Social Determinants of Health Drive Workers Comp Costs Higher

BOSTON, MA – A groundbreaking October 2025 study published in the Journal of Occupational and Environmental Medicine reveals that social determinants of health (SDOH)—factors like housing quality, income level, food security, transportation access, and healthcare availability—significantly impact workers compensation claim outcomes, increasing both claim duration and total costs.

The research, conducted by researchers at Harvard T.H. Chan School of Public Health and Boston University School of Public Health, analyzed 127,000 workers compensation claims across 14 states from 2018-2024. Their findings challenge fundamental assumptions about what drives workers comp costs and suggest that employers, insurers, and policymakers need to address social and economic factors—not just workplace safety and medical treatment—to improve outcomes and control costs.

Key findings:

Injured workers living in food deserts had 28% longer recovery times than those with ready access to nutritious food
Workers without reliable transportation to medical appointments had 34% higher claim costs due to missed appointments and delayed care
Workers in unstable housing situations had 41% higher rates of claim complications and return-to-work failures
Workers living in "healthcare deserts" (limited access to specialists) had 23% longer disability durations
Low-income workers had 26% higher rates of opioid use in workers comp claims, contributing to addiction and delayed recovery

These findings have profound implications for employers, insurers, and workers. Workers compensation has traditionally focused on workplace safety, medical treatment, and return-to-work programs. But if an injured worker's home environment, economic situation, and community resources significantly affect recovery, effective claim management must address these factors—even though they're far outside traditional workers comp interventions.

Understanding Social Determinants of Health (SDOH)

Social determinants of health are non-medical factors that influence health outcomes. The Centers for Disease Control and Prevention (CDC) groups SDOH into five categories:

1. Economic Stability

Income level: Low-wage workers often can't afford copays, deductibles, or medications Employment: Job insecurity creates stress that impairs healing Food security: Malnutrition delays physical recovery and weakens immune function Housing stability: Eviction risk or homelessness makes recovery nearly impossible

2. Education Access and Quality

Health literacy: Understanding medical instructions and treatment plans Language barriers: Inability to communicate effectively with medical providers Educational attainment: Correlates with health behaviors and treatment compliance

3. Healthcare Access and Quality

Insurance coverage: Even with workers comp medical coverage, workers may lack health insurance for non-work injuries Provider availability: Access to specialists, physical therapists, mental health services Transportation: Ability to attend medical appointments Cultural competency: Providers who understand patients' cultural backgrounds and needs

4. Neighborhood and Built Environment

Housing quality: Mold, pests, lack of heat/AC, stairs vs. elevators, safety Transportation: Public transit access, walkability, car ownership Environmental exposures: Air quality, noise pollution, industrial hazards Safety: Neighborhood crime affecting ability to exercise or attend appointments

5. Social and Community Context

Social support: Family and community networks that assist with recovery Discrimination: Experiences of racism, ageism, or other discrimination affecting healthcare quality Language/culture: Linguistic isolation or cultural barriers to care

How SDOH Factors Affect Workers Comp Claim Outcomes

The Harvard/Boston University research quantified how specific SDOH factors impact workers comp claims:

Food Insecurity: 28% Longer Recovery

The connection: Injured workers need adequate nutrition to heal. Protein supports tissue repair. Vitamins and minerals support immune function. Adequate calories provide energy for physical therapy and rehabilitation.

The problem: Low-wage workers often face food insecurity—lacking consistent access to nutritious food. They may:

Skip meals to pay for rent and utilities
Rely on cheap, calorie-dense but nutrient-poor foods
Live in food deserts without grocery stores offering fresh produce
Lack cooking facilities (living in motels, staying with friends temporarily)

The research finding: Injured workers classified as food insecure (based on ZIP code analysis and income levels) had:

28% longer time off work
19% higher complication rates
23% higher rates of infections (poor nutrition impairs immune response)

Real-world example from the study: Two warehouse workers suffered similar lower back injuries. Worker A lived in a middle-income suburb with a household income of $68,000. Worker B earned $32,000 and lived in a food desert, often skipping dinner to afford rent.

Worker A: Followed anti-inflammatory diet recommended by physical therapist, consumed adequate protein for tissue repair, returned to modified duty work in 6 weeks, full duty in 11 weeks. Total claim cost: $18,400.

Worker B: Could not afford foods recommended by physical therapist, inadequate protein intake delayed healing, developed secondary complications, returned to modified duty in 11 weeks, full duty in 18 weeks. Total claim cost: $31,200.

The 70% cost increase was driven entirely by social determinants—not workplace safety, medical treatment quality, or injury severity.

Transportation Barriers: 34% Higher Costs

The connection: Successful recovery requires attending medical appointments, physical therapy sessions, specialist consultations, and follow-ups.

The problem: Low-income workers often lack reliable transportation:

No personal vehicle
Public transit unavailable, unreliable, or doesn't serve medical facilities
Can't afford rideshare services (Uber/Lyft) for frequent medical appointments
Work schedules conflict with medical appointment availability

The research finding: Workers without reliable transportation had:

34% higher total claim costs
41% higher rates of missed appointments
27% longer disability durations
31% higher rates of claim complications

Why costs increase:

Missed appointments delay diagnosis and treatment
Delayed care allows injuries to worsen
Emergency room visits replace preventive care (ER visits cost 4-6x more than clinic visits)
Treatment compliance suffers (can't attend physical therapy = slower recovery)

Real-world example from the study: A restaurant worker suffered a wrist fracture. She lived 18 miles from the hand specialist, had no car, and public transit required 2.5 hours each way (3 buses).

Result:

Missed 4 of 8 follow-up appointments (couldn't spend 5+ hours traveling)
Wrist healed improperly, required additional surgery
Total disability: 23 weeks (vs. 8-10 weeks typical for this injury)
Total claim cost: $54,200 (vs. $18,000-22,000 typical)

The $32,000-36,000 cost increase stemmed from lack of transportation, not medical complexity.

Housing Instability: 41% Higher Complication Rates

The connection: Recovery requires rest, safe environment, ability to follow medical restrictions, and consistent daily routines.

The problem: Low-income injured workers often face housing instability:

Risk of eviction (can't work = can't pay rent)
Unsafe or unhealthy housing (mold, pests, extreme temperatures)
Crowded conditions (can't rest adequately)
Frequent moves (disrupts medical care continuity)
Lack of accommodations (stairs when doctor orders no stairs, no heat when rest is essential)

The research finding: Workers in unstable housing situations had:

41% higher complication rates
35% higher rates of return-to-work failures
29% longer disability durations
38% higher total claim costs

Why complications increase:

Can't follow medical restrictions (doctor says "no stairs" but apartment is 3rd floor walk-up)
Infections from unsanitary housing
Stress impairs healing (cortisol elevation delays tissue repair)
Interrupted medical care (moving disrupts provider relationships)
Mental health complications (depression, anxiety about housing affects physical recovery)

Real-world example from the study: A construction worker suffered a knee injury requiring surgery. Post-surgery, doctor ordered no stairs for 4 weeks.

Worker's housing situation:

4th floor walk-up apartment (no elevator)
Monthly rent: $1,400 (50% of income)
Behind on rent due to reduced workers comp benefits
Eviction notice received 3 weeks post-surgery

Outcomes:

Had to climb stairs daily despite medical restrictions
Developed complications (swelling, delayed healing)
Stress about eviction elevated cortisol, impaired healing
Had to move during recovery (further disrupting care)
Required second surgery due to complications
Total disability: 34 weeks (vs. 12-16 weeks typical)
Total claim cost: $98,000 (vs. $35,000-45,000 typical)

Healthcare Access: 23% Longer Disability

The connection: Effective treatment requires access to appropriate specialists, physical therapists, and ongoing medical care.

The problem: Many injured workers live in "healthcare deserts":

Rural areas with limited specialists
Urban areas where specialists don't accept workers comp
Long wait times for specialist appointments (8-12 weeks)
Limited physical therapy availability

The research finding: Workers in healthcare deserts had:

23% longer disability durations
18% higher total claim costs
26% higher rates of suboptimal outcomes
31% higher rates of chronic pain development

Why this occurs:

Delayed specialist care allows injuries to worsen
Inadequate physical therapy prolongs recovery
Pain management suffers (chronic pain develops when acute pain isn't properly managed)
Mental health support lacking (depression/anxiety complicate physical recovery)

Real-world example from the study: A retail worker in rural Montana suffered a rotator cuff injury requiring orthopedic consultation. Nearest orthopedic surgeon: 140 miles away, 8-week wait for new patient appointments.

Result:

8-week delay before seeing specialist
Injury worsened during delay (became more severe tear)
Required surgery instead of conservative treatment that would have worked if started immediately
Total disability: 28 weeks (vs. 10-12 weeks if treated promptly)
Total claim cost: $67,000 (vs. $24,000 with timely conservative treatment)

Income Level and Opioid Risk: 26% Higher Opioid Use

The connection: Pain management is critical for workers comp recovery. Opioids are effective short-term but carry addiction risk.

The problem: Low-income injured workers are at higher risk for opioid addiction:

Financial stress increases vulnerability to substance use
Limited access to non-pharmaceutical pain management (acupuncture, massage, physical therapy)
Poor health literacy about opioid risks
Higher baseline rates of chronic pain and mental health conditions

The research finding: Low-income workers had:

26% higher rates of opioid prescribing in workers comp claims
41% higher rates of long-term opioid use (>90 days)
34% higher rates of opioid use disorder diagnosed during claim
52% longer disability durations when opioid addiction developed

Why this matters:

Opioid addiction transforms temporary injury into chronic disability
Treatment for opioid use disorder adds substantial costs
Workers addicted to opioids rarely return to work successfully
Long-term disability and life impacts extend far beyond initial injury

Real-world example from the study: Two workers suffered similar back injuries.

Worker A (middle income, $72,000 household income):

Insurance covered physical therapy, massage, acupuncture
Could afford copays for frequent PT visits
Used opioids for 10 days post-injury, then transitioned to non-opioid pain management
Returned to work in 9 weeks
Total claim cost: $22,000

Worker B (low income, $28,000 household income):

Workers comp covered PT but couldn't afford copays for other pain management
Used opioids for 14 weeks (doctor kept prescribing because patient reported ongoing pain)
Developed opioid dependence
Required addiction treatment program
Never returned to previous employment
Total claim cost: $187,000 (including addiction treatment and long-term disability)

What This Means for Employers

The SDOH research challenges employers to think beyond traditional workers comp management:

1. Return-to-Work Programs Need Social Support Components

Traditional return-to-work focus: Modified duty jobs, physical accommodations, gradual increase in hours

SDOH-informed approach: Address transportation, childcare, housing, and economic barriers to returning to work

Examples:

Provide transportation assistance for injured workers without cars
Offer flexible schedules that accommodate medical appointments
Provide advance pay or emergency loans to prevent housing instability
Connect injured workers with social services (food assistance, housing support)

ROI: A manufacturing company implemented transportation assistance for injured workers. They provided Uber credits for medical appointments and work during transitional duty.

Results:

Missed appointment rate dropped from 31% to 8%
Return-to-work time decreased 22%
Average claim cost declined 18%
Program cost: $180 per claim average
Savings: $2,400 per claim average
Net savings: $2,220 per claim (1,233% ROI)

2. Employee Benefits Can Reduce Workers Comp Costs

Connection: Employees with strong benefits (health insurance, paid sick leave, stable income) recover faster from work injuries

Why: They can address health issues before they become chronic, access preventive care, afford copays and medications, maintain stable housing

Example: A distribution company enhanced benefits for hourly workers:

Increased health insurance coverage (reduced deductibles and copays)
Added paid sick leave (5 days annually)
Implemented earned wage access (workers can access earned wages before payday)

Workers comp impact:

Claim frequency decreased 14% (workers addressed health issues before injuries occurred)
Claim duration decreased 19% (workers recovered faster with stable income and healthcare access)
Claim costs decreased 21%
Benefits cost increase: $240 per employee annually
Workers comp savings: $420 per employee annually
Net savings: $180 per employee (plus improved retention, productivity, morale)

3. Wage Levels Affect Total Risk Costs

The paradox: Paying higher wages increases payroll (and workers comp premium calculation is based on payroll)

But: Higher-wage workers have:

Lower claim frequency (better health, less physically demanding roles often)
Faster recovery when injured (stable housing, transportation, healthcare access)
Lower claim severity (address injuries early, have resources for recovery)
Better outcomes (return to work successfully)

Total risk cost analysis: Compare "total risk cost" (workers comp premium + claim costs + productivity loss) not just workers comp premium

Example: A restaurant chain analyzed two locations:

Location A (low wage strategy):

Average hourly wage: $12.50
High turnover (140% annually)
Annual payroll: $850,000
Workers comp premium: $68,000 (8% rate)
Actual claim costs: $94,000 (high frequency, poor outcomes)
Productivity loss: $47,000 (frequent staff shortages due to injuries)
Total risk cost: $209,000 (24.6% of payroll)

Location B (higher wage strategy):

Average hourly wage: $16.50
Lower turnover (45% annually)
Annual payroll: $1,100,000
Workers comp premium: $77,000 (7% rate, better mod)
Actual claim costs: $42,000 (low frequency, good outcomes)
Productivity loss: $12,000 (minimal disruption)
Total risk cost: $131,000 (11.9% of payroll)

Location B's higher wages resulted in $78,000 lower total risk cost despite higher payroll.

4. Social Support Benefits Have Measurable ROI

Emerging programs employers are testing:

Emergency financial assistance funds:

Interest-free loans for housing emergencies, medical costs, transportation
Prevents economic instability during injury recovery
ROI: $4-7 saved in workers comp costs per $1 in assistance

Transportation assistance:

Rideshare credits for medical appointments
Shuttle services to medical facilities
ROI: $8-12 saved per $1 spent

Housing stability programs:

Emergency rent assistance
Referrals to affordable housing resources
ROI: Difficult to quantify but measurable in reduced claim complications

Nutrition assistance:

Subsidized cafeteria meals for recovering workers
Grocery gift cards during recovery
Meal delivery for workers with mobility restrictions
ROI: $3-5 saved per $1 spent

Health navigation services:

Staff who help injured workers navigate healthcare system
Appointment scheduling, transportation coordination, interpreter services
ROI: $6-9 saved per $1 spent

What This Means for Insurers and Claims Management

Workers comp insurers are beginning to address SDOH factors:

1. Social Determinants Risk Scoring

Emerging practice: Insurers analyzing policyholder employee demographics to identify SDOH risk factors:

Average wage levels
Geographic indicators (food deserts, healthcare deserts, housing costs)
Industry indicators (employees likely to face economic instability)

Use: Target interventions to high-risk populations, price policies more accurately

2. SDOH-Informed Claims Management

Progressive claims practices:

Screen injured workers for transportation, housing, food security issues
Connect workers with community resources (United Way 211, local social services)
Provide flexible medical appointment scheduling
Offer telehealth options for workers with transportation barriers
Coordinate with social workers and case managers

3. Value-Based Provider Networks

Traditional model: Workers comp networks based on provider discounts

SDOH-informed model: Networks emphasize providers who:

Understand and address social determinants
Offer culturally competent care
Provide flexible appointment scheduling
Coordinate with social services

Early results: Insurers using SDOH-informed provider networks see 12-18% lower claim costs and 15-20% better return-to-work outcomes

4. Community Partnerships

Innovative insurers partner with:

Food banks and nutrition programs
Transportation services
Housing assistance organizations
Community health centers
Immigrant and refugee services
Faith-based organizations

Goal: Address social barriers to recovery that medical care alone can't solve

Policy Implications: Addressing SDOH at System Level

The research findings suggest workers comp system-level reforms:

1. Higher Wage Replacement Rates

Current: Most states replace 60-67% of wages during disability Problem: Low-wage workers can't afford rent, food, medications on 60% of already-low wages Proposal: Sliding scale wage replacement (higher percentage for lower-wage workers)

Example: Instead of flat 66%, provide:

90% wage replacement for workers earning under $35,000
75% for workers earning $35,000-60,000
66% for workers earning over $60,000

Expected impact: Reduced housing instability, better nutrition, lower stress = faster recovery and lower total costs

2. Transportation Benefits

Proposal: Require workers comp coverage to include transportation to medical appointments

Current practice: Only medical care is covered; transportation is worker's responsibility Impact: Reduces missed appointments, speeds recovery, lowers costs

3. Social Services Coordination

Proposal: Workers comp insurers required to screen for and address SDOH barriers

Model: Similar to Medicaid managed care plans that address housing, food, transportation

Expected impact: Improved outcomes, lower long-term costs, better return-to-work rates

4. Prevention-Focused Incentives

Current: Experience modification rewards employers for lower claim costs Proposal: Additional credits for employers who address SDOH factors

Examples:

Higher wages for hourly workers
Comprehensive benefits including health insurance
Transportation assistance programs
Financial stability programs (emergency loans, advance pay)

Goal: Incentivize employers to address root causes of poor claim outcomes, not just reduce claims reporting

The Controversial Question: Who Should Pay for Social Determinants?

The SDOH research raises difficult questions about responsibility:

One perspective: Employers cause work injuries, so workers comp should address all factors affecting recovery—including social determinants.

Another perspective: Social determinants are societal problems (poverty, healthcare access, housing affordability). Workers comp shouldn't have to fix what government and social programs should address.

The pragmatic answer: Regardless of who "should" pay, addressing SDOH factors reduces total costs:

Injured workers recover faster and return to work
Claim costs decrease
Productivity improves
Workers comp premiums decline

Economic reality: A dollar spent on transportation assistance saves $8-12 in claim costs. A dollar spent on housing stability support saves $5-8. These interventions have measurable positive ROI—even if philosophically we might think other entities should provide them.

Most likely future: Hybrid model where:

Employers address SDOH factors during workers comp claims (because it reduces their costs)
Government programs improve baseline social support (healthcare access, housing affordability, nutrition assistance)
Insurers provide tools and resources to facilitate SDOH interventions
Community organizations deliver services

Practical Steps for Employers

Addressing social determinants doesn't require massive investment. Start with these steps:

1. Screen Injured Workers for SDOH Barriers

When a work injury occurs, ask:

Do you have reliable transportation to medical appointments?
Do you have stable housing?
Are you able to afford medications and copays?
Do you have support at home during recovery?
Are there language or communication barriers with your medical providers?

Cost: $0 (just requires asking questions) Impact: Identifies barriers you can address before they delay recovery

2. Create Resource List for Claims

Compile resources for injured workers:

Local transportation services (public transit, rideshare vouchers, volunteer drivers)
Food assistance programs (food banks, SNAP enrollment assistance)
Housing assistance (emergency rent assistance, housing counseling)
Healthcare navigation (free clinics, interpreter services, social workers)
Financial assistance (emergency loans, earned wage access)

Cost: Time to research and compile (one-time effort) Impact: Enables quick intervention when SDOH barriers identified

3. Implement Targeted Assistance Programs

Based on your workforce and common barriers, implement 1-2 targeted programs:

If transportation is common barrier: Rideshare credits for medical appointments If housing instability is common: Emergency rent assistance fund If nutrition is common issue: Meal assistance during recovery If healthcare access is limited: Telehealth options, health navigation services

Start small: $5,000-10,000 pilot program Measure impact: Track claim duration, costs, return-to-work outcomes Scale if ROI is positive: Most SDOH interventions show 3:1 to 10:1 ROI

4. Partner with Community Organizations

You don't have to solve social determinants alone:

United Way 211 connects people to community resources
Local food banks provide nutrition assistance
Community health centers offer affordable care
Transportation authorities may have programs for medical appointments
Housing assistance organizations help prevent evictions

Build relationships before injuries occur, so you can quickly connect injured workers with support.

The Future of Workers Comp: Social Determinants Will Be Central

The October 2025 SDOH research will likely be seen as a turning point in workers compensation. For decades, the industry focused on workplace safety, medical treatment, and return-to-work programs. Now it's clear that injured workers' social and economic circumstances profoundly affect recovery outcomes.

The employers, insurers, and policymakers who adapt to this reality—addressing housing, transportation, nutrition, and economic stability alongside medical care—will achieve better outcomes and lower costs.

Those who ignore social determinants will continue seeing poor claim outcomes, high costs, and frustrated workers whose injuries become chronic disabilities not because of medical complexity but because they couldn't afford nutritious food, couldn't get to medical appointments, or faced eviction during recovery.

The evidence is clear: Social determinants of health drive workers comp costs. The question is whether the industry will act on this knowledge.

Need help managing workers comp costs in light of social determinants research? Understanding how economic and social factors affect your workforce's injury outcomes is increasingly important. Modern workers comp management combines traditional approaches—safety programs, medical management, return-to-work—with newer recognition that employee benefits, wages, and social support measurably impact claim costs and outcomes.

Sources: Journal of Occupational and Environmental Medicine, Harvard T.H. Chan School of Public Health, Boston University School of Public Health, CDC Social Determinants of Health, Workers Compensation Research Institute