provides unprecedented resources to prevent illness and keep people healthy and includes, for the first time, a National Prevention Strategy. Although the ACA will take years to produce results, its potential is great. It could be generations until resources for population health such as those reflected in the legislation re-appear. Along the way, the ACA presents the opportunity to realize what Flores called the “health dividend” by transferring funds now spent on medical care to social and infrastructure investments that can both stabilize the nation’s fiscal health and improve the well-being of its citizens. Today, 97 percent of national health expenditures go to health care services, with only 3 percent going to prevention even though the biggest determinants of health are not medical care or even genetics, but rather, behaviors and environmental factors (Bipartisan Policy Center, 2012). “Health largely depends on conditions where we live, learn, work, and play, not just on the medical treatment we receive,” said Flores. “Health is not just in pills and surgeries and hospitals. We need to think more broadly than that.”

A more productive approach to thinking about health comes from considering it in the context of the social ecology model that the state of California uses. This model consists of four domains—the social milieu, the community, the family, and the individual (see Figure 2-1)—and it reflects the importance of socioeconomic factors, public health interventions, and health awareness education as key determinants of individual health. Flores said the ACA is creating opportunities to deal with each of these domains and providing incentives for developing innovations that will shift health care from today’s high-volume and high-cost health care system focused on personal service to a future system that stresses healthy lifestyles and healthy environments. In his view, achieving this transformation is essential if the nation is to reduce morbidity and enable people to live longer, healthier lives through a sustainable investment in individual medical care.

Flores stated that the critical path for reform of the health care delivery system will first move from the current acute care system that focuses on episodic, non-integrated care to one that is coordinated, seamless, and provides care in a manner that is that is accountable for outcomes. A next step would create a community-integrated, learning health care system that uses population health strategies capable of rapidly deploying best


at Lower Cost: The Path to Continuously Learning Health Care in America (2012); For the Public’s Health: The Role of Measurement in Action and Accountability (2011); A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension (2010); an IOM workshop summary, Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice: Workshop Summary (2013); and the IOM Roundtable on Health Literacy and the IOM Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities.

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