What if one of the most effective health care interventions wasn’t a medical treatment at all, but a set of pots and pans?
That may sound surprising, but it captures an important lesson from New York’s Medicaid 1115 waiver, one of the country’s most ambitious efforts to address social needs as part of health care. In Staten Island, the results suggest that improving health sometimes starts far outside a doctor’s office.
Health care solutions need to be personalized. Not all states face the same challenges, and not all people need the same support. That premise is at the heart of a growing shift in how Medicaid programs are approaching health, one that connects health and social care systems through data, screening, and referrals rather than clinical treatment alone.
In 2022, New York State received federal approval for a Medicaid 1115 waiver, a policy mechanism that allowed the state to redirect Medicaid funding toward social care services, such as food, transportation, housing support, and home modifications, that traditional health care budgets had never covered. The state divided itself into regions, each responsible for selecting its own technology platform and building its own network of community partners.
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The process begins with a screening, though not the kind you get at a doctor’s office, checking blood pressure or reviewing medications. This one asks different questions: How much do you earn? Is it enough to cover your bills? How many times a week do you eat? Do you ever go hungry? Do you need help getting to a pharmacy, modifying your home, or paying your electricity bill?
Once the screening is complete, the responses are automatically reviewed, eligible needs are identified, and each person is matched with available nearby resources. The referral is made, the help is delivered, and Medicaid reimburses the organizations that provided the support.
The results have been notable. New York recently surpassed one million screenings under the waiver across all regions of the state. Staten Island, despite being the smallest region, achieved the highest screening rate and delivered more services than any other region.
But statistics only tell part of the story. One of the most revealing findings was that many residents who struggled to afford food also lacked the basic equipment needed to prepare meals. When resources are scarce, purchasing a new set of pots and pans is rarely a priority. Recognizing this barrier, community partners distributed approximately 500 cooking kits to local residents. It was a simple intervention, but one that addressed a need the health care system would never have identified through a traditional clinical encounter.
Other services included transportation assistance, food delivery, home modifications for disability access, and behavioral health support. None of these interventions is typically considered health care, yet all have a direct impact on health and well-being.
The screenings were conducted by the Staten Island Performing Provider System, a network of case managers and social workers serving approximately 250,000 Medicaid beneficiaries across the borough. Individuals who chose to participate completed a structured assessment developed by Staten Island and New York State, and were connected with more than 80 community organizations throughout the borough. That model is now expanding into selected ZIP codes in Brooklyn and Queens, bringing the same community-connected approach to new populations across New York City.
When people ask why Staten Island succeeded where other regions struggled, technology is part of the answer, but not the whole story. Many referral networks are designed to work everywhere, at a national scale. The challenge is that a system built to fit every community often fails to adapt to any one of them. What worked in Staten Island was different: each implementation was built specifically for the community it served, with eligibility rules, covered services, and partner networks tailored to local needs. A change made for one region did not ripple into another.
The lesson is not that every community needs pots and pans. It is that health care systems cannot solve problems they never ask about. Making an invisible need visible, in this case something as ordinary as a missing set of pots and pans, may be one of the simplest ways to change what health care can actually accomplish.
The future of health care will extend beyond hospitals and clinics. It will include food, transportation, housing, and the everyday conditions that shape people’s health long before they enter an exam room. Staten Island offers a glimpse of what that future can look like.
James Gallagher is a health care executive.
