April 1, 2026 Forum

This is a complex political, cultural challenge. Bill B brought up the fractal nature of this challenge. There’s a subsystems mirroring. So we have to begin focusing on things from a different perspective. And how to solve them probably requires a lot of partnerships, which is not the strong suit of healthcare in general, right? We have a tendency to say: “Let us go rescue you. And the rescuing model of healthcare is very expensive because you’ve got to have people who need to be rescued. And so that becomes a self-fulfilling challenge.

Jack, could you speak briefly about how communities get deeply insulted when they get called the unhealthiest communities?

Jack

I’ve worked with many communities around this country. And we always dread when the county health rankings come out because several of the counties I work with are ranked at the bottom of the county health rankings. And it just annoys the hell out of them because they get pointed out. They are featured in an article in the New York Times about counties being in the top 10 or bottom 10. And here they are, one of the bottom 10 counties. By and large, those preparing the lists miss the point. They don’t take into consideration the actual people who live there. And so we always dread when the county health rankings come out. In fact, when I was at the Graham Center, I made an effort to convert the social deprivation index to the community health index. This index contained essentially the same factors, but we flipped them upside down. We said, here’s the community health index based on the positive assets of those communities rather than the negative. You tell somebody, your county sucks. There’s not a solution there. There’s not a way to build an asset. But if you talk about an asset score, then people have the opportunity to build and improve those assets. Every place has assets. And then they can build and improve those assets. And instead of a ranking from 1 to 4,590, the number of counties, you do a score so that everybody has the opportunity to move up their score rather than simply go from 4,588 to 4,485.

But you could go from an asset score of 10 to an asset score of 12 by looking at what are those assets. And they are not just access to a hospital, emergency room. There are other assets in a community that I think we have largely forgotten in healthcare. Not this group probably, and not many people. But from a financial standpoint, we have no problem spending $100,000 on somebody’s bypass surgery at the end of life and we aren’t going to put $100,000 into making sure that kids get educated and people have walking paths and there’s connections in communities.

Bill B

A couple of things, Jack. First, an appreciative approach has been kind of a theme in this Salus group from the start. It is first of all, a matter of appreciative metrics. We can avoid the bias of unequal starting points. For instance, it is common in higher education to measure the quality and success of a college or university by pointing to the accomplishment of graduates (percent going on to graduate work or income earned 10 years after graduation). However, no consideration is given to the socio-economic status or competencies of the students when they enter the collegiate institution. The wealthy, well-educated incoming student will inevitably do better than the student who comes from an impoverished setting.