Despite the accomplishments and purported value of the US health system, the United States still lags behind other developed countries in the health outcomes it produces.1 Clinical care consumes 95% of the health dollar but accounts for only about 20% of the determinants of health.2 The other 80% is determined by behaviors and the health of communities: the social and physical environments. The United States compares unfavorably with other nations on many of those determinants.3 Failure to understand how those determinants can be improved will result in paying extraordinary costs for interventions to treat the illnesses and injuries that are their natural outcome. Regardless of how much more sophisticated the US medical care system becomes, without fundamentally changing health improvement strategies, including using what already is known to modify underlying determinants as well as conducting research to improve this understanding, the health gap that exists between the United States and other nations will remain.
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