such “silo” or “chimney” approaches are not well equipped to tackle issues that cut across traditional structures and processes.

The report notes that silos within and across agencies make it difficult for leaders who address one social factor (e.g., education) to interact with health agencies. With the exception of some success stories (e.g., school health), meetings across agencies occur only occasionally except the Cabinet level. Looking at policies on social factors and other nonmedical determinants of health, the report notes:

•   [They] must be viewed as only one of several competing priorities for policy makers’ attention and resources. Economic policy or foreign affairs [often] take precedence over health concerns. More specifically, SDH may be over-shadowed … by [concerns over] health-care itself. However, this health care focus is often to the neglect of health and [its broader determinants].

The report further notes that a focus on health care also ignores the important connection between health and the economy: nonhealth policies that reduce disease burden and thus the costs of health care have enormous implications for medical spending and the economy itself (Milstein et al., 2011; Woolf, 2011). Unfortunately, the report notes, political realities often limit attention to “short-term [returns] rather than the long-term [ramifications] and on discrete interventions rather than coordinated, collaborative initiatives….” Lastly, the report notes that globalization has been changing the role of national governments in shaping policy making:

•   Governments’ ability to shape and mould SDH with the goal of improving their population’s health is becoming limited as many of the [upstream causes] no longer fall within their responsibility. There is a parallel argument that decentralization [of authority] to regions and cities has had a similar effect on the policy-making capacity of national governments.

Ultimately, meaningful initiatives to address the underlying causes of the U.S. health disadvantage may have to address the distribution of resources that are now directed to other categorical priorities—a change that is likely to engender political resistance. Is a shift in priorities warranted? This report documents that the United States is not keeping pace with other high-income countries in many areas of health and socioeconomic well-being, and the consequences to the nation can be measured not only in lives, but also in dollars. Understanding why this is occurring and identifying policies that could reverse these unfavorable trends are clearly important for the nation’s future.



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