Abstract
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Implicit in its name, the direction of population health is a product of the health care accessible to a group and the overall well-being of that group. This lends itself to the question: what is the future direction of health care in the United States? The concepts governing the direction vary with time, but an overarching theme remains unchanged. Health care, as an industry in the United States, has been steadfast in its prioritization of capital generation.
Since its introduction in the early 1930s to the modern economic vernacular, gross domestic product (GDP) has gradually earned acceptance as the most significant economic metric. 2 Its growth has become synonymous with the welfare of a nation. 3 In the United States we tout ourselves for having the world's most powerful economy and, in turn, being the most successful nation. We are able to do so because we have the largest GDP. 4 Yet, in recent years, the rumblings of whether a greater GDP is tantamount to a more fortunate populous have grown louder. 2
As its introducer warned from the outset, a focus on GDP optimization primed by economic disparity has led to a marriage of accelerated economic output, with a disproportionate distribution of the benefit. 3 Similarly, the economic output in health care has been profound yet, the benefits of that spend are not equally accessible. This lack of access is recognized as a substantial driver of our lagging quality indicators. 5
This GDP fetishism2 has led to the divergence of our health care expenditures from our quality metrics relative to other nations. In 1960, health care as an industry accounted for 5% of the US GDP. Prepandemic, this number increased to 17.6%, ultimately peaking during the pandemic at 19.7% in 2021. 6 In terms of national health care spend, this is equivalent to $4.2T. 6 Despite this aggressive capital allocation, it has become common knowledge the United States lags its peers in health care quality metrics. 5
What happens when more, is clearly not better? How does health care serve 2 seemingly opposing needs? More pointedly, how does health care stay true to its tenets to serve individuals and the public while furthering the nations goals by serving as the fifth, soon to be third, largest economy in the world? Moreover, if capital generation is the priority, do policy makers truly regard health care as “broken” or is the “health care is broken” crowd an economically viable sector unto themselves. Last, if nations are judged by their GDP, what is a nation's incentive to reduce health care's economic output with cost-saving models that may improve outcomes?
The Affordable Care Act (ACA) attempted to harmonize these 2 truths—the desire to be an economic juggernaut while tending to the health care needs of the populous as a whole. As part of its tenets, the ACA looked to expand access to health care through Medicaid expansion while leveraging the nation's infrastructure for innovation.
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This support for innovation served health care's need to improve substantively in the short term, while priming for continued fiscal growth in the mid to long term. This era, facilitated by the pandemic, brought: the loosening of regulatory restrictions in health care broadly (telehealth, antikickback, stark, and so on); new billable codes extending the reach of health care outside of typical health care settings; and the lowering of barriers to technology utilization including the ability to leverage data.
These are features that have served to expand access to, and reach of, health care in the short term while driving opportunities for both mid-term and long-term economic growth.
Armed with loosened regulatory restrictions, technological literacy, and an unprecedented amount of public and private funding, an avalanche of innovative companies entered the market to tackle the cost/quality problem during this era. 8 With these companies came novel ideas to improve health care while cutting costs.
The central premise of these companies, however, continues to be at odds with the system in which they reside. The American industrial apparatus does not reward a reduction or shifting of the economic pot, it favors the growing of the pot. Hence, as capital investments have diminished, many of these innovative companies will find themselves out of business, acquired by corporate investors, or consolidated into larger systems. 8
Who will remain? Those who have optimized their capital generation and those who have attached themselves to corporate entities with balance sheets capable of supporting their growth. These corporate entities include large technology and data companies. 8 The combination of health care and technology entities will undoubtedly lead to the continued direct to consumerization of much of health care.
These changes will provide the substrate for technology companies such as Apple, and data entities such as Tealium, to become major stakeholders in the delivery of health care. These changes will occur predominantly outside of the institutional setting, ultimately expanding the economic pot available to health care, while leveraging technology to improve quality.
Yet these groups remain plagued by the same issue. When presented with the decision to optimize health care toward quality for the populous or toward fiscal growth, what will health care choose? If history is an indicator of the past, the answer is clear. Where is health care headed and in turn population health as an industry? For the answer, follow the money.