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2020 was arguably one of the most difficult years in American history, challenging our resilience and surfacing enduring and systemic challenges to our collective health and well-being. As we continue to measure the pandemic's impact on short- and long-term health, as well as other social and economic indicators, it is useful to note where we stood pre-pandemic. Understanding the conditions and trends that shaped our health before COVID-19 helps us assess whether the systems now being tested to respond to COVID-19 are robust.

Last year, the Robert Wood Johnson Foundation (RWJF), along with the RAND Corporation, shared an update on the national set of measures that we have been using to track our journey toward a culture where every person has a fair and just opportunity to live the healthiest life possible. The goal of the Culture of Health measures is to offer signals of change with a focus on broader social and economic drivers of health, well-being, and equity, as well as the role all sectors play in influencing health outcomes. Developing a clearer picture of what is changing (or not) via the Culture of Health measures is useful for directing investments and identifying where, as a nation, we need to make progress.

What Was the Nation's Health Before the Pandemic?

In 2019, when we updated the measures, we reported small, positive changes in appreciation for social determinants of health and the need for broader community health investments. However, we also found slow progress on education, housing, and other systemic factors that influence health, well-being, and equity. Now, COVID-19 has added stress to many of those systems.

In our 2020 update, we again had some notable improvements in areas likely susceptible to pandemic impacts (e.g., mental health, health care). Still, progress on social and economic drivers that influence health remained slow. Here is what we found.

Sectors That Influence Health Are Making Some Progress

To achieve a Culture of Health, sectors outside of health care and public health (e.g., media, business) must recognize and leverage their influence on health outcomes. For instance, youth exposure to advertising by the corporate food and beverage sector is associated with children asking parents to buy specific—and potentially unhealthy—foods. This challenge may have become more acute as families stayed home during the pandemic. In 2018, data from Nielsen Media Research indicated that young children viewed an average of 1.7 food product ads daily during children's programming, which was down from 2.5 ads in 2015. Nearly 71% of the products advertised failed to meet federal guidelines for nutrition standards, down from 80% in 2015. While more improvement is needed, these pre-pandemic decreases indicate that the food and beverage sector is either making healthier products or reducing advertising of unhealthy products to children—which may improve equity in terms of healthy weight.

Progress on Mental Health and Well-Being Is Mixed

Adverse childhood experiences (ACEs) are linked to mental illness, chronic health conditions, and premature death. The physical, social, and economic environment in which children live can influence their exposure to ACEs. There may be signs of hope on this front. The National Survey of Children's Health data showed that, in the most recent data (the 2017–2018 school year), 42% of children in the United States had one or more ACEs, such as family divorce, domestic violence, or drug or alcohol use problems in the household. That is a 3 percentage point reduction from what was reported in 2016–2017. While this finding is promising, it will be important to track whether the pandemic worsens and increases exposure to ACEs. In contrast, general well-being as measured by life satisfaction did not improve in the years prior to the pandemic, according to the OECD Better Life Index, which found no improvement in life satisfaction (reported at just 6.9 on a ten-point scale) among U.S. residents aged 15 years and older from 2014–2016 to 2015–2017. Now the pandemic is testing an already-low U.S. life satisfaction that likely is worsening due to COVID-19.

There Are Improvements in the Health Sector, but Costs Remain High and Flexibility Elusive

• New payment and health care delivery models are intended to provide higher value care. Analysis by Leavitt Partners found that, as of the end of 2019, about 12% of the U.S. population had a health care provider who is part of a population-based alternative payment program, an increase of about 2% since 2018. This may mean that more people have better care at lower cost.
• However, the news prior to the pandemic was not all rosy. According to Medicare beneficiaries' data (Kapinos, 2020), in 2017 the average total health expenditures in the last year of life was $66,176. This number has gone up by an average of about $3,000 per year since 2013. The pandemic's pending health care bills will only exacerbate rising health care costs.
• Finally, removing scope of practice barriers for nurse practitioners can broaden their ability to provide diagnostic and treatment services, which can improve COVID-19 response, particularly in medically underserved areas. But before the pandemic, there had been no increase in the number of states with full practice laws for these health care providers (holding at only 22 states since 2017).

Progress to Create Healthier, More Equitable Communities Remains Slow

The community conditions that represent some of the most entrenched, systemic issues are usually not tracked with other health measures, even though they are key influences on health. There is no improvement in environmental protections such as the number of states with cross-sector climate action plans (in fact, Alaska rescinded its plan) or states with air quality protections in bars and restaurants. 2020's reckoning on racial issues is occurring at a time when the nation still has significant racial residential segregation. And while there was no change in 2018 from prior years in the percentage of American households spending 50% or more of their income on housing (12%), there was some improvement since 2014 in the burden on communities of color (an average reduction of 3%). However, there remains a disproportionate housing cost burden on Black, Hispanic/Latinx, and American Indian/Alaskan Native households, which are communities being disproportionately affected by COVID-19.

What Do These Changes Mean and Where Do We Go, Given the Pandemic?

Measuring health and the social and economic factors that influence it before the pandemic gives us a picture of the kind of risks the nation was dealing with before the devastation 2020 brought. In sum, the nation was making slow progress in some areas but was not moving the needle nearly as rapidly as many would hope to improve key aspects of our health care system, our environment, and our economic conditions. Critical systemic changes needed for more transformative health improvements have been slow or stalled and, as a result, inequities remain pervasive.

As we look ahead and capture more detailed information on COVID-19's effects, it will be important to track whether these Culture of Health measures worsen or appear resilient to further stress. Even if it is unlikely that we will observe improvements in many areas of health, social status, and the economy during the pandemic, continuing to track the choices and investments various sectors make to cultivate healthier communities can inform the choices we make and directions we take going forward. In fact, it may be key to the nation's ability to recover from 2020.

A fuller description of these measures and the data underlying them can be found at www.rwjf.org/cultureofhealth. Making progress on them is imperative if we are to become a healthier, more equitable country.

Carolyn E. Miller is a senior program officer in the Research-Evaluation-Learning unit of the Robert Wood Johnson Foundation. Anita Chandra is vice president and director of RAND Social and Economic Well-Being and a senior policy researcher at the RAND Corporation.

This commentary originally appeared on Robert Wood Johnson Foundation's Culture of Health blog on January 29, 2021. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.