The politics of integrating health systems and public programs: a review of political headwinds, tailwinds, and policy maker recommendations

Amidst low trust in public institutions, policy makers and scholars have proposed using the health system to help rebuild trust in other institutions. One potential mechanism to do so is linking the health system with public programs, e.g. simple referrals, shared financing, or delivering social services via the health system. While other reviews have examined the technical aspects of such linkages, few have examined the political calculus involved. We conducted a narrative review of the academic and grey literature on the relationship between health and trust in public institutions, as well as political considerations when integrating health systems and social programs, including the attitudes, concerns, and constraints of beneficiaries, stakeholders (e.g. service providers), and political actors. For beneficiaries, attitudes about the health system are associated with attitudes about public institutions, and linking the health system to less popular public programs has been shown to increase engagement in the latter. However, unsuccessful handoffs and administratively burdensome social programs can alienate beneficiaries. Stakeholders are often eager to partner in linkages but can become frustrated by redundant roles and uncoordinated financing. For political actors, embedding social services in the health system may be logistically easier than maintaining standalone programs, but it may also result in weaker long-term public support. Thus, linking health systems and public programs can produce mutual "co-benefits" when done well. At the same time, policy makers must consider the political trade-offs inherent in the linkage. Future research should directly test whether these linkages causally impact broader social outcomes, such as political trust.