Supporting Population Health and Reducing Health Inequalities

Two Viewpoint articles JAMA highlight continuing healthcare deficiencies and inequalities in the United States and present a call to action for bold new strategies to direct resources toward improvements in support of population health. The articles point out that despite being a wealthy nation with large investments in healthcare, as a nation we are less healthy than other countries with a comparable standard of living.

People in the United States have a lower life expectancy at birth and a higher infant mortality rate than all other industrialized nations. By the World Health Organization’s definition of health—the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity—the United States has work to do to hone in on improving total population health and making changes to put the health of communities first.

In “Putting the Health of Communities and Populations First,” Lynn R. Goldman, MD, MS, MPH, of George Washington University’s Milken Institute School of Public Health, and colleagues write that the greatest gains in health and prosperity will be realized by investing in society’s promise of providing a strong foundation for lifelong well-being. They asserted that bold strategies are needed to direct resources toward prevention, along with a strong commitment to leveraging inherent assets of communities, mitigating circumstances of social disadvantage, and assuring the protection of vulnerable populations like children, the elderly, and people with chronic conditions. Too little attention has been paid to implementing the National Prevention Strategy and the goals of Healthy People 2020. Congress has yet to authorize a dedicated, long-term financing structure to generate the federal revenue needed to deliver a minimum package of public health services in every community, the authors wrote.

Public/private sector collaborations could be used to address neglected systems, such as water and sewer and transportation, which are creating public health threats across the country. There are already tools to help identify communities most in need and for support in these areas but they are not being used, the authors stated.

Nancy E. Adler, PhD, of the University of California San Francisco School of Medicine, and colleagues, wrote in “Addressing Social Determinants of Health and Health Inequalities” that the United States invests far more in providing clinical services than in addressing social and behavioral factors that greatly affect health and mortality compared with other high-income nations that have better health.

“Policies that reduce social disadvantage can reduce health inequalities,” the authors noted.

Socioeconomic conditions underlie many health inequalities and compel attention to social policies that affect health. Existing programs that can help reduce disparities and shift health financing to reward improvements in individual and community health are not being used.

“Health improves as income increases at all income levels,” the authors wrote, but the benefits of additional income are greatest at the bottom. Policies regarding wages, income, and paid time off for new parents or caregivers can increase the financial security of people with the least income, improve population health, and reduce inequalities.

“Promoting healthy behaviors involves making healthy behavioral choices easier, less expensive, and more socially normative,” Adler and colleagues wrote.

Healthcare access and financing contribute to overall health and health inequalities. While the Affordable Care Act significantly improved healthcare access by establishing insurance exchanges and expanding Medicaid, 3 million potentially eligible people live in states that opted out of Medicaid expansion, perpetuating health disparities.

The authors support moving completely away from fee-for-service systems, increasing incentives to move the healthcare system to a value-based rather than volume-based system that rewards improvements in population health and covers chronic disease management and oral healthcare to improve population health and reduce inequalities.