The old adage that “What gets measured gets done” is the central premise of the Healthy People initiative and why it is such an important tool in the national effort to improve our nation's health. For 40 years, Healthy People has been providing a set of science-based, achievable 10-year goals, designed to move the nation to become healthier over time. The Healthy People initiative is the result of a landmark report, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention published in 1979, by Surgeon General Julius Richmond. Since then the United States has made steady progress toward becoming a healthier nation.
The United States Is Not the Healthiest Nation
However, the United States still has a long way to go to achieve optimal health. The nation ranks last in terms of life expectancy when compared with other industrialized nations and other health system metrics. This is despite spending almost twice the average spending per capita of the other Organization for Economic Co-operation and Development (OECD) nations.1 Groups such as the American Public Health Association (APHA) have been working to catalyze the national effort by leading a movement to “Create the healthiest nation in one generation.” This movement aligns with Healthy People's 2030 vision to create “a society in which all people can achieve their full potential for health and well-being across the life span.” By aligning these 2 visions using Healthy People's objectives as benchmarks for progress, it is possible to not only improve the health of the nation but also address the enormous disparities the United States has in morbidity and mortality outcomes when compared with other OECD nations. Healthy People's role in moving the nation toward better health over the years is undisputable and well known. However, its potential role in closing the disparities gap between the United States and other nations is not well known. To do that, one must explore the reasons the United States is not achieving its full potential when compared with other nations.
What Are the Barriers?
There are 4 major reasons that the United States is not reaching its full potential when compared with other OCED nations. These are as follows: the lack of universal insurance coverage; the underuse of primary care; the complexity and administrative inefficiency of the US health system; and the underinvestment in the societal conditions that impact health.2
The United States has made progress in increasing access to quality and affordable health care. The Affordable Care Act has been catalytic in achieving these advances. Nevertheless, we have not yet attained a system with everyone in and no one out when compared with other high-income nations. In addition, we continue to have significant health disparities between various population groups within our health care delivery systems. Therefore, eliminating health disparities as a component of overall health improvement is central to Healthy People. Healthy People 2030 has more than 30 core objectives focused on increasing access to health care, as well as improving the quality of care received. Collectively working to achieve the objectives related to health care access and quality could result in enormous progress in addressing the health care factors that impact the nation's health.
The United States invests extensively in specialty care and other high technology services. The investment in primary care services, especially in the primary care workforce, is not as well supported as other comparative nations. There is no question that the health care received in the United States is among the best in the world; however, it occurs at an extremely high price and is often needed because of the underinvestment in primary care and preventive services. Two specific examples of Healthy People objectives focused on primary care and preventive services are as follows: “Increase the proportion of people with a usual primary care provider” and “Increase the proportion of adults who get recommended evidence-based preventive health care.” In 2017, 76% of people had a usual primary care provider and the target for 2030 is 84%. In addition, the 2030 target for people to receive the recommended evidence-based clinical preventive services is 10.9%, an increase from the 2017 baseline of 8%. For both of these objectives, disparities by age and race/ethnicity persist.
America has a complex health system, both in its financing and in its delivery. It has enormous administrative inefficiencies and is estimated to cost as much as 25% of total health care spending.3 The financial system alone causes great confusion and inefficiencies and in many places the delivery system is just as confusing. One of Healthy People 2030's foundational principles is to promote decision making and policy formulation across all sectors to improve health. Healthy People 2030 does not include specific goals for health system design, but its many health and quality metrics support a learning health system that promotes systems change in directions that improve health. We will need to think thoughtfully about what systems changes will need to occur as we understand our accomplishments from Healthy People 2020 and work to remodel our system for better performance to achieve the new 2030 goals. This may result in some tough decisions as we look to improve our health system performance.
Most of what makes you healthy occurs outside the health care setting through factors that make it easier or harder to achieve optimal health. These social determinants of health include education, housing, transportation, food security, the environment, and community safety. Healthy People 2030 has an enhanced focus on the social determinants of health and has grouped these determinants into 5 overarching domains. The domains are economic stability, social and community context, education access and quality, neighborhood and the built environment, and health care access and quality. The fact that the United States spends less on social spending as a share of our gross domestic product than the other OECD nations results in higher spending for health care services that are often preventable. Healthy People 2030's focus on the social determinants of health provides a pathway to focus on societal factors that can improve health.
Healthy People 2030, like its predecessors, is a metric-driven road map to a healthier nation. Yet, goal setting and measurement, while important, are not sufficient without appropriate policy change, adequate resources, and the national commitment to be the healthiest that we can be. Healthy People 2030 can be the mechanism for stimulating that national commitment. We have indeed made enormous progress over the years, but we still have a way to go to become the healthiest nation. But we are a competitive people, and we like to win!
1. Tikkanen R, Abrams M. U.S. Health Care From a Global Perspective, 2019: Higher Spending, Worse Outcomes? New York, NY: The Commonwealth Fund; 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019
. Accessed July 25, 2021.
2. Schneider E, Sarnak D, Squires D, Shah A, Doty M. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. New York, NY: The Commonwealth Fund; 2017.
3. Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. 2019;322(15):1501–1509.