 evaluation of North Carolina’s Healthy Opportunities Pilots found declining Medicaid spending trends after participants entered the program. The program funded services such as food assistance and housing navigation. These findings support further evaluation, not assumptions that every social intervention will automatically save money.
Third, payers should measure whether patients receive needed care, rather than focusing only on service counts. A lower number of medical visits may reflect better health. It may also reflect unmet need, cost barriers, or disconnected care. The difference matters, for both equity and outcomes.
The Important Questions That Remain
The new study has limitations, of course. Its cross-sectional design cannot establish whether social needs caused differences in care. Poor health and limited access may also contribute to worsening social conditions. The All of Us sample was voluntary, and many participants enrolled through health care organizations. This may affect how broadly the findings apply.
The study also compared Medicare adults ages 65 and older with younger Medicaid and privately insured adults. These differences prevent simple conclusions about the independent effects of insurance type. Still, the study’s large sample and consistent measures across payer groups offer a valuable contribution to health services research.
From Coverage to Meaningful Access
Health services researchers have studied the relationship between social needs and medical care for decades. The new Medical Care study shows why this question remains so important. Insurance coverage can make care possible. But food insecurity, housing instability, and other social challenges still determine whether patients can obtain it.
For payers, the next challenge is translating these findings into better benefit design, stronger community partnerships, and more meaningful measures of access. For researchers, it means continuing to separate health care need from health care use.
The ultimate measure of an insurance system should not simply be how many people it covers. It should be how well that coverage helps people receive the care they need.
Ben King