Necessary But Not Sufficient

Why Health Care Alone Cannot Improve Population Health and Reduce Health Inequities

Steven H. Woolf, MD, MPH


Ann Fam Med. 2019;17(3):196-199. 

In This Article

Abstract and Introduction


The health of Americans is in decline, a crisis that has been building for some years. Since the 1980s, US life expectancy has risen at a slower pace than in other countries. United States life expectancy peaked in 2012 and is now falling, while life expectancy in other countries continues to increase.[1,2] Shorter lifespans are not the only US health disadvantage. For many years, other industrialized countries have been outperforming the United States on a long list of health conditions.[3] All this despite lavish US spending on health care, which far exceeds that of any other country.[4]

The reason why nations that spend less on health care can experience better health is obvious: health is about more than health care. Studies suggest that medical care accounts for only 10% to 20% of variation in premature mortality.[5] In this issue of the Annals, Kaplan and Milstein put a finer point on that estimate. Based on 4 prior studies, they conclude that health care accounts for 5% to 15% of the variation in premature mortality, centered on 10%.[6] Other studies have examined this issue[7–9] and researchers will continue to refine this point estimate, but more data are unlikely to change the bottom line: the major influences on health lie outside the clinic. The decline in US health will not be solved by more bench science, more drugs, or more spending on health care—none of these have slowed the decline in US health. The average lifespan of Americans will probably continue to shorten unless society quickly shifts its focus from health care to root causes.