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VALUING AMERICA’S HEALTH

Our nation’s health system¹ is failing. Between 2020 and 2022, more than 1 million Americans died from the COVID-19 pandemic (CDC, 2022). Due to the pandemic, in 2020, Americans experienced the largest 1-year drop in life expectancy since World War II (CDC, 2021a). Americans now have the lowest life expectancy observed since 2003, with structural racism driving even larger declines in life expectancy among Black and Latinx populations (Andrasfay and Goldman, 2021; CDC, 2022).

While uniquely devastating, the damage wrought by the pandemic belies a broader national health crisis. Before the pandemic, U.S. life expectancy fell from 2014 to 2015 and continued to decline through 2017—the longest sustained decline in life expectancy in a century (NASEM, 2021b). Additionally, our nation experiences the highest chronic disease burden among Organisation for Economic Co-operation and Development (OECD) countries, including the United Kingdom, France, and Germany (CDC, 2021c). The U.S. obesity rate, for example, is roughly two times that of our peer nations, on average.

Because of our high chronic disease prevalence, the United States experiences unusually high rates of avoidable and premature deaths, which has worsened over time and has disproportionately affected Black, Indigenous, and People of Color (BIPOC) populations due to structural racism (KFF, 2022; Tikkanen and Abrams, 2020). The number of reported pregnancy-related deaths in the United States has steadily increased from 7.2 deaths per 100,000 live births in 1987 to 17.3 deaths per 100,000 live births in 2017—the highest among OECD countries (CDC, 2021b; Tikkanen and Abrams, 2020). At the same time, Black women experienced a maternal mortality rate that is three and a half times more than that experienced by non-Hispanic White women and were five times more likely to die from pregnancy-related heart failure and blood pressure disorders (PRB, 2021).

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¹ For the purposes of this publication, the term “health system” refers to the collective group of people, institutions, and resources that provide health care and related services in the United States.

Our nation is also experiencing a crisis in mental health. Approximately 1 in 5 adults—nearly 50 million people—have experienced at least one mental illness, while more than 2.5 million youth report severe depression. Moreover, more than 60 percent of youth with severe depression do not receive treatment (Mental Health America, 2022). Thus, it is unsurprising that the United States reported the highest rates of death by suicide among OECD countries before the COVID-19 pandemic (Tiikanen and Abrams, 2020). Age-adjusted suicide rates increased 35 percent from 1999 to 2019, with an even higher increase (57 percent) in youth suicide rates from 2007 to 2018 (Curtin, 2020; SPRC, 2021). Furthermore, nearly 1 in 4 young girls have been found to self-harm, portending a protracted mental health crisis in the years to come (Pirani, 2018). Other deaths associated with feelings of despair have also occurred in shockingly high numbers. Driven by the opioid epidemic, where prescription painkillers were improperly approved, prescribed, and used, the number of drug overdose deaths has quadrupled since 1999, with nearly 500,000 individuals losing their lives to opioid overdoses (CDC, 2021c). The crisis continues to wreak havoc on the nation’s social fabric, with illicit fentanyl and heroin continuing to cause avoidable deaths and secondary effects such as homelessness, unemployment, and school truancy (Feldscher, 2022). Overdoses are now a significant contributor to reductions in U.S. life expectancy, killing more Americans than suicides, motor vehicle accidents, firearms, and homicides (Graham, 2021). The evidence of a national health crisis could not be clearer.

Despite higher spending than any other OECD nation, at $4.1 trillion per year and growing, the U.S. health system is failing Americans through well-documented

issues of unaffordability, inaccessibility, and disparities in care quality and access (CMS, 2021; Osborn et al., 2016; Schneider et al., 2021). Unfortunately, as much as one-third of these dollars are wasted due to the inefficiencies of the health care system. Care remains too expensive due to market failures and incentives that favor unnecessary, fragmented, or even harmful care, excessive prices, and administrative overhead. Meanwhile, programs and services that have been shown to maintain or improve health are woefully under-resourced (Berwick and Hackbarth, 2012).

The current trajectory of health spending, coupled with the nation’s declining health status, is untenable and perilous. As evidenced by the COVID-19 pandemic, the systemic failure to invest adequately in a system that protects and promotes health led to disastrous outcomes in loss of life and economic productivity for individuals, families, and communities. These outcomes clearly demonstrate that—in both spending and practice— it is time to re-prioritize health and the services and interventions that advance it. Aligning financial incentives in ways that promote whole health across the life course requires a reimagination of how and what we pay for. Additionally, the nation will need to develop and implement innovative policies, clinical strategies, and new ways of investing in social, environmental, and community factors that change how we value² health.

A NEED FOR URGENT ACTION

The Steering Group recognizes that many efforts have centered on the need to transform health financing and health care payment from fee-for-service toward value-based care, including those led by nonprofit organizations, federal actors such as the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare & Medicaid Innovation (CMMI), and private players alike. While some improvement has been made over the past few decades, especially through the work led by CMMI, progress has largely been incremental. The lack of large-scale progress in transitioning from volume to value is not surprising, given that the status quo is quite profitable for many health care organizations and leaders (NAM, 2022). However, in light of the current negative trajectory of health in the United States and the profound impacts of a wasteful health system on

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² The Steering Group largely defines value in health care through the prism of value-based care (i.e., exchange value). Health can also be improved by upstream social, environmental, and community factors that prevent disease and reduce morbidity incidence and prevalence, leading to reduced costs. Finally, the Special Publication defines value as an indicator of societal priorities (e.g., whether employers provide an environment and benefits that protect employee health, or whether the nation can accept the increasingly serious health impacts of racial and income inequality).

American society and well-being, the Steering Group believes that the time for incremental change is over.

By shining light on persistent inequities and vulnerabilities in the health and health care workforce and the crumbling public health infrastructure in the United States, COVID-19 has illustrated the dire consequences of not prioritizing health and the systems needed to maintain and promote it equitably across populations. Furthermore, our nation does not presently focus enough on the poorer outcomes of marginalized populations, especially along racial and ethnic lines but also including intersections across communities, identities, and factors including, but not limited to, sexual orientation and gender identity, income, and education. Finally, as experts in public health and health care, the Steering Group is concerned about the health and developmental outcomes in our nation’s future—our children. We are alarmed by the high rates of childhood obesity and poverty, low social mobility and income stagnation, housing insecurity, and poor educational outcomes experienced by millions of American children. Because the Steering Group understands that health occurs on a continuum, with early childhood experiences substantially impacting health at every stage of life in increasingly compounding ways, we understand that transformation and change cannot wait.

The weight of these consequences necessitates the advocacy of patients, families, and communities to force urgent action by leaders in every sector—from the local to federal levels—to address existing and deepening health inequities and drive attention toward prioritizing health and tackling perverse incentives, market failures, and structural racism. Faced with the harrowing reality of the pandemic era, it is clear that investing time, finances, and collective efforts toward creating a healthier and more resilient system and populace is urgently needed. But how do we, as stakeholders and leaders of the U.S. systems of health, health care, and biomedical science, approach and galvanize a broader movement to prioritize health? How do we invest in the strategies that build and protect it in a more equitable manner?

The Steering Group looks to the example of climate change as both an inspiration and a model. Today, the global climate change movement is considered, perhaps, the world’s most prominent social movement (Curran, 2015). Over the first two decades of the 21st century, a combination of public facilitators emphasized climate change as a critical global priority: the widespread impact of the 2006 film The Inconvenient Truth (Nolan, 2010); alarm from extreme hurricanes and wildfires across the United States; a global grassroots campaign led by youth activists and low-lying island nations (Daly, 2022; Witze, 2022); and renewable energy innovation (Eurasia Group, 2022).

Between 2019 and 2022, 3,135 companies across the globe committed to net-zero carbon by 2040—a bold, aggressive commitment that will require new investments, new technologies, change management, and broad-scale re-engineering and re-envisioning of how these organizations do business (The Climate Pledge, 2022). Those profiting from the status quo, such as fossil fuel companies, are not expected to lead a business transformation that has the potential to be financially damaging to them. Yet, these companies are slowly being pressured to join the many corporations working to shrink their carbon footprint. There is a growing recognition that addressing climate change is beneficial for all and that every economic and social sector should do its part. The need to address climate change has now experienced enough success and been viewed with enough urgency that, hopefully, decades of effort will make a meaningful impact.

While the climate change analogy has perhaps only partial applicability to the American health crisis, the issues identified by the Steering Group and the 2021 workshop described in Appendix A indicate that a similar approach and urgency is needed to address the nation’s declining health status and worsening health inequities. The American health care system can no longer be looked to as the primary entity accountable to produce health for individuals and communities. It is often noted that, as currently structured, the American health care system pays for and profits from “sick care”—paying for illness and not for health—while the nation’s public health system—which includes state and federal public health agencies and departments and is responsible for promoting health and well-being by preventing morbidity and mortality—has not been adequately funded or supported (Maani and Galea, 2020). Optimizing the effectiveness of this reactive method of improving individual and community health is, therefore, an inherently limited approach. Instead, similar to the climate change movement, the nation must elevate the goal of whole person population health across the life course as a priority far beyond the health care industry to include all sectors, including real estate that is affordable and equitably distributed and investments that reward the work of community-based organizations.

If leadership on prioritizing and producing health comes from empowered state, federal, and local actors, along with other non–health care system stakeholders (e.g., employers, investors, and entrepreneurs), the Steering Group believes that health care will eventually respond to new market demands and evolve to a system that profits from keeping people healthy as well as serving them when they are ill. In order to secure the cross-sector leadership and resources needed to invest in the mechanisms that we know can produce whole person health at scale, the circle of accountability for health must be broadened to reach far beyond the

health care system. Collective accountability is not a revolutionary leap, as many entities are already invested in health in one form or another, ranging from U.S. taxpayers who are increasingly asked to fund ever more costly bills to sustain publicly supported health care, to employers who pay ever-increasing costs for sicker employees, and the many others who desire a more efficient and effective health system.

COVID-19 clearly demonstrated that, while everyone suffers from a sicker population, everyone can also benefit from a healthier society. This is because as societal conditions improve, the health and well-being benefits are experienced by everyone. The time has come for the United States to embrace these truths and take the long overdue steps to move away from incremental change and toward the bold action and leadership that is needed to propel our nation’s health and health care system toward one that ensures better health for all. Just as businesses have committed to reducing their carbon footprint, the authors of this Special Publication hope to see organizations making commitments to improve the health of their employees and the communities in which they operate. Additionally, public and private resources should be redirected away from health care as we know it today, and toward those entities and programs that can improve and maintain health.

Just as COVID-19 demonstrated the need for urgent action, the national response to the crisis has shown us that rapid, meaningful change is possible where our priorities and purpose are clear and aligned. The speed of monumental actions undertaken to respond to COVID-19, including Operation Warp Speed, the rapid growth of telehealth, the unprecedented cross-sector collaboration among health care entities, strategically expanded scopes of practice, and the shifting of many services into the home, was previously considered impossible (NAM, 2022). As a nation, we must apply this same urgent and disruptive energy to the national crisis of declining American health to jolt us from our current course and reorient the nation on a path toward greater health and well-being. Our future and pre-eminence as a nation and world leader depend on it.

The insights included in this Special Publication provide both a vision for what a transformed U.S. health system could look like and key examples and strategies that stakeholders and leaders can use to progress. Chapter 2 describes six pillars of the transformative vision, while Chapter 3 details the elements of health care delivery and health financing models that have been successful in delivering, resourcing, and incentivizing whole person care, demonstrating that progress is already under way. Chapter 4 discusses priority actions that diverse stakeholders—including communities, government leaders, and private investors—can take to advance transformative efforts. These priority actions are intended to provide a

useful, but not comprehensive, assessment of starting points for aligned action, acknowledging that other societal actors outside the scope of the Steering Group’s expertise, such as education and law enforcement leaders, have a role to play as well. Lastly, Chapter 5 reiterates the need for disruptive change to achieve health transformation and provides examples of disruptive actions that can address upstream health determinants in a manner that is consistent with the vision and goals highlighted throughout the Special Publication.

REFERENCES

Lee, and A. Williams, editors. NAM Special Publication. Washington, DC: The National Academies Press. https://doi.org/10.17226/26657.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2021a. Financing That Rewards Better Health and Well-Being: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26332.

NASEM. 2021b. High and Rising Mortality Rates Among Working-Age Adults. Washington, DC: The National Academies Press. https://doi.org/10.17226/25976.

Nolan, J. M. 2010. “An inconvenient truth” increases knowledge, concern, and willingness to reduce greenhouse gases. Environment and Behavior 42(5):643-658. https://doi.org/10.1177/0013916509357696.

Osborn, R., D. Squires, M. M. Doty, D. O. Sarnak, and E. C. Schneider. 2016. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Affairs 35(12):2327-2336. https://doi.org/10.1377/hlthaff.2016.1088.

Pirani, F. 2018. Nearly 1 in 4 Teen Girls in the US Self-Harm, Massive High School Survey Finds. Available at: https://www.ajc.com/news/health-med-fit-science/nearly-teen-girls-the-self-harm-massive-high-school-survey-finds/EQnLJy3REFX53HjbHGnukJ (accessed January 24, 2023).

PRB (Population Reference Bureau). 2021. Black Women Over Three Times More Likely to Die in Pregnancy, Postpartum Than White Women, New Research Finds. Available at: https://www.prb.org/resources/black-women-over-three-times-more-likely-to-die-in-pregnancy-postpartum-than-white-women-new-research-finds (accessed January 23, 2022).

Schneider, E., A. Shah, M. M. Doty, R. Tikkanen, K. Fields, and R. D. Williams. 2021. Mirror, Mirror 2021: Reflecting Poorly. The Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly (accessed March 31, 2022).

SPRC (Suicide Prevention Resource Center). 2021. Suicide Mortality in the U.S., 1999–2019. https://sprc.org/news/suicide-mortality-us-1999-2019 (accessed March 31, 2022).

The Climate Pledge. 2022. Net-Zero Carbon by 2040. Available at: https://www.theclimatepledge.com (accessed June 8, 2022).

Tikkanen, R., and M. K. Abrams. 2020. U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? The Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019 (accessed March 31, 2022).