Our Challenge

There is a mismatch between what creates “health” and how we allocate our overall health spending. “Personal” healthcare spending per capita in 2014 was $9,523. In contrast, combined federal and state funding for the health of the public as a community was $250 per capita. The ratio is 38:1.

During the same decades that personal health care spending rose sharply, our society became unhealthier in fundamental ways. Obesity rates tripled, driving an epidemic of type 2 diabetes and its heavy burden of complications, including heart disease, stroke, blindness, kidney failure, and lower limb amputations. With current trends, 40% of U.S. children born in the last decade will be diagnosed with diabetes; 35% for non-Hispanic whites and 50% for Hispanics and African Americans.

Behind the obesity and diabetes numbers is an alarming fact: the entire distributions of American’s body weight and blood sugar are moving higher. For example, readings for the healthiest 10% and the unhealthiest 10% of Americans’ blood sugars rose by exactly the same amounts from 1999-2009. In other words, the trend isn’t limited to a few at risk; it spans our society.

And diabetes is just one challenge. Many chronic diseases share the same roots in unhealthy behaviors. Forty-five percent of cancers in men and 40% in women could be prevented by optimal control of personal risk factors. All told, chronic diseases now account for 70% of our personal healthcare bill, currently at 17% of GDP. This massive personal health care spending is unsustainable. Our minimal spending on prevention is indefensible. The two problems are linked in an unhappy cycle: personal healthcare spending crowds out many other necessary expenditures, including those for public health, and the failure to invest in public health increases personal healthcare spending.

Promoting a Broader View of “Health”

Medical care influences just 10-20% of our overall population health outcomes. The rest is shaped by the conditions of everyday life: how we work, play, and transport ourselves; the food we make, grow, sell, and eat; the neighborhoods we build and live in. To create health community wide, we need to ensure that opportunities for health are the norm, not the exception.

True prevention requires acting outside the personal healthcare system to create opportunities for healthy living in every home, school, neighborhood, and workplace. It means recalibrating what’s “normal” in our daily patterns of living and our communities. It means considering health outcomes in policy making across all sectors of our community. It means rebalancing our spending on personal health by expanding investment in healthy opportunities for all.

Promoting “Health Impact Investing”

We therefore propose “health impact investing” – using resources to moderate health risk factors “upstream” from the actual provision of medical care.

What would the resources buy? Examples are provided by Communities Putting Prevention to Work (CPPW), the 2010-2012 CDC grant awarded to San Antonio’s Metro Health. It funded safe routes to schools, school salad bars, and fitness equipment, school grounds opened after hours for community use, Síclovía, Fitness in the Park, fitness stations, expanded walk and bike trails, B-cycles, healthy meal labeling in restaurants, neighborhood walking groups, a ride-to-own bike program for kids in public housing, worksite lactation initiative, pedestrian enhancements, a Complete Streets Policy, a pedestrian safety action plan, Active Living Council, Food Policy Council, Mayor’s Fitness Council, FitCitySA website, and other initiatives.

The results? Over the two years of CPPW funding, San Antonio’s obesity rate dropped from 35.1% to 28.5%.6 The cost was $5 per city resident per year. Public health is high impact investing.

But the roots of community health go deeper than what we eat or how much we exercise. To flourish, people need the basic ingredients of a dignified human life: education, meaningful work, the ability to do and be what they value, a sense of belonging. So health impact investing would address the many determinants of health, with a portfolio including shorter-term initiatives to promote healthy behaviors and longer-term community development.

How would health impact investing work? One example is a local authority including key stakeholders from multiple sectors assembling resources. Such organizations, called “health trusts” in some jurisdictions, are beginning to emerge across the U.S. Our local authority would prepare a return on investment analysis to justify funding. Initiatives would be developed through a participatory process that included the community voice. Some efforts would involve multi-sectoral collaborations that broadly address where residents live, learn, work, and play, while others would be narrowly targeted to specific conditions with great local impact. Progress would be evaluated by specific metrics, with transparency and accountability for meeting them.

Many U.S. communities are in the early stages of health impact investing. We are actively studying their experiences with different financing vehicles, including health trusts, social impact bonds, community development financial institutions, philanthropy, and capturing savings from reducing personal healthcare costs.

The Business Case for Health

A business’s health is unavoidably tied to the well-being of its workers and its community. Healthier, better educated, more secure workers are more productive and cost less to insure. Workplace wellness programs promote healthier behaviors among organizations’ current workers but don’t address the context out of which those behaviors arise or the workforce of tomorrow. Poor community health hurts business in four ways:

  1. Profits diverted to employee’s healthcare insurance premiums.
  2. Employer spending on healthcare premiums compresses wages.
  3. Consumer spending on health care reduces purchasing power for a business’s product.
  4. Public spending on medical care crowds out funding for education and infrastructure necessary for firms’ success.

The Health Collaborative’s Role

Our proposed role is to serve as a “community health integrator” responsible for identifying shared values and shared vision, moving later to creating a “playbook” of innovations that accounts for stakeholder values and expected return on investment (ROI), assembling financing, and coordinating action.

The Mission

Our goal is for local investment under local control to moderate upstream health risk factors. Resources to promote a community that offers all its residents real opportunities for health and flourishing, regardless of social class. We are all in this together. Without a vision for creating community wide health, the endlessly rising fraction of our economic resources devoted to personal health care is a moonshot without a moon.


Top image: Community members participate in a Zumba session held for the opening of Pearsall Park earlier this year.  Photo by Scott Ball. 

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Robert Ferrer

Robert Ferrer, MD, MPH is the Dr. John M. Smith, Jr. Professor and Vice Chair for Research in the Department of Family and Community Medicine at the University of Texas Health Science Center at San Antonio....