What can we learn from Link Health?
Imagine a world where low-income individuals walk into a community health clinic for a check-up and leave with the financial resources to build a healthier, more secure future for their families. That vision is now a reality.
Recently, I visited a community health clinic[i] where Link Health works to connect low-income households with essential federal and state benefits. Link Health is a nonprofit organization based in Boston and Houston, founded by HKS MPP alum Dr. Alister Martin, an ER physician and Assistant Professor at Harvard Medical School. There, three navigators stood by a table near a prominent Link Health signboard. When patients arrived and waited for their appointments, a Link Health navigator would approach and assist them in applying for federal or state benefit programs.
To date, the U.S. has launched programs like SNAP, WIC, and TANF (similar to TAFDC in Massachusetts, but with differences in eligibility and benefits) to address poverty and its broader societal costs, notably including health inequity. A study published in Nature suggests that cash transfers to low-income communities can effectively improve health outcomes and serve as a powerful tool for reducing health disparities caused by health inequity, ultimately benefiting society through their spillover effects.[ii]
Various challenges, however, hinder equitable access to these programs. When I interviewed Dr. Martin about his motivation for starting Link Health, he explained, “I had witnessed countless preventable [emergency room] visits by patients who could have avoided these situations if they had access to adequate resources. Despite significant funding being allocated to create these resources, they remain largely underutilized.”
Studies have shown that with additional income, beneficiaries would have improved health, reduced food insecurity,[iii] and fewer ER visits.[iv] Children of beneficiaries would achieve higher educational attainment, and families experience less financial stress, which in turn generates broader societal benefits. These would lead to fewer lost workdays,[v] lower healthcare costs from decreased ER visits[vi] and acute care use[vii], and a decline in recidivism rates.[viii]
Many targeted populations, however, lack access to information or even awareness of support programs, leading to misunderstandings about application requirements or assumptions that they do not qualify. Language barriers further impede access, making it harder for people to navigate the system.
The application process can be overwhelming and redundant. Poorly designed formats and outdated systems drain time and energy for both applicants and administrators, leaving those in urgent need struggling to get support. In Massachusetts, for instance, there is no common application for benefits, requiring individuals to repeatedly enter the same information across multiple forms.
These challenges create benefit gaps that prevent communities from accessing the support they need, leading to the underutilization of social safety net programs designed to help them. This underscores the need for targeted solutions. But how?
Link Health has successfully supported patients and families across Massachusetts and Texas by implementing a model focused on three key factors comparable to an operating room.
The “surgeon,” or the driving force behind Link Health, is its workforce. The team consists of highly trained and motivated patient navigators, most of whom are students in health-related fields such as medicine, public health, public policy, and social work. Navigators are trained to assist patients in federally qualified health centers (FQHCs), such as the one I visited, meeting patients where they are and providing direct, culturally competent support.
One critical barrier to patients is a lack of information. Many patients are unaware that they qualify for benefits. By proactively engaging with patients, navigators identify those who are eligible and guide them through the enrollment process, ensuring they receive the support they need but might not have sought on their own.
Another significant barrier is language. During my visit to the clinic, I witnessed a patient whose native language was Spanish. Without hesitation, the navigator switched to fluent Spanish, ensuring the patient understood the process and received the assistance they needed. This helps ensure that no eligible individual is left behind.
Just as a needle and thread physically close gaps in tissue during surgery, Link Health’s human-centered approach serves as the stitching that bridges the benefit gap. This model emphasizes human connection and the reduction of bureaucratic barriers, ensuring patients receive the support they need without unnecessary obstacles.
Navigators are integrated with patients and their families as part of their close-knit communities. Volunteers played with patients’ children, offering candy or toys while assisting their mothers with benefit applications. Some children even expressed excitement about returning, making sure the volunteer had their favorite toy ready for them.
Beyond fostering a welcoming environment, this model also tackles a critical issue: bureaucratic hurdles. Many hospitals have social worker programs to help patients navigate available financial resources, but the typical experience involves receiving yet another phone number to call and scheduling another appointment. Link Health removes these extra steps by integrating social services directly into community care settings. Once a patient is deemed likely eligible, a senior navigator gathers all the necessary information for their applications. Moreover, what sets Link Health apart is its hands-on approach; navigators not only provide guidance, but also complete the applications alongside patients, eliminating the need for additional appointments with social workers. This seamless, in-person support removes barriers that often prevent individuals from accessing the benefits they qualify for.
Finally, just as advanced surgical tools improve precision, speed up recovery, and make procedures more efficient, Link Health’s artificial intelligence (AI)-powered platform simplifies and accelerates the application process. This reduces the time patients spend navigating multiple websites and forms, making access to benefits much easier.
While not immediately visible during my visit, this technology plays a crucial role in quietly streamlining applications behind the scenes. Link Health’s AI-powered platform consolidates all applications in one place, which is especially important for states where benefits applications are scattered across different systems. To date, just 34 states have an integrated application covering three programs, only 15 extend it to four, and a mere five states integrate five programs, leaving most states with fragmented processes.[ix] Of the two states Link Health primarily serves, Massachusetts benefits most from this common application platform. Texas, on the contrary, has an integrated benefits application system called YourTexasBenefits, which combines all five essential benefit programs.
With Link Health’s platform, patient navigators collect all necessary information from the patient at once. Instead of filling out the same details repeatedly, the system stores key information, such as patient details, phone numbers, and consent for follow-up, in a single, comprehensive record. Volunteers then use this data to complete application forms and submit them directly to the relevant state agencies.
Link Health operates in many FQHCs like the one I visited and is continually seeking new partnerships to expand its reach. It is also exploring new ways to improve efficiency, such as developing an AI chatbot to reduce the time patients spend navigating the system and to streamline the application process.
Thus far, Link Health has helped families access over $4M in federal and state benefits, providing support to more than 3,000 households. While Link Health has made significant progress, it still faces key challenges. Its reliance on philanthropic funding creates uncertainty, and its unique combination of AI-powered technology, a skilled workforce, and a human-centered model makes scalability difficult. Can Link Health continue to hire and retain top talent? Will its in-person, hands-on approach change as it expands? Increased personal interaction reduces scalability. While crucial for social programs’ effectiveness, it requires significant resources and is difficult to standardize, making expansion challenging.[x] Without direct human support, can an AI chatbot truly meet patients’ needs? Link Health is currently running a pilot program in a community health clinic’s ER, monitoring how well its AI chatbot supports patients.
Despite these challenges, Link Health demonstrates that a highly skilled and motivated workforce, a human-centered approach, and the use of efficient technology, can ensure benefits reach those in need. For families struggling with food insecurity, medical costs, or unreliable internet and phone access, timely access to benefits isn’t just about extra financial support, but also about addressing the root causes of health inequities, reducing stress, and creating a more stable future.
This essay is based on work conducted collaboratively with the author’s Policy Analysis Exercise (PAE) partner, Hannah Marks (HKS MPP Class of 2025), as part of our engagement with our client, Link Health. The interviews and research we worked on together have significantly informed the ideas and insights presented here.
The author gratefully acknowledges the Link Health team for sharing their insights and information, which also contributed to this work.
[i] The name of the clinic is anonymized.
[ii] Aaron Richterman et al., “The Effects of Cash Transfers on Adult and Child Mortality in Low- and Middle-Income Countries,” Nature 618 (2023): 764–769, Accessed January 10, 2025, https://www.nature.com/articles/s41586-023-06116-2.
[iii] Samantha Waxman, Arloc Sherman, and Kris Cox, “Income Support Associated with Improved Health Outcomes for Children, Many Studies Show: Refundable Tax Credits Among Programs That Boost Income,” Center on Budget and Policy Priorities, May 27, 2021, https://www.cbpp.org/research/federal-tax/income-support-associated-with-improved-health-outcomes-for-children-many.
[iv] Sumit D. Agarwal, Benjamin Lê Cook, Jeffrey B. Liebman, “Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study,” JAMA 332, no. 17 (2024):1455-1463, doi:10.1001/jama.2024.13004.
[v] National Institute on Minority Health and Health Disparities, “The Economic Burden of Health Disparities in the U.S., 2018,” NIMHD, accessed January 10, 2025, https://www.nimhd.nih.gov/about/publications/economic-burden-health-disparities-US-2018.html.
[vi] Jessica Bartlett, “New Survey Reveals Stark Racial Disparities Among Those Who Rely on ERs for Health Care,” CHIA Massachusetts, November 30, 2022, accessed January 10, 2025, https://www.chiamass.gov/new-survey-reveals-stark-racial-disparities-among-those-who-rely-on-ers-for-health-care.
[vii] Marta L. McCrum, et al, “Taking Action to Achieve Health Equity and Eliminate Healthcare Disparities Within Acute Care Surgery,” Trauma Surgery & Acute Care Open 9, no. 1 (2024): e001494, https://pmc.ncbi.nlm.nih.gov/articles/PMC11481130/.
[viii] Office of Minority Health, “Justice and Health Initiatives,” U.S. Department of Health and Human Services, accessed January 10, 2025, https://minorityhealth.hhs.gov/omhs-justice-and-health-initiatives.
[ix] Code for America, The Benefits Enrollment Field Guide, Code for America, 2024, https://codeforamerica.org/explore/benefits-enrollment-field-guide/.
[x] Gregory Dees, Beth Battle Anderson, and Jane Wei-Skillern, “Scaling Social Impact,” Stanford Social Innovation Review 1, no. 4 (2004): 24–32, https://doi.org/10.48558/CNNZ-7276.