Parekh is an internal medicine physician and health policy advisor.

Myriad challenges exist for today’s healthcare leaders: tight supply chains, high labor costs, payment reforms, growth in new technologies, artificial intelligence, disruptive competitors, and the prospect of a rising number of uninsured Americans. But there’s a greater challenge than all of these: America’s declining health.

Even prior to the pandemic, America’s health rankings in areas such as life expectancy and infant mortality lagged in comparison to peer countries in the Organization for Economic Co-Operation and Development (OECD). Indeed, U.S. life expectancy began to stagnate a decade prior to COVID-19, and then fell remarkably during the 3-year period between 2014 and 2017.

The plateau in the decline of mortality rates from cardiovascular deaths, the obesity crisis, and the opioid and substance use epidemic have driven this trend, with disparities widening based on factors such as income, race, and geography.

What will it take to reverse these trends that were further exacerbated by the pandemic? To start, a re-commitment by healthcare leaders to three critical areas: primary care, public health, and prevention.

While primary care has long been associated with better health, better care, and lower costs, it remains in crisis with low reimbursement rates, a stretched and shrinking workforce, and a quarter of adults reporting that they don’t have a usual source of care. Despite public health quietly contributing to the majority of health improvements over the last century, challenges abound from a depleted workforce, lack of sustainable funding, an antiquated data infrastructure, and political threats to governance. And while many high-value clinical preventive services — cancer screenings, substance abuse and mental health screenings, and immunizations — could cost-effectively save thousands of lives each year, patients’ utilization of these services are suboptimal despite the Affordable Care Act removing patient cost-sharing.

Unfortunately, the primary care, public health, and preventive sectors received a small slice of the $4.3 trillion spent on healthcare in the U.S. in 2021 according to various analyses, including a recent one from the Office of the Actuary at CMS. It’s estimated that only 6% to 7% of total spending goes to primary care (half as much as comparable OECD countries), only 5% goes to clinical preventive services, and only 4% goes to public health — and these categories are not mutually exclusive. If we’re to achieve a healthier nation, we must take steps to ensure our resources support this goal.

Public and private payers need to strengthen primary care by measuring spending rates, setting targets, and taking action to increase primary care investment. More than one-third of states have now passed laws or regulations to track and improve investment in primary care over time. For example, Rhode Island’s percentage of healthcare dollars invested in primary care increased from 5.7% in 2008 to 12.3% in 2018, and Oregon’s percentage increased from 9.9% in 2014 to 13.9% in 2019. Greater investment in hybrid and full capitation value-based models, higher primary care reimbursement, and removal of cost-sharing for primary care services would improve patient outcomes and could attract a new generation of healthcare professionals committed to providing whole-person care.

Hospitals and health systems should partner with local public health organizations to address patients’ social needs and broader social determinants of health impacting the community’s well-being. Specifically, nonprofit hospitals should jointly conduct community health needs assessments with public health departments and ensure their community benefit spending addresses these needs and supports the hiring of trusted community health workers. In addition, healthcare entities should actively support data sharing agreements with public health departments to automate exchange of clinical information, such as through electronic case reporting.

Even with the uncertainty around Braidwood Management vs. Becerra, which challenges the requirement that private health insurers cover recommended clinical preventive services, purchasers and payers should remain committed to guaranteeing these benefits without cost-sharing. Increasing further uptake of these services will require a robust patient education campaign, tackling additional barriers such as transportation and patient scheduling, as well as prioritizing related provider quality metrics and linking them to greater financial incentives. Over time, these metrics should be complemented with health status measures focused on the incidence of chronic diseases and prevalence of chronic disease risk factors. This will in turn catalyze the clinical-community linkages necessary to keep vulnerable Americans healthy and reduce preventable healthcare spending.

By recommitting to primary care, public health, and prevention, the healthcare industry can reclaim its true North star, which is not only better care and lower costs, but most importantly better health.

Anand Parekh, MD, is an internal medicine physician, chief medical advisor for the Bipartisan Policy Center, former deputy assistant secretary of health at the Department of Health and Human Services, and author of Prevention First: Policymaking for a Healthier America.


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