The jigsaw puzzle of U.S. counties fits neatly together into a pleasing whole, displaying America as a land of many parts. Within those parts, people in adjacent communities may have similar lifestyles and incomes. They may eat similar foods, enjoy the same music, picnic in the same parks and vacation at the same campgrounds or beaches.
But look more closely and you'll find people living in neighboring communities often live very different lives. Residents in one county may suffer many more days of poor physical or mental health – or both – than those in the county next door. People in many communities even live longer than those in communities nearby, a pattern that extends nationwide.
Which is why community health assessments – including a new U.S. News ranking of the nation's Healthiest Communities, to debut in March – are so valuable for identifying trouble spots and targeting remedies to where they'll do the most good.
Think of them as diagnostic scans of what ails America, from soaring rates of obesity, hypertension and diabetes to pervasive mental health problems and opioid abuse. The overlapping epidemics are having a profound impact nationwide. For the first time in nearly a century, life expectancy has begun to decline in major population groups, and not just in poor underprivileged neighborhoods. Death rates rose for white men, white women and black men, and remained essentially unchanged for black women and Hispanic men and women.
"This is the first time we've really seen fairly marked decreases in life expectancy in key groups and not simply the socially disadvantaged," says Dr. William Stead, chief strategy officer at Vanderbilt University Medical Center and McKesson Foundation professor of biomedical informatics.
In most measures of population health, the world's richest country lags behind other developed countries, despite trillions spent each year on medical care.
"Waves of chronic disease are reaching historic rates," says Tyler Norris, chief executive of the Well Being Trust, a $100-million nonprofit funded by Providence St. Joseph Health to help improve the nation's mental and physical health. Chronic diseases not only reduce productivity, he says, they have driven health care costs so high that they are "unaffordable no matter who you are."
Eighty percent of the growth in Medicare spending – now totaling nearly $650 billion a year – is due to chronic disease, says Kenneth Thorpe, of the Rollins School of Public Health at Emory University and chairman of the Partnership for Chronic Disease.
Tragically, this chronic-disease epidemic of diabetes, hypertension, heart disease, stroke, arthritis and other ailments is occurring against the backdrop of a revolution in medical care, one that ushered in countless innovations including antibiotics, blockbuster drugs, high-tech surgery and genetic medicine.
The roots of the problem run deep, anchored in national neglect of festering social problems and each community's history, culture, economy, schools, hospitals, neighborhoods and sense of place. These so-called social determinants offer a way of assessing community health. They show that poor health and other social problems are more heavily concentrated in some neighborhoods than others, variations that may not be apparent when examined at the national or state levels.
Look deeper, Stead says, and a more nuanced picture emerges. He cites Seattle as an example of a city held up as one of the healthiest in the nation. Seattle's positive image, he says, overshadows a darker reality in some Seattle neighborhoods. "Nationally, the Seattle area looks quite good, but if you look more closely you see many pockets that get bad outcomes."
Stead points to data compiled in 2013 by a coalition of local public health organizations, community groups and elected officials. The data profile approximately two million people who live in urban and suburban King's County, home to Seattle, in nearly 4,000 census tracts of approximately 5,000 residents each.
By almost any measure, people in north Seattle and east of Lake Washington are healthier and better off than those living farther south, where poverty rates are higher and obesity, diabetes, smoking and other public health problems are more common.The analysis appears in an Urban Institute report, What Counts for America, on how local leaders are using data drawn from Kings County neighborhoods as a catalyst for change.
Poverty is one of the most powerful determinants of health, says John Auerbach, president and CEO of the nonprofit, nonpartisan advocacy group Trust for America's Health. "The poorer you are, the more likely it is that you will die prematurely or be diagnosed with a wide range of preventable diseases."
A study out in October offers a poignant illustration of this. Researchers found that black women are more likely to die of breast cancer because a bigger proportion of them lack adequate health insurance.
Making Ends Meet
Communities with less-than-healthy populations have big implications for every strata of society, from legislators wrestling with tight budgets to consumers trying to stay healthy and make ends meet to business leaders worried about the bottom line.
With prices rising, resources shrinking and an unprecedented number of Americans aging, gaining weight and abusing drugs and alcohol, community health and well-being has suddenly become a vital, national concern.
Norris says the narrow focus on "ever more treatment and sick care" won't solve the problem.
"We're at an inflection point," he says. "It's unethical for our nation to continue pretending that the way we're dealing with these issues is going to create a different result. We now know better."
The place-based population health movement got its start in the U.S. three decades ago, on the heels of a healthy-cities movement started in Europe with a push from the World Health Organization. Market forces nudged the field forward in the U.S., when for-profit hospital chains began buying up nonprofits in the 1990s.
To satisfy IRS requirements that communities also benefit from these high-dollar transactions, the for-profit hospital systems set up and funded foundations to tackle health and social issues.
For the most part, the foundations were local and focused on narrow problems, such as better schools, smoking cessation and affordable housing. Federal funding agencies, such as the Agency for Health Research and Quality, adopted a similar approach.
Typically, these programs tackled one challenge at a time, such as reducing soaring urban childhood asthma rates.
That has changed dramatically over the last three to five years. The burgeoning place-based healthy communities movement has gained new momentum, driven by concerns over soaring health care costs, by Affordable Care Act reforms designed to cut costs by keeping patients out of the hospital and by public health problems that are spiraling out of control.
The public health statistics are alarming. Today, more than one-third of U.S. adults and nearly one in five young people meet the Centers for Disease Control and Prevention definition of obesity. And CDC data indicate that drug overdose deaths in 2016 topped 64,000, a 21 percent increase over the previous year. Two-thirds of the overdoses resulted from opioid abuse, according to a report released in September by the Police Executive Research Forum. The toll exceeds the approximately 58,200 deaths of U.S. personnel who died during the entire course of the Vietnam War and the 51,628 who died of HIV/AIDS in 1995, the worst year of the epidemic, the report says.
These statistics signify that a significant percentage of the U.S. population is, instead, experiencing profound emotional and psychological distress. Contentment seems beyond their reach, says Norris, of the Well Being Trust. Under the circumstances, he says, behavior change isn't the answer.
"We try to get people to adopt healthier habits," Norris says, "but the behaviors we're trying to change are the very [ones] that people use to self-medicate to deal with anxiety, depression and hopelessness."
'Toxic Stress'
There's another issue as well. New evidence underscores the notion that community factors beyond an individual's control can also have a big impact on health and well-being. For instance, a study in the journal Lancet in October pegged the global death toll from pollution in 2015 at roughly 9 million people, outstripping war, natural disasters and smoking. The U.S. ranked eighth on the list, just after Russia. India, China and Pakistan ranked first, second and third, respectively.
Even something as seemingly intangible as stress can have a big impact on health. In a landmark study published in 2015, researchers reported that people living in neighborhoods characterized by "toxic stress" experience measurable genetic changes linked to aggressive prostate cancer. The findings support a notion of "neighborhood cancerization," says lead researcher Shannon Lynch, of Fox Chase Cancer Center in Philadelphia.
Concerns over the poor quality of life in scores of communities, and the likely impact on health, prompted population health experts and community groups to consider possible solutions. "We got strategic and focused on a set of issues," says Monte Roulier, president of Community Initiatives, a nonprofit that helps organizations and communities launch population health and well-being programs. "We want to go back to a kind of community experience of living well."
Michellene Davis, executive vice president and chief corporate affairs officer at RWJBarnabas Health, New Jersey’s largest integrated health system with 11 hospitals and other facilities, says there are practical reasons for tackling problems at the community level.
“What we have found is that the folks who are trying to deal with health care costs are not dealing with root causes. That’s why we’re finding chronic diseases in certain communities – and why our efforts aren’t having an impact,” Davis says. “We have to realize that there’s something wrong with our approach.”
The hospital has taken steps to remedy this in many of the communities it serves, she says. Downtown Newark, for example, lacks a large-scale grocery store. Instead, there are bodegas scattered on every corner. “We created a greenhouse next to a community-wellness center,” Davis says. “We employ an urban farmer who has created a relationship with a prison early-release facility. The farmer teaches newly released prisoners hydroponic farming, so they can get job training.” The greenhouse also serves as an occupational therapy and behavioral health facility, she says.
Data offer the best window into communities that will benefit from this sort of approach. Two decades ago Roulier and Norris founded Community Commons as a public, data-rich platform to enable users to access and analyze available data on a host of health, social and economic issues. The federal government has made important contributions to this effort by packaging and releasing public-use data files from multiple agencies, including the U.S. Census Bureau, The National Center for Health Statistics, the Centers for Disease Control and Prevention and the Department of Housing and Urban Development.
Momentum continues to build. One of the most prominent backers of the population health movement is the Robert Wood Johnson Foundation, which partnered with the University of Wisconsin Population Health Institute to create County Health Rankings and Roadmaps, an online tool that draws on data to profile counties and recognizes those that make important strides in community health and safety.
The Institute for Healthcare Improvement, a nonprofit initially focused on patient safety and performance, has also stepped into the population health arena, with the 100 Million Healthier Lives campaign, which aims to achieve that goal by 2020. And now U.S. News has partnered with the Aetna Foundation to create Healthiest Communities, a U.S. News ranking that builds on the newest research in the field to build a database that offers residents an opportunity to compare their communities with those of their neighbors or in peer groups nationwide.
Over the last three years, the movement has begun to catch on at the local level, Norris says. "What we're finding is that good solutions solve multiple problems," he says. For example, growing the food economy in modest or low-income neighborhoods by establishing food stores, farmers markets and neighborhood gardens also promotes access to healthy foods and green jobs.
