Cracks in the Foundation, Part 3: Overcoming Healthcare’s Services-Need Mismatch

This piece is the third in a series of six columns in which David Johnson addresses five structural defects undermining nonprofit healthcare. He outlined all five defects in the first column of the series. Part two is here.

At the top of my reading list last summer was The Hospital: Life, Death and Dollars in a Small American Town by Brian Alexander. I expected Alexander’s book to portray the ups and downs of a rural hospital fighting for survival. It does that superbly.

Surprisingly, The Hospital also chronicles the daily travails of local residents seeking vital care services they desperately need. Among them is Keith Swihart, an affable, hard-working, heavyset man who struggles to care for a special-needs son, afford insulin and ward off medical bill collectors. Diabetes ultimately costs Keith his right foot and most of his eyesight. Only 39, Keith hobbles to endless medical appointments and treatments. An effective diabetes management program could have kept Keith active and productive. Instead, as he spirals downhill, American society funds Keith’s enormous treatment and disability costs. What a monumental and preventable tragedy.

Healthcare's Profound Services-Need Mismatch

There are countless Keith Swiharts living in America, especially in low-income urban and rural communities. U.S. healthcare is not providing them with the basic care services they need to lead longer, healthier and happier lives. Inadequate access to coordinated social and healthcare services underlies expansive differences in life expectancy, exceeding 20 years between wealthy and poor communities. Despite medical advances, U.S. life expectancy has declined consistently on both an absolute and relative basis since 2014.[1]

By the early 1990s, sedentary lifestyles, greater portion sizes and processed food consumption had triggered massive increases in obesity and related chronic conditions. In response, the Centers for Disease Control (CDC) added “Prevention” to its name in 1992. Even with more preventive care, the CDC estimated in 2020 that, as of 2018, more than 42% of U.S. adults were obese.[2] Meanwhile, chronic disease and mental health conditions account for 90% of the nation’s healthcare expenditure.[3] It doesn’t have to be this way. Providers are ideally positioned to engage and help Americans improve their well-being and to promote healthier communities.

Elevating health promotion to equal status with disease treatment, however, runs counter to medical practice, culture and economics. Overcoming legacy behaviors and attitudes will require full-throttled commitments to improving social determinants of health.

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