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JAMA. 2017 Apr 11;317(14):1461-1470. doi: 10.1001/jama.2017.1964.

Vital Directions for Health and Health Care: Priorities From a National Academy of Medicine Initiative.

Author information

National Academy of Medicine, Washington, DC.
Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC.
Malcolm Wiener Center for Social Policy, John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts.
AVIA, Chicago, Illinois.
Departments of Pediatrics and Preventive Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Adolescent Health Center, New York, New York.
The Daschle Group, Washington, DC.
Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee.
Center for Patient Partnerships, University of Wisconsin-Madison Law School.
Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Leavitt Partners, Salt Lake City, Utah.
Emory University School of Medicine, Atlanta, Georgia.
UnitedHealth Group, Minnetonka, Minnesota.
University of Southern California, Los Angeles.
xG Health Solutions, Columbus, Maryland.
American Organization of Nurse Executives, Chicago, Illinois.
Global Research and Development, Sanofi, Paris, France.



Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.


To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.

Evidence Review:

Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.


The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.

Conclusions and Relevance:

The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress.

[Indexed for MEDLINE]

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