Health and health care outcomes for Americans should be better for most, and much better for some. This should be possible with currently available knowledge and resources. Capturing the potential will require adapting our strategies and approaches to the reality that health is not immutably determined at birth, but shaped by different factors over time. Similarly, caring for health cannot be confined to singular interactions within the walls of the health care system, but must fully engage powerful determining influences residing in other systems—e.g. education, employment, justice, transportation—which are natural parts of our lives. Exploring the nature and strategic opportunities inherent in these intersecting influences is the focus of this paper, and the implications for societal attention and resources suggest the promise of shifting emphases across the life span, across systems, and within the health care system.
Our assessment begins with an overview of the prominent health and health care challenges for Americans, and they are many. U.S. life expectancy at birth ranks 43rd in the global community, and has even recently declined among some specific groups. Unacceptable disparities in health outcomes and access persist among certain populations, in particular African-Americans and Native Americans. The U.S. health system ranked in a World Health Organization assessment only 37th in performance among 191 member nations, and in a recent study of 11 highly industrialized OECD nations, the U.S. ranked last. These deficiencies are all the more glaring in the face of health expenditures that are clearly the highest in the world, about 50% higher than the country next behind us, and requiring investment of nearly 18% of our total economic productivity (GDP) in 2015. Why are we performing so poorly relative to our potential? A major reason lies in the fact that the foci of our attention, our resources, and our incentives are too narrow and too late: despite an increasingly strong and specific understanding of the preventable elements in the development of many of our health challenges—social, behavioral, environmental—our investments are primarily directed to their biomedical manifestations, well after the problems have taken root.