Where and how is health created

Reforming our health care system is necessary but not sufficient for improving the health of the nation. If you look at The World Bank’s most recent data on the percentage of a country’s gross domestic product (GDP) that is devoted to public and private expenditures on health, only Liberia and Sierra Leone have a higher percentage than the United States (The World Bank, n.d.), and none of these countries lead the world in indicators of health status of their populations including the United States (OECD, 2013). We are spending almost one fifth of our GDP on preventive and curative care (mostly the latter). Why does health care spending as a percentage of GDP matter? The health care system is siphoning off limited resources that could be invested in promoting health “upstream” in ways that could prevent the need for costly acute care services. Health and illness are embedded in the socioeconomic conditions of our communities. As Marks (2009) framed it, “your zip code may be more important to your health than your genetic code.” Indeed, geographic variations in health indicators support the importance of one’s zip code to health, well-being, and quality of life (Will, Nwaise, Schieb, & Zhong, 2014; Wold, 2008). Population health is now a priority. In addition to enhancing patient experience and reducing health care costs, one of the Institute for Healthcare Improvement’s Triple Aims is “improving the health of populations” (Institute for Healthcare Improvement, n.d.). The Affordable Care Act emphasizes population health, for example, by requiring accountable care organizations to attend to it. The Affordable Care Act also requires that nonprofit hospitals develop a community health improvement plan after an assessment of a geographic community it serves. It is important to note that a disease-defined population is not the same as a geopolitical community. Both are important, but “place matters” di.e., health is largely determined in the places where people live, work, and play (Bell & Rubin, 2007). This focus on building the health of communities is not new. For example, Lillian Wald demonstrated an understanding of this more than a century ago. Besides establishing what today would be considered a patient-centered medical/health home (Keeling & Lewenson, 2013), she started the first playground in New York City with the understanding that children need a safe place to play. Almost a century later, the Ottawa Charter on Health Promotion identified the “fundamental conditions and resources for health” as peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity (World Health Organization, 1986). In 2005, the World Health Organization established a Commission on Social Determinants to “marshal the evidence on what can be done to promote health equity, and to foster a global movement to achieve it” (Commission on Social Determinants of Health, 2008). In fact, the evidence is compelling. There is a growing body of research that links health status with the conditions of people’s lives where they live, work, and play (Wilkinson & Marmot, 2003; World Health Organization, n.d.). With this in mind, one of the Academy’s three new strategic goals is to “lead efforts, in partnership with others, to address the broad range of factors that affect the health of populations” with “population” defined in terms of geopolitical communities, disease, and demographic characteristics. In my next column, I’ll discuss how the Academy is approaching this important goal.