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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Anna Nicholson and Tamara Haag, Rapporteurs Roundtable on Population Health Improvement Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of Sci- ences and Aetna Foundation, Kresge Foundation, New York Health Foundation, Robert Wood Johnson Foundation, and additional support from the Association from American Medical Colleges, Blue Cross Blue Shield of North Carolina, F ­ annie ­Rippel Foundation, Nemours, Samueli Foundation, and Wake Forest Baptist Health. Any opinions, findings, conclusions, or recommendations expressed in this publica- tion do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26425 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2022 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. U.S. health care expenditures: Costs, lessons, and opportunities: Proceed- ings of a workshop. Washington, DC: The National Academies Press. https://doi. org/10.17226/26425. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON U.S. HEALTH CARE EXPENDITURES: COSTS, LESSONS, AND OPPORTUNITIES1 SANNE MAGNAN (Chair), Senior Fellow, HealthPartners Institute, Emerald Isle, NC ADAM BRESS, Associate Professor of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City DORA HUGHES, Associate Research Professor, The George Washington University, Washington, DC MARC GOUREVITCH, Chair and Muriel G. and George W. Singer Professor of Population Health, Department of Population Health; Professor, Department of Medicine; Professor, Department of Psychiatry, NYU Grossman School of Medicine and NYU Langone Health, New York, NY RACHEL BLOCK, Program Officer, Milbank Memorial Fund, New York, NY MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare Economics and Policy; Economic Consultant, FTI Consulting, Washington, DC ERIC SCHNEIDER, Senior Vice President for Policy and Research, The Commonwealth Fund, New York, NY KOSALI SIMON, O’Neill School of Public and Environmental Affairs, Class of 1948 Herman Wells Professor, Associate Vice Provost for Health Sciences, Indiana University, Bloomington LAUREN TAYLOR, Postdoctoral Fellow, Department of Population Health, NYU Grossman School of Medicine, New York, NY 1  The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

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ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 RAYMOND BAXTER (Co-chair), Trustee, Blue Shield of California Foundation, San Francisco, CA KIRSTEN BIBBINS-DOMINGO (Co-chair), Professor and Chair of the Department of Epidemiology and Biostatistics; Lee Goldman, M.D., Endowed Professor of Medicine; Vice Dean for Population Health and Health Equity, University of California, San Francisco, School of Medicine PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges, Washington, DC DAWN ALLEY, Chief Strategy Officer, Center for Medicare & Medicaid Innovation, Washington, DC JOHN AUERBACH, Executive Director, Trust for America’s Health, Washington, DC CATHY BAASE, Chair, Board of Directors, Michigan Health Improvement Alliance; Consultant for Health Strategy, Dow Chemical Company, Saginaw, MI DEBBIE I. CHANG, President and Chief Executive Officer, Blue Shield of California Foundation, San Francisco, CA ALLISON GERTEL-ROSENBERG, Operational Vice President, National Policy and Practice, Nemours, Washington, DC MARC N. GOUREVITCH, Professor and Chair, Department of Population Health, NYU Grossman School of Medicine and NYU Langone Health, New York, NY MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare, Economics and Policy, FTI Consulting, Washington, DC GARTH GRAHAM, President, Aetna Foundation, Hartford, CT GARY R. GUNDERSON, Vice President, Faith Health, School of Divinity, Wake Forest University, Winston-Salem, NC DORA HUGHES, Associate Research Professor of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC SHERI JOHNSON, Director, Population Health Institute; Associate Professor, Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison 1  The National Academies of Sciences, Engineering, and Medicines planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

WAYNE JONAS, Executive Director, Integrative Health Programs, H & S Ventures, Samueli Foundation, Alexandria, VA ROBERT M. KAPLAN, Professor, Center for Advanced Study in the Behavioral Sciences, Stanford University, Stanford, CA MICHELLE LARKIN, Associate Vice President, Associate Chief of Staff, Robert Wood Johnson Foundation, Princeton, NJ MILTON LITTLE, President, United Way of Greater Atlanta, Atlanta, GA PHYLLIS D. MEADOWS, Senior Fellow, Health Program, Kresge Foundation, Troy, MI BOBBY MILSTEIN, Director, ReThink Health, Morristown, NJ JOSÉ T. MONTERO, Director, Center for State, Tribal, Local and Territorial Support; Deputy Director, Centers for Disease Control and Prevention, Atlanta, GA VON NGUYEN, Senior Vice President and Chief Medical Officer, Blue Cross Blue Shield of North Carolina, Durham, NC WILLIE OGLESBY, Interim Dean, College of Population Health, Jefferson University, Philadelphia, PA JASON PURNELL, Vice President, Community Health Improvement, BJC HealthCare; Associate Professor, Brown School, Washington University in St. Louis, St. Louis, MO LOURDES J. RODRÍGUEZ, Senior Program Officer, St. David’s Foundation, Austin, TX PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ KOSALI SIMON, Herman B. Wells Endowed Professor, Associate Vice Provost for Health Sciences, Paul H. O’Neill School of Public and Environmental Affairs, Indiana University, Bloomington HANH CAO YU, Chief Learning Officer, The California Endowment, Oakland, CA Health and Medicine Division Staff ALINA BACIU, Roundtable Director CARLA ALVARADO, Program Officer (through January 2021) AYSHIA COLETRANE, Senior Program Assistant MAGGIE ANDERSON, Research Assistant (beginning September 2021) HARIKA DYER, Research Assistant (through July 2021) ROSE M. MARTINEZ, Senior Board Director viii PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evi- dence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: Shirley Girouard, SUNY Downstate Health Sciences University JoAnn Yánez, Association of Accredited Naturopathic Medical Colleges Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by Martin J. Sepulveda, Claraluz LLC. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully consid- ered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. We also thank staff member Constance F. Citro for reading and provid- ing helpful comments on this manuscript. ix PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xiii 1 INTRODUCTION 1 Workshop Overview, 3 Organization of the Proceedings, 5 2 ECONOMIC PERSPECTIVES FRAMING HEALTH CARE EXPENDITURES 8 A Health Dividend for America: U.S. Health Care Expenditures and Opportunity Costs, 8 Expanding Health Access While Decreasing Wasteful Health Spending, 13 Health Equity Initiatives, 14 Discussion, 17 3 INNOVATION TO BEND THE SPENDING CURVE 21 A State Roadmap to Developing Health Care Cost Growth Benchmarks, 22 Case Example: Delaware’s Journey Toward Health and Quality Benchmarks, 24 Collaborative Approach to Public Goods Investment, 25 A Federal-Level Perspective, 28 Discussion, 30 xi PREPUBLICATION COPY—Uncorrected Proofs

xii CONTENTS 4 FRAMING AND SHIFTING THE HEALTH NARRATIVE IN THE UNITED STATES 37 Perspectives on Health Care Challenges, 38 Shifting an Individualistic Mindset, 41 The Potential Impact of COVID-19 and the Racial Equity Movement on Health Policy, 42 Role of Community-Level Efforts in Policy Change, 45 Perspectives of Medicare Recipients, 46 Techniques Used in Framing Health Spending Reform, 47 Final Thoughts, 50 5 RESEARCH PRIORITIES 51 Areas of Current Research, 52 Discussion, 58 Closing Remarks and Reflections, 63 APPENDIXES A References 67 B Biographical Sketches 73 C Workshop Agenda 89 D Readings and Resources 93 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACA Affordable Care Act ACO accountable care organization AHC accountable health communities ARP American Rescue Plan CAPGI Collaborative Approach to Public Goods Investment CBO Congressional Budget Office CHART Community Health Access and Rural Transformation CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services DHSS Department of Health and Social Services ED emergency department Geo Geographic Direct Contracting GDP gross domestic product HUD U.S. Department of Housing and Urban Development HCE health care expenditure Mass DPH Massachusetts Department of Public Health MassUP Moving Massachusetts Upstream MMF Milbank Memorial Fund xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv ACRONYMS AND ABBREVIATIONS OECD Organisation for Economic Co-operation and Development ROI return on investment SNAP Supplemental Nutrition Assistance Program TCF The Commonwealth Fund USofCare United States of Care UWGC United Way of Greater Cleveland PREPUBLICATION COPY—Uncorrected Proofs

In Memoriam David K. Jones 1981–2021 xv PREPUBLICATION COPY—Uncorrected Proofs

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The Roundtable on Population Health Improvement, a convening activity of the National Academies of Sciences, Engineering, and Medicine, held a workshop on March 15-16, 2021, to explore issues related to increasing health care spending in the United States. The workshop, U.S. Health Care Expenditures: Costs, Lessons, and Opportunities, was organized to highlight the persisting challenge of health care expenditures that are not commensurate with the health outcomes they produce. This publication summarizes the presentation and discussion of the workshop.

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