The Social Determinants of Health (SDoH) are the non-medical factors that affect health outcomes. These include where people are born, live, work, play, worship, and age. For individuals in poverty, the insecurity of these social conditions can create real, physical medical problems. Addressing the social determinants of health requires more than isolated interventions; it requires coordinated systems that meet people’s needs across these conditions. Yet, many social services are offered through siloed programs, solving one problem while leaving gaps in other areas.
At the same time, the American health system is mainly able to only offer intervention after conditions have escalated to the point of requiring medical care. This can lead to costly, short-term responses that do not fully address the underlying factors driving poor health outcomes. And now, with the looming Medi-Cal cuts due to HR1 passed in 2025, more individuals will lack the means to cover healthcare costs once it gets to that point. What would our low-income communities look like if we invested in whole-person preventative care with well-rounded social supports to overcome America’s poor healthcare access?
This question is what the California Department of Health Care Services (DHCS) set out to answer through California Advancing and Innovating Medi-Cal (CalAIM) initiatives. CalAIM represents a transformation of Medi-Cal with initiatives that focus on whole-person care, such as behavioral health initiatives, community supports, enhanced care management, and more. Rather than waiting to address the conditions that force low-income Californians to the emergency room, CalAIM seeks to address the root causes of their needs through preventative and cost-effective wraparound services. It is important that the state continues to invest in connections of systems across health and social services to provide well-rounded support for low-income communities.
In Bakersfield, the Community Action Partnership of Kern (CAP K) provides Enhanced Care Management (ECM) services for residents of Kern County. There, individuals are connected to programs that offer wraparound services, not siloed approaches to single issues. For example, one of their clients, who we’ll refer to as John, grew up witnessing extreme violence; he was in and out of foster care, became gang affiliated, and began abusing substances. Eventually, John became homeless as a result of a complex mix of personal and environmental challenges. The following is an excerpt from an email from John:
“There came a moment when I knew I could not continue down that path. I made the decision to change my life, and that decision led me to an incredible program called CapK in Bakersfield, California. The team there believed in me when I struggled to believe in myself. They provided support with mental health services, alcohol and substance use counseling, employment assistance, and housing resources. Because of them, I am stable, clear-minded, and moving forward with purpose.”
By providing treatment options for addiction and mental health, coupled with the social supports such as housing, employment assistance, and case management to help him feel socially and emotionally secure, CAP K helped John achieve long-term outcomes. John has maintained sobriety, has a job, has more stable housing, and is developing a personal support system, which are all going to help his health in the long-term, and John is now able to give back to the community. John’s experience illustrates how addressing behavioral health, housing, and employment together can lead to more stable, long-term outcomes than treating each challenge in isolation.
In 2017, the Center for Disease Control estimated that the combined cost of opioid use disorder and fatal opioid overdoses cost the state of California more than $61 billion. Investments in prevention and coordinated care aim to reduce both these human and economic costs over time, focusing on a healthcare and social services system centered on people’s collection of needs. Not only does this relieve the burden on state healthcare systems, but it also relieves the burden on local emergency health systems and social safety net providers, by helping individuals before they reach a point where it becomes more difficult and expensive to provide the wraparound support and care needed for addiction recovery.
In Orange County, the Community Action Partnership of Orange County (CAP OC) operates CalAIM programs “to provide access to specialized non-medical services that address challenges affecting a person’s health.” They share the story of one of their clients, who we’ll refer to as Jane, a single mother on the road to recovery after experiencing homelessness and ongoing mental health challenges, who remained incredibly dedicated to her son’s well-being.
Recognizing the family’s complex needs, the Housing Navigation team at CAP OC partnered with Western Youth Services to ensure Jane and her son receive the support, housing assistance, and case management they need to thrive. This collaboration created a wraparound network of care that addresses both their immediate and long-term challenges, including care coordination, connection to behavioral health supports, and ongoing case management for the family, providing utility and basic needs assistance.
Thanks to Jane’s perseverance and the support of her care team, she and her son now have stable housing and are on a path toward healing. Without coordination across services, Jane’s family may not have been able to achieve long-term outcomes spanning across their domains of need. Integrated care models help ensure that progress in one area is not undermined by unmet needs in another. In 2025, CAP OC had 25 other individuals and families go through their Housing Navigation program with stories like Jane’s.
According to the California Budget and Policy Center, total homelessness-related spending at the state level has exceeded $22 billion since 2020. This investment reflects a strong commitment to addressing housing insecurity. However, housing alone cannot resolve the interconnected challenges many individuals face. Pairing housing solutions with supportive services and pathways to economic mobility can help California build more comprehensive systems that address both the root causes of poverty and its effects.
In Merced County, the Merced Community Action Agency (MCAA) provides ECM for maternal support services, “aiming to improve outcomes for both mother and baby by providing comprehensive, personalized, and supportive healthcare” to pregnant and postpartum mothers. They offer both clinical and non-clinical services to provide well-rounded and cost-effective care for mothers in the Central Valley. Unlike crisis-driven interventions, these ECM supports reach families early, when stability can have lifelong impacts on both parents and children.
MCAA also operates the Diaper Distribution Demonstration Research Pilot (DDDRP) program, and provides monthly diaper allocations to many of the mothers enrolled in the ECM. This is one example of how MCAA pairs basic needs support with clinical care, and is one of many of the opportunities MCAA is able to provide as a community-based organization, offering positive health outcomes for both mother and child.
“Lowering healthcare cost starts even prior to birth,” explains David Knight, CalCAPA Executive Director, “Ensuring our families have a healthy home, access to healthy food and prenatal care, and attempting to prevent events that create adverse childhood experiences are the key to curbing the ever rising healthcare cost.”
As the cost of living continues to rise, there is broad bipartisan support across all levels of government to make communities more affordable, safe, and healthy for families. Supporting California’s growing families and strengthening pathways to economic mobility is a common-sense investment. Programs like the one in Merced demonstrate the value of providing systems as solutions to poverty, showing that individual initiatives are most effective when they are part of a coordinated system that addresses multiple needs.
As California continues to invest in its most vulnerable communities, the focus should not only be on how much is spent, but on how systems work together to deliver results. The examples from Kern, Orange, and Merced counties are just three from our network of agencies and partners who are integrating healthcare and social services to provide well-rounded community-based systems of care for low-income Californians through CalAIM programs.
Initiatives like California Advancing and Innovating Medi-Cal (CalAIM) reflect exactly what their name suggests: a commitment to advancing more effective models of care and innovating beyond fragmented systems that leave critical needs unmet. By prioritizing coordination across health and social services, California can move toward solutions that address the complexities of people’s lives. The result is healthier communities, greater stability for families, and a more impactful use of public resources over time.