Center Research

About the Research

Systems for Action (S4A) is a national program of the Robert Wood Johnson Foundation (RWJF) that aims to discover and apply new evidence about ways of aligning the delivery and financing systems that support a Culture of Health.


Affordable Care Act Implementation and Multi-Sector Contributions to
Public Health Delivery Systems

The Affordable Care Act established new resources and incentives for hospitals, insurers, public health agencies, and others to contribute to disease prevention and health promotion activities, potentially changing the structure of public health delivery systems and expanding the implementation of strategies that improve population health. This study uses data from the 1998-2014 National Longitudinal Survey of Public Health Systems to examine: (1) the degree and nature of change in multi-sectoral contributions to public health activities; and (2) the extent to which these system changes are attributable to key ACA provisions including coverage expansions, Prevention and Public Health funding, and adoption of public health accreditation standards.

Preventable Death Rates Fell Where Communities Expanded Population Health Activities Through Multisector Networks

The US health system faces mounting pressure to improve population health. Research suggests a need for greater coordination and alignment across the sectors that deliver medical, public health, and social services. This study uses sixteen years of data from a large cohort of US communities to measure the extent and nature of multisector contributions to population health activities and how these contributions affect community mortality rates. The results show that deaths due to cardiovascular disease, diabetes, and influenza decline significantly over time among communities that expand multisector networks supporting population health activities. The findings imply that incentives and infrastructure supporting multisector population health activities may help close geographic and socioeconomic disparities in population health.

Public Health Spending and Medicare Resource Use: A Longitudinal Analysis of U.S. Communities

Preventable health conditions account for more than 75 percent of annual health care expenditures in the U.S., yet less than 5 percent of these expenditures are devoted to public health programs and services that are designed to prevent and control disease and injury rather than to treat the downstream consequences of these conditions. This study examined data on local public health spending and area-level Medicare expenditures over a 20-year period from 1993 to 2013. Between 1993 and 2013, local public health spending increased from $32 to $55 per capita for the average community. Nearly two thirds of communities experienced positive growth in per capita public health spending of nearly $4, unfortunately a third of the communities though suffered a loss of more than $11 per capita. Findings indicate that the degree of inequality in local public health spending closely mirrors the level of income inequality observed among U.S. households such that the public health spending levels ranged from less than $1 per capita to as high as $400 per capita. The results indicate a 10 percent increase in local public health spending per capita is associated with a 0.8 percent reduction in Medicare expenditures per person after 1 year and a 1.1 percent reduction after 5 years. These results suggest Medicare could recover an average of $1.10 for each dollar invested in public health activities after 5 years. If the spending offsets we estimate in this study apply to other populations beyond Medicare, the societal return on investment could be even larger. Finally, results also showed that Medicare spending offsets are more pronounced in low-resource communities, such as areas with higher poverty, lower rates of health insurance coverage, and substantial health professional shortages.

Multi-Sector Population Health Activities Reduce Income-related Disparities in Life Expectancy

Landmark research by Raj Chetty and colleagues at Health Inquality finds wide geographic and intertemporal variation in the relationship between income and life expectancy in the U.S., using 1.4 billion administrative tax records from the IRS linked to nearly 7 million federal death records. Many questions remain about the underlying causes of these findings and their implications for policy.  This study links Chetty’s income and life expectancy data with the 1998-2014 National Longitudinal Survey of Public Health Systems to examine whether the existence and strength of multi-sector population health improvement activities influence income-related disparities in life expectancy over time. Communities attaining the highest level of multi-sector population health activities increased from 24% of the sample in 1998 to 37% in 2006, but fell to 31% in 2012 and recovered modestly to 33% in 2014.  Within sectors, hospitals increased their contributions to population health activities by nearly 20% between 2012 and 2014, while insurers, employers, and nonprofit community-based organizations showed smaller but significant increases in contributions (p<0.05).  Residing in a community with the highest level of population health activity was associated with a 3.9 year gain in life expectancy for individuals in the bottom quartile of the income distribution after controlling for observed and unmeasured confounders (p<0.05), but no significant gain in life expectancy for the top income quartile.  Differences in life expectancy between the top and bottom income quartiles declined by an estimated 2.1 years in communities with the highest level of activity (p<0.01).  Community capacity to implement widely-recommended population health activities is one important contributor to geographic variation in the relationship between income and life expectancy.   

The Effect of Uncompensated Care Costs on Hospital Contributions to Population Health Improvement Activities

The Affordable Care Act (ACA), along with Medicaid expansion, was expected to reduce the rising burden on hospitals from uncompensated care provision to uninsured people while creating new resources and incentives for hospitals to contribute to disease prevention and health promotion activities. By examining the association between area-level hospital uncompensated care provision and hospital contributions to public health activities for the period 2006-2016, our analysis lends empirical evidence to the hypothesis from the extant literature that reducing uncompensated care costs might enable hospitals to re-allocate resources for population health improvement. Hospital participation in public health activities increased from 41% in 2006 to 47% in 2016 with hospitals most likely to contribute to assessment and policy related core public health functions. In 2014 constant dollar terms, relevant area-level uncompensated care costs were estimated to decline from 126 dollars per capita in 2006 to around 103 dollars per capita in 2016. Results from the multivariate model indicate that a one percent increase in the total cost of area-level hospital uncompensated care is associated with a 9 percentage point decrease in hospital contributions to public health activities (p<0.05). Our findings suggest that hospital contributions to population health activities increase as uncompensated care provision declines, consistent with a substitution effect.


National Longitutindal Survey of Public Health Systems

Principal Investigator: Glen P. Mays, PhD, MPH

Since 1998, the National Longitudinal Survey of Public Health Systems (NLSPHS) has followed a nationally representative cohort of U.S. communities to  measure the implementation and impact of multi-sector population health improvement activities. The survey asks local public health officials in each community to report information on a set of 20 activities that are nationally recommended for monitoring, protecting and improving health status at the population level.