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The poor US performance on key population health measures is a call to action that justifies bold strategies to direct resources toward improvements in support of population health. US investments in health care amount to nearly one-fifth of national expenditures. Yet the United States is less healthy than other countries with a comparable standard of living, with a comparatively lower life expectancy at birth and a comparatively higher infant mortality rate higher than all other industrialized nations.
Promising opportunities and actionable steps exist to achieving healthier communities. In this Viewpoint examining possibilities and priorities, we embrace the World Health Organization definition of health as “the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”; define the term population health in the sense of “total population health”; discuss actions to improve health in entire geographic regions1; and embrace the vision for a healthy community as a “strong, healthful, and productive society, which cultivates human capital and equal opportunity.”2
Importantly, vital directions are highlighted for continuing to move US public health eﬀorts on the path toward prevention.3 Many are national strategies to guide and facilitate universal and equitable reach. Their implementation requires a strong commitment to leveraging inherent assets of communities, mitigating circumstances of social disadvantage, considering the cultural and historical contexts of diverse communities, and assuring the protection of those that are particularly vulnerable to social and environmental stressors (ie, children, the elderly, and individuals with other conditions).
Initiatives already under way have substantial potential if given the emphasis necessary. The level of understanding about the multiple determinants of health is unprecedented, as is the level of evidence on demonstrated effectiveness of population-wide programs in reducing unnecessary deaths from leading causes of mortality and morbidity, ranging from cancer to infectious diseases such as influenza, pneumonia, and human immunodeficiency virus—including approaches to preventing newly emerging threats like the Zika and Ebola viruses.
The National Prevention Strategy and the goals of Healthy People 20202 lay out the prospects and strategies systematically, but have been assigned scant attention and resources relative to the potential gains. The Institute of Medicine has identified a minimum set of public health services needed in every community, but Congress has yet to “authorize a dedicated, stable, and long-term financing structure to generate the enhanced federal revenue required to deliver the minimum package of public health services in every community.”4
The traditional focus on disease screening and treatment reinforces a focus on health problems at a relatively late stage in the process and is not cost-effective. Over the last few decades, the traditionally divided public health and clinical care components of the US health care system have come closer together, much to the possible benefit of total population health. However, health care organizations and systems can also expand their emphasis on the maintenance of good health and well-being in the people and communities they serve, employing several complementary strategies in promoting wellness.
Rather than respond to disasters as they occur (such as Zika virus, Ebola, and natural disasters like hurricanes, earthquakes, and ﬂoods), communities need to anticipate threats, minimize adverse health effects, and rapidly recover after a crisis. This capacity would be enhanced by private and public sector collaboration. For example, water contamination in Flint, Michigan, is only the latest symptom of how basic infrastructure supporting health in US cities is at risk. Neglected systems—for transportation, water and sewer, and energy distribution—are creating public health threats, with negative health and economic consequences across many communities. It will be necessary to engage multiple sectors in jurisdictions with older physical infrastructure to implement community structural improvements—leveraging assets in health and other relevant departments like labor and housing and urban development.
Tools are available to help in this respect. Efforts like the County Health Rankings project, which ranks the more than 3000 counties in the United States based on a model that combines health outcomes with health factors, provide a basis for identifying communities that are most in need of health improvement efforts and for rallying support for those efforts across sectors.5 Much more can be done to enhance data for public health, for example, standardizing reporting of population health measures within existing efforts to coordinate health information technology and providing analyses of data that enable policy making across sectors.
The National Research Council and the Institute of Medicine recommended that the federal government increase the portion of its budget allocated to population-based and community-based prevention research. These organizations suggested that this research should address population-level health problems, involve a deﬁnable population and operate at the level of the whole person, evaluate the application and effect of new discoveries on the actual health of the population, and focus on behavioral factors, environmental factors, or both, associated with primary and secondary prevention of disease and disability in populations.
Support strong national public health objectives with leadership and investments. There is a critical need to embrace national goals that reach many sectors and foster incorporation of health considerations into the policies of all these sectors. The National Prevention Strategy and the goals of Healthy People 20202 need to be elevated to a much higher level of priority within the administration and the US Department of Health and Human Services. Under White House leadership, a Health in All Policies approach, via requirement of Health Impact Assessments, could be established for major federal expenditures. The White House also can broaden the investments in human capital through new financial vehicles and tax policies that can mobilize resources for total population health. Congress and the administration can work together to deﬁne the public health services that could best be supported by the federal government, and to enact legislation to authorize and appropriate resources for these purposes at federal, state, and local levels.
Promote efforts by health care organizations and systems in advancing community and total population health. Community beneﬁts requirements under Internal Revenue Service 501(c)(3) regulations should be refined to incentivize regional population health improvement eﬀorts, including local health departments as well as academic public health expertise in such analysis and planning eﬀorts. Accountable care organizations today include only traditional components of medical care, but could be incentivized to develop comprehensive wellness models that incorporate other elements of prevention and wellness. Health care systems can leverage the entirety of their assets (eg, as employers, purchasers, consumers, and energy consumers, with intentional business practices to improve population health).
Address social and environmental determinants of health in communities. A synchronized focus on levers across multiple sectors can more effectively address social and environmental determinants of health in communities. Local and state health departments need resources for leadership and participation in the following 4 areas: (1) broad multisectoral partnerships for community health agendas that promote population health by leveraging assets, making health a locally deﬁned issue, and moving policy change to the local and regional level; (2) shoring up the infrastructure for a health-related system; (3) strengthening community public health surveillance capacity; and (4) leveraging economic development efforts that can enhance a community culture of health (eg, work of the finance community, philanthropy, corporations, and health care systems).
Translate evidence to action. Advancing community and population health requires acting immediately on what is already known and setting research priorities and creating funding mechanisms to strengthen the evidence base for new population health interventions. The US Department of Health and Human Services should expand its support for public availability of health data sets and the development of informatics tools to facilitate aggregation and linkages with related data sets. Data.gov and similar efforts are helping researchers and policy makers understand and solve problems related to health effects in association with physical and social environments. Yet significant opportunities exist for the sharing and co-mingling of public and private data sets, taking the effects on population health to the next level.
These strategies are intentionally designed to take advantage of current opportunities and to resonate throughout society. 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. To do so, it is necessary to responsibly steward and amplify shared economic, human, and community resources over the life course—both within and beyond the clinic walls. The influence of health on all sectors of this economy must be made visible. The interdependence of private and public institutions across these sectors must be highlighted to accelerate health promotion. Through such efforts, our society will be able to move forward and protect the futures of generations to come.
Corresponding Author: Lynn R. Goldman, MD, MS, MPH, George Washington University Milken Institute School of Public Health, 950 New Hampshire Ave NW, Washington, DC 20052 (firstname.lastname@example.org).
Published Online: September 26, 2016. doi:10.1001/jama.2016.14800
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: The National Academy of Medicine’s Vital Directions initiative is sponsored by the California Health Care Foundation, The John A. Hartford Foundation, the Robert Wood Johnson Foundation, and the National Academy of Medicine’s Harvey V. Fineberg Impact Fund.
Disclaimer: This Viewpoint on actions needed to focus on the health needs of US communities and populations provides a summary of a discussion paper developed as part of the National Academy of Medicine’s initiative on Vital Directions for Health & Health Care (http://nam.edu/vitaldirections). Discussion papers presented in this initiative reflect the views of leading authorities on the important issues engaged, and do not represent formal consensus positions of the National Academy of Medicine or the organizations of the participating authors.
Additional Contributions: Coauthors of the National Academy of Medicine discussion paper were Georges Benjamin, MD; Lynn R. Goldman, MD (lead); Sandra R. Hernandez, MD; David A. Kindig, MD; Shiriki K. Kumanyika, MD; Carmen R. Navarez, MD; Nirav R. Shah, MD; Winston F. Wong, MD. Elizabeth Finkelman, MPP (National Academy of Medicine), served as the initiative director.
Goldman LR, Kumanyika SK, Shah NR. Putting the Health of Communities and Populations First. JAMA. Published online September 26, 2016. doi:10.1001/jama.2016.14800