The Democratization Of Health Care: Building Sustainable Communities

With competing crises dominating the daily news, the public may not be aware that healthcare policy is losing its way and that a new path forward is urgently needed. Recent news about healthcare policy has covered the cost of care, who would be reimbursed for what, and who would be able to afford access to care. The public should be concerned about this state of affairs. The health system emerging from these policy deliberations will be designed to meet financial objectives rather than to grow into an integrated, community-based learning system that delivers quality care while innovating quickly and rapidly, deploying novel therapies that promote community well-being.

The federal government is the nation's largest single payer of healthcare in the United States, yet it has no coherent plan or strategic vision beyond developing and executing alternative payment models. [Footnote 1] It seems to interpret payment reform as the most urgent innovation, and it only incidentally invests in innovative therapies and devices. Indeed, some in government bemoan medical innovation as a driver of cost. [Footnote 2] There is little evidence that policy makers recognize that investment today could reduce cost and improve outcomes tomorrow or that we should reward novel therapies and system designs because we are working toward a comprehensive vision of healthcare in which managing population health is a component of building sustainable communities. The government treats the impact of its reimbursement models on human lives (short and long term) as a hidden variable that is neither measured nor disclosed, or it reduces life to a present-day financial value and determines that required therapies that exceed that value are not worth the investment. These alternative payment models are blind to the paradigm shift that is before us -- the convergence leading us toward building sustainable communities.

Contemporary ideas about sustainability are rooted in efforts to associate our economies with energy supplies that do not destabilize the environments that make human society possible. But our interest in sustainable communities should drive a more fundamental awakening: A consciousness that we can -- indeed, we must -- empower ourselves to manage the complex social and physical forces that sustain life to produce community well-being. This empowerment will require the collaboration and integration of disciplines and fields of inquiry that have long existed in relative isolation from one another. Throughout human existence, our fate has been tied to the fundamental laws of nature. These laws sustain life, but they also govern the extinction of species. Here and there, as we better understand these laws, we have claimed small dominions where we have been able to regulate some outcomes: We are cleaning up our water, air, and food supplies for example, and we are making progress in medicine.

Immortality may be unachievable, but we certainly have within us the capacity to reduce preventable mortality and to make sure that no one in our society is exposed to unequal risks. Some physical and social environments are more beneficial than others to human life. Science tells us that postal codes predict life expectancy. Residents of one zip code may live many years longer than those of a neighboring zip code, and we are finding that social determinants of health are contributing to these variations in longevity. The inability of systems to deliver timely, equitable, quality healthcare, especially in many rural and urban communities, is a social determinant of health.

The inequalities festering in minority communities are evident in healthcare. We have inherited a healthcare system that plays favorites. Subsets of the US general population, including African Americans, Hispanic Americans, Native Americans, and poor whites, are adversely affected by healthcare disparities when contrasted to better-resourced communities. These healthcare disparities degrade the quality of life while raising the risk of premature death. We are in the midst of historic demographic change today: the majority of children born in the United States are minority, in four years 40% of the total population will be classified as minorities. In 2044, the United States will have no majority population group. [Footnote 3]

Now is the time for health policy makers to join efforts to build sustainable communities. We have the power to manage the social determinants of health, including the design of healthcare systems. We can use that power to improve health outcomes across our populations. Our goal should be to build sustainable communities where well-being is a measurable outcome, and we should strive to make sure that no community has to endure systemic health disparities.

As we work to establish a new foundation for our communities so that the energy that powers our living and working spaces no longer produces toxic wastes, we should extend the paradigm shift to upgrade our healthcare research, finance, and delivery systems. We encourage those who think and write about healthcare policy to look broader than alternative payment models. We urge them to contribute to a vision of sustainable communities, where we take responsibility for the management and regulation of population health. It is an awakening for which our children's children will be grateful.


1 - National Health Expenditures 2014 Highlights,

2 - Peter Orszag, CBO Testimony,, pg. 1.

3 -