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American Health Care Is Broken. Major Hospitals Need to Be Part of the Solution

6 minute read
Berwick, MD, a pediatrician, is the former Administrator of the Centers for Medicare and Medicaid and President Emeritus at the Institute for Healthcare Improvement. Williams, ScD, an epidemiologist, is the Dean of Faculty at the Harvard T.H. Chan School of Public Health.

American health care is broken. And American health care systems must transform radically to lead the repair.

Let’s first look at the data: The U.S. now spends more than $4 trillion a year on health care. That’s nearly 20% of gross domestic product. Yet U.S. life expectancy lags literally dozens of other nations—including Portugal, Slovenia, and Turkey—by as much as seven years. If trends continue, we will drop to 64th in the world in life expectancy by 2040, though we will continue to spend significantly more per capita than nearly any other nation.

Diagnosing this failure is not difficult. Nearly all the money we spend on health care goes to pay for medical interventions. But clinical care is responsible for at most 20% of health outcomes. The overwhelming majority of factors that determine an individual’s health are embedded in the world around them: How many bus transfers they need to reach a store that sells fresh vegetables. Whether the windows in their workplace let in light and fresh, clean air. How often they face the stress and pain of discrimination because of the color of their skin.

These are the social drivers of health—and for far too long, our health care systems have largely ignored them.

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They’ve ignored them, in part, in pursuit of profit. Billing for cancer treatments makes money. Using institutional clout to demand sidewalks and parks and streetlights in poor communities does not.

There’s a myopia, too, built into the system. A recent analysis of board members at top-ranked hospitals in the U.S. found that fewer than 15% of their board members were health care professionals. Nearly 57% were from the financial and business sectors, mostly private equity, wealth management, and banking. They are accustomed to looking at spreadsheets, not the worry lines etched into patients’ faces, and their decisions reflect that experience.

Read More: Why So Many Americans Are Dying So Young

This status quo is no longer acceptable.

Hospitals and health care systems have enormous wealth. The biggest—even those technically listed as non-profits—have billions in cash and investments on their balance sheets, and some rang up record surpluses during the pandemic. Health care systems also have enormous clout: They’re often among the biggest employers in a region and a source of substantial political donations.

It’s time to use that wealth and that clout to tackle the social drivers of health. Hospitals and health care systems must mobilize to treat—and ultimately, prevent—diseases caused by poverty, inequality, racism, and loneliness just as aggressively as they mobilize to attack a cancer with sophisticated drugs and surgeries.

There are some promising models for this work.

Kaiser Permanente has pledged $400 million to a social impact investment fund that is on track to create 30,000 units of affordable housing by 2030. The fund will also support economic development to in low-income communities. In Portland, Ore., six large health care systems have teamed up to build almost 400 apartments — which are supported with extensive case management services—for people who had no shelter or were at risk of losing their housing. Similar projects have been launched by hospital and health care systems in Denver, Toronto, and elsewhere.

Other hospitals have focused on improving access to nutritious meals by launching food pharmacies stocked with fresh produce or by offering free cooking classes.

These are welcome initiatives, but they are only the start. To change health in America, every profitable health care system must devote real money—we suggest at least 2% of their annual budgets—to addressing a wide range of social drivers. They must build authentic partnerships with community groups to identify local needs and promote local solutions. And they must raise up champions for this work in their C-suites and on their boards.

It may seem unfair to ask hospitals to take on this work now, in the midst of an epidemic of provider burnout and exhaustion.

But there is increasing evidence that disillusionment with the health care system, rather than the sheer volume of work, is behind provider burnout. And no wonder. Doctors and nurses pour their heart and soul into saving patients from a medical crisis, only to send them back out to communities where the lack of nutritious food, safe housing, affordable childcare, mental health counseling and so much more all but guarantees another medical crisis within weeks. It’s dispiriting and demoralizing.

In the short term, we hope a full-fledged effort by health care systems to address the upstream drivers of poor health will energize providers. In the long term, we are certain that it will pay real dividends in improving not just the well-being of individuals, but also the welfare of our nation. The poor state of Americans’ health takes a heavy toll on productivity, the economy, and even national security. Tackling the social drivers of health has the potential to unleash tremendous growth.

Where to start? One of us has previously proposed a “10 teams challenge” for health care systems. Here, we add one more area of focus to that original framework.

This list below raises an obvious question: Do hospitals have any business working to bolster voting rights or to reform the prison system? Our unequivocal answer: Absolutely, they do, maybe not always as the leaders, but as active and generous convenors and participants.

We recognize that we are proposing nothing less than a fundamental shift in the business model of American health care. This will be hard work. It will take decades. But it must be done. Any less is a dereliction of health care’s duty.

Every hospital and health care system should put resources toward measurable progress in:

  • Universal healthcare coverage, because access to regular preventive care is a crucial first step to promoting well-being.
  • Food security, to ensure everyone has access to healthy and nutritious food.
  • Housing security, including evidence-based methods for ending chronic homelessness.
  • Health care and social support for immigrants, including the 10 million undocumented migrants in the U.S., who often lack access to preventive care.
  • A criminal justice system built on healing and restoration, which would go a long way toward addressing mental illness and substance abuse.
  • Decarbonization of health care, because the industry is responsible for about 8.5% of the world’s greenhouse gas emissions.
  • Voting rights, to ensure that every adult citizen has a voice in selecting policy makers who will listen to the community’s needs.
  • Strong schools, because education levels are highly correlated with health.
  • High-quality support for pregnant people and babies, to dramatically reduce the toll of maternal mortality and give infants a good start in life.
  • Social supports for the elderly to end the loneliness and isolation that is a significant driver of infirmity.
  • An end to gun violence, which destroys far too many lives.

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