One of the goals of the Affordable Care Act is to focus more on population health. With millions more people insured, the assumption is that governments could devote more resources to efforts that target broader social determinants -- foundational ways to keep people healthy, such as stable housing, clean air and violence-free neighborhoods.

Three years after the launch of the federal law’s insurance exchanges, the rate of uninsured adults is lower than ever. But for the most part, state and local health departments haven’t quite figured out how to incorporate population health-focused programs into their overall efforts.

To try to find out why, a couple of Yale University researchers conducted a study with the Milbank Memorial Fund to learn what the challenges were in implementing a more social services-oriented approach within health departments and across communities. Erika Rogan and Elizabeth Bradley visited local governments across the country and held work sessions with decision-makers from different specialties and political ideologies.

They found three “root causes” that routinely get in the way of population health efforts. The health of a state’s population is not always prioritized relative to other societal goals. Incentives to improve health, including financial and political ones, are misaligned. And there is a lack of consensus regarding who is responsible for health.

It’s tough for bureaucracies to rethink the basic functions of their departments, but Rogan says a relatively easy place to start is with incentives to support a culture of collaboration. “Think about co-locating departments that would work well together to achieve a common goal. Start setting common objectives,” she suggests. “It’s important to realize that in a community, all of the players are part of one large health ecosystem.”

And while it may be expensive in the short term, another smart first step is to work on data integration across agencies, departments and jurisdictions. “It’s really helpful to show decision-makers where the needs are,” Rogan says. “We saw a few places that integrated IT systems to focus on high-need populations that were successful.”

The report points to a few population health initiatives that are making a positive impact, including Vermont’s Blueprint for Health, Live Well San Diego and Rhode Island’s establishment of “health equity zones.”

Spearheaded by Nicole Alexander-Scott, director of Rhode Island’s Department of Health, the zones pinpoint communities where social factors have a particular measurable impact on population health. Community needs assessments are conducted. In Woonsocket, for example, the biggest issues identified were substance abuse, teen pregnancy and trauma. Appropriate programs are then rolled out over a three- to four-year period.

There’s widespread agreement on the importance of flexible programs that can address the specific needs of each community. Indeed, Rogan and Bradley found that programs that were carbon copies of one another were less likely to succeed. “One size does not fit all,” says Rogan. “We found that you have to adapt any sort of population health program within the context of your state or community.”

It’s likely to be some time before programs addressing social determinants of health are common in communities, but Rogan is encouraged just to see more attention paid to the idea. “There seems to be this common understanding that the costs of health care are simply not sustainable,” she says, “so now we have to pivot to spending smarter.”