America finally belongs to the 21st century.

It is a moment of great challenge and opportunity. Our new president and Congress, along with public and private leaders all across the country and around the world, are grappling with economic, health, environmental, energy and security threats more immediate and frightening than most of us have ever known. What our leaders choose to do and what we ask them to do, or not do, will affect every aspect of our lives.

The American people expect improving health and health care to be among the priorities at the top of the national agenda. Polling every year since 2000 consistently registers a strong and unwavering public concern over the adequacy, cost, safety and fairness of health care financing and delivery. Not surprisingly, the people know what they are talking about. They take health care’s measure each time they see their doctor, go to the hospital, pick up a prescription at the pharmacy, pay an insurance premium.

Patients and their families, employers, leading thinkers, policy-makers, researchers and health care providers all know that the system is not working. Yet many people still believe that Americans receive the best health care in the world. It is true that American medicine’s technology is unsurpassed. But we pay more for the quality care we receive and we experience poorer patient outcomes than most other developed countries.

For longer than most of us have been alive, most serious attempts at systems change and quality improvement have fallen short. Perhaps that’s because we have focused too much on isolating symptoms as stand-alone problems to be treated individually and incrementally. We realize that the confounding array of separate symptoms actually are a tightly bound interdependent complex system that resists division. Only recently, aided by sophisticated data collection and analysis, are we able to better understand and describe the interactions.

The most apparent symptoms include:

If any consensus is common among knowledge­able health and public policy experts it is this: Our health is part of a broader, complex and systemic problem. What to do about it is what this report is all about.

Much of the political discussion around health and health system reform is abstract, focusing on an often fuzzy big picture. Health and health care, however, are more down-to-earth, involving real people living real lives in the real world. I know this because I’ve seen medicine, health care and health policy through almost every facet of the prism. But there is seeing and there is “seeing.”

My early days training in Boston hospitals were typical of medical residents everywhere. We worked 36 hours on, 12 hours off, surviving on vending machine snacks and gallons of coffee. The attending physicians were intimidating, the fatigue excruciating.

The procession of patients was never-ending. At each encounter the person was unique in history, symptoms and treatment. We worked fast: examine, diagnose, treat, next please. Total immersion in the minutia of medicine. That was it. I’ve never learned so much so fast that’s stuck so long. It was one of the great experiences of my life.

Only after treating thousands of patients presenting across the spectrum of human malady and disease did the connections become clear to me: In our human ecology, the health of one person affects the health of all, and vice versa.

In our human ecology, the health of one person affects the health of all, and vice versa.

My awakening began, as it has so often for many health care providers, with a single patient. I’m not sure she even knew her real name. I do know she was homeless and helpless and even though she was a military veteran we were unable to give her the level of care she needed.

She appeared very late on a winter night at the admitting station on the first floor of the old West Roxbury VA medical center, bringing the cold in with her. My guess is she came to us out of the woods that separates Roxbury from the Charles River and Cow Island Pond.

Her feet were swollen and covered by flimsy house shoes. Painful leg ulcers made it difficult for her to walk. Her medical chart was very thick; she’d been to the VA many times before. We did what they always did for her: A good tidying-up, antibiotics and a place to rest.

The next morning we had to let her go. Though I never saw her again, I’ve never forgotten my sadness and frustration that, apart from a few hours in a warm bed, some medicine and a decent meal, the system was not equipped to protect our patient from the harshness of her reality outside the hospital.

She limped back into the same problems she had before: no home, far too little nutritious food, inadequate clothing, no one to care for her, no social network to come to her aid. She was a vet with health coverage, but medical care alone was no match against the enormity of the social factors destroying her health and almost certainly shortening her life.

They didn’t teach us in med school how to connect the dots between health, health care, community prevention programs, and a continuum of services that allow people to enjoy healthy lives. Like many of my medical colleagues, we learned it the hard way, by going up against conditions controlling a patient’s health and coming away wanting.

Comprehending the linkage between the health of a single individual and the macro factors affecting all of society radically altered my understanding and practice of medicine, shaped my appreciation of health and economic policy as powerful tools for change, and sharpened my vision of this Foundation’s role in helping guide the country to better health and meaningful health system reform.

RWJF’s efforts to improve health and health care for years ran along parallel tracks. Now we are merging the tracks. After years of research, trial, error and trying again, we are able to put in the hands of America’s decision-makers a detailed picture of:

1

The causes of health care’s chronic failure to deliver higher-quality care, better patient outcomes and higher value.

2

The toxic social, economic and cultural factors that can determine the status of our health more than our engagement with the health care system itself.

This is new. The earnest efforts of political, business and health system leaders to improve health and health care have been stymied for decades because the true causes and real cures remained hidden and mysterious. The veil, however, at long last is lifting; the mysteries solved.

We see four fundamental factors at play:

Once puzzling riddles of social and economic determinants of health no longer baffle us thanks to years of research and data gathering. We know the nature of health and health care depend so strongly on education, income level, race, geography and residence that the condition of any one depends upon the condition of all others.

New knowledge is re-engineering health care’s systems, driving how we measure the performance of doctors, hospitals, and health plans and reward their results, connect quality to patient outcomes, make performance information available to the public, redirect resources, and overcome regional and racial disparities in treatment and in health.

Knowledge has power. For political and health care leadership, not knowing is no longer an excuse for inaction. New insight and information are filling in the old blanks. Evidence is replacing guesstimates.

Improving health and health care without busting the budget or carelessly rekindling ideological fires is doable economically and politically. One study, for example, estimates spending could be cut 30 percent if we stopped providing care that is not needed.1

Reformulate the four factors and we have what we did not have before: A formula for change. It works this way:

Formula for Change
(Knowledge + Understanding) (Motivation + Action) Systems Change

The question remains: How do America’s leaders and policy-makers put the formula to work? The answer is clear: We translate our knowledge into action and we do it on a scale that hasn’t been done before. Yes, the barriers are formidable. But our health care system is in critical condition. The time to act is now and the action begins—but should not end—with coverage.