In the United States, entrenched inequity leads to great disparities in health outcomes across population groups. Depending on ethnic background, socioeconomic status, gender, sexual orientation, legal status, or mental and physical capabilities, one individual is more or less likely to die of certain diseases, have a shorter life expectancy, and be vulnerable to serious physical and emotional harm than another. These differences stem from unequal access to high-quality healthcare, education, employment, income, a safe community environment, affordable housing, public safety, and transportation. Because so many people are unable to live the healthiest lives possible, the well-being and prosperity of entire communities are threatened.
Systems are often inequitable and can exacerbate these health inequities, so it’s crucial to examine the ways in which systems and institutions work. To make a difference, this inquiry must happen within and across all the systems that influence health.
The Robert Wood Johnson Foundation supported Reos Partners in convening a multi-stakeholder team of system leaders to examine the systems and relationships that produce individual and community health and illness. The purpose was to catalyze open and reflective strategic thinking and conversation about the possible futures of health and health equity, and the opportunities, risks, and choices these futures present. Seeing these possible futures more clearly can stimulate individual and collective actions to adapt to and influence these futures.
The United States faces a health crisis. The country spends almost one-fifth of its GDP on healthcare, yet has poorer health outcomes than other nations that spend much less. It spends more on healthcare per person than any other country but is at or near the bottom in rankings of industrialized countries for health indicators such as infant mortality and life expectancy.
The United States also ranks poorly on health equity, with significant disparities in morbidity and mortality by race, income, and geography. The root causes of many of these disparities can be traced back to differences in healthcare access, behavioral risk factors, exposure to environmental hazards, and the social determinants of health.
Cumulatively, these risk factors have contributed to making preventable chronic diseases the leading cause of early death and disability in the United States. As a result, there has been a decline in the number of years people live in overall good health. Better outcomes would require a significant change to how the United States views and addresses health—not only in how health insurance and clinical care are provided, but in the multiple social, economic, and environmental determinants of health as well.
How will the United States respond to this mounting pressure to improve health outcomes? Will it reduce the role of government and rely on the Marketplace? Will it bring national stakeholders together in the Conference Room? Or will it organize change from the bottom up, at the Kitchen Table? These scenarios explore three possible directions for how the health system in the United States could evolve and what each path would mean for health and health equity.
Three scenarios for how the health system could change through 2030.
A new federal framework for regulating and funding healthcare markets is enacted. Changes to Medicare and Medicaid narrow eligibility and reduce coverage. Small and medium-size businesses reduce healthcare benefits. Medical debt and bankruptcies rise and safety net hospitals experience increases in uncompensated care. Meanwhile the use of healthcare products and services by those who can afford them grows. Health inequity increases and threatens the health of all.
An unhealthy population and the rising cost of care contribute to a slumping economy. Corporate leaders and insurance companies demand that politicians implement regulations and policies that reduce healthcare costs by incentivizing holistic approaches to health and well-being. Stakeholders around the country experiment with approaches to respond to the root causes. Both health and health equity gradually improve.
Civil unrest and local grassroots activism are fueled by marginalized and vulnerable people who are unable to access the resources they need to be healthy. Activists and organizers give voice to their concerns and to demand action. Local multi-sector collaborations drive local action. Health and health equity improve—but only in places with effective local leadership.