Can Social Policies Improve Health? A Systematic Review and Meta‐Analysis of 38 Randomized Trials

Original Scholarship
Population Health

Policy Points:

  • Social policies might not only improve economic well‐being, but also health. Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs.
  • Since the 1960s, a large number of social policies have been experimentally evaluated in the United States. Some of these experiments include health outcomes, providing a unique opportunity to inform evidence‐based policymaking.
  • Our comprehensive review and meta‐analysis of these experiments find suggestive evidence of health benefits associated with investments in early life, income support, and health insurance interventions. However, most studies were underpowered to detect health outcomes.

Context: Insurers and health care providers are investing heavily in nonmedical social interventions in an effort to improve health and potentially reduce health care costs.

Methods: We performed a systematic review and meta‐analysis of all known randomized social experiments in the United States that included health outcomes. We reviewed 5,880 papers, reports, and data sources, ultimately including 61 publications from 38 randomized social experiments. After synthesizing the main findings narratively, we conducted risk of bias analyses, power analyses, and random‐effects meta‐analyses where possible. Finally, we used multivariate regressions to determine which study characteristics were associated with statistically significant improvements in health outcomes.

Findings: The risk of bias was low in 17 studies, moderate in 11, and high in 33. Of the 451 parameter estimates reported, 77% were underpowered to detect health outcomes. Among adequately powered parameters, 49% demonstrated a significant health improvement, 44% had no effect on health, and 7% were associated with significant worsening of health. In meta‐analyses, early life and education interventions were associated with a reduction in smoking (odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.86‐0.99). Income maintenance and health insurance interventions were associated with significant improvements in self‐rated health (OR = 1.20, 95% CI 1.06‐1.36, and OR = 1.38, 95% CI 1.10‐1.73, respectively), whereas some welfare‐to‐work interventions had a negative impact on self‐rated health (OR = 0.77, 95% CI 0.66‐0.90). Housing and neighborhood trials had no effect on the outcomes included in the meta‐analyses. A positive effect of the trial on its primary socioeconomic outcome was associated with higher odds of reporting health improvements. We found evidence of publication bias for studies with null findings.

Conclusions: Early life, income, and health insurance interventions have the potential to improve health. However, many of the included studies were underpowered to detect health effects and were at high or moderate risk of bias. Future social policy experiments should be better designed to measure the association between interventions and health outcomes.

Keywords: social experiments, randomized controlled trials, policy analysis, population health, social determinants of health.

Open Access

Read on Wiley Online Library

Published March 2020
DOI: 10.1111/1468-0009.12451

Milbank Quarterly in Conversation: The Impact of Social Policy on Health

Published June 14, 2020. COVID-19 is demonstrating just how much poverty can affect health. In this episode of The Milbank Quarterly’s podcast, Emilie Courtin of the London School of Hygiene and Tropical Medicine and Peter Muennig of Columbia University, discuss their June Milbank Quarterly article, which systematically reviewed all known randomized social policy experiments in the United States that included health outcomes. Their work found that early life, income-related, and health insurance policies all have the potential to improve health. Read the transcript. Visit our podcast page to subscribe through Spotify or other listening platforms.