While early 21st century politics roiled with the sound and fury of polarized Baby Boomers, deep below the surface a profound cultural shift was reshaping society by lifting a broader conception of health up to become a central concern of the nation. While the mainstream media focused public attention on the many divides (e.g., political, ideological, legal, and societal), deeper trends were uniting Americans in the face of major challenges. The remarkable changes that were to become central to the national identity were beginning to surface, though up to 2020 most of the public attention was captivated by contentious arguments marked by denial, fear, and a romanticization of the country’s past.
But around the country great programs were demonstrably improving health and health care even in the early 2010s. The Harlem Children’s Zone, for example, demonstrated that fundamentally caring about health meant addressing nutrition, housing, and education. Cities all over the country followed the lead of Detroit, Milwaukee, and Baltimore to tackle food deserts by promoting access to affordable healthy food, often grown locally. A growing number of communities used open-source tools, such as CreativeCommons.org and the Urban Institute’s “Community Platform”, to map social problems and identify effective solutions. The Convergence Partnership had been bringing resources together in communities around the vision of “healthy people, healthy places.” As a result, people – especially poor people – in many neighborhoods, communities, and cities began eating better and getting healthier. By 2015, programs germinating all over the country were showing that communities could tackle many of the great problems of the day.
People in 2032 find it hard to believe that in 2012 the mainstream media was able to shape the public discourse such that these stories of remarkable success barely made the news – that political competition overshadowed cooperation for the public good. However, people’s focus shifted to the new media, including social networking, YouTube, and TED talks, that helped turn public attention from bad news to good. While aging and shrinking audiences still tuned into the television networks, the majority of the population and virtually all of the nation’s youth were taking in a new reality. New ideas from entertaining success stories began to be reflected in a variety of alternative conferences for the policy community that prompted government action to improve 21st century life.
The vitality visible online stood in stark contrast to the solutions put forth by the country’s elected leaders, who often relied on the ignorance of the many and the wealth of the few to advance narrow, short-term objectives. The transparency afforded by the new technologies exposed the failings of established power structures and fueled a frustration with the political and economic status quo. As a result, in the elections of 2016 a majority of Americans recognized that competitive excesses had converted the political system into a win-lose venture that was inefficient at best. Power was controlled by a small number of people who had benefited from what many perceived as a “winner-take-all” economy. A series of stories about political manipulation of legislation for corporate gain galvanized the public to demand better representation. While some longtime politicians were able to see the parade and get in front of it, many others could not, and were swept from office. In subsequent elections, voters rewarded candidates who articulated a vision of political cooperation, transparency, and anticipatory democracy – a democracy where citizens and decision-makers are active and future-conscious partners in collectively shaping the future of their community, state, and nation.
Throughout the 2020s, innovative technologies spurred the growth of a new, decentralized manufacturing sector, which followed the agricultural sector in making customized, local, and green production successful and economical. What began as a “buy local” fringe movement grew into a reshaping of economics at the community level. These shifts destroyed some jobs while creating others, and reshaped whole industries around new value propositions and business models. By connecting to global networks, communities were able to access the capital they needed for transformative investments at the local level. By 2025, the recognition that communities implementing these changes were far healthier than others prompted a reorientation of entertainment and other services toward improving health. Education systems, which had been designed largely to create a productive workforce, now had an added mandate: to improve health from conception to death.
The success of these communities also highlighted the correlation between health and social equity, which was revealed by massive databases with sophisticated software analytics. As new knowledge came flooding from the consilience of the physical, life, and social sciences, millions engaged with this knowledge through “social networking with a purpose,” opening up a new period of creativity and accelerating a societal mind change. While in earlier times such changes had taken decades, in the 2020s it only took a few years to galvanize a broad-based commitment to achieving a healthy, equitable society.
As cooperation displaced the divisive politics of the past, government agencies aggressively used online technologies to engage the public and enhance governance. In 2021, the White House conducted a 72-hour “governance game” in which more than 80 million Americans helped to identify the priorities that the new President should address in her first term. Many of the priorities built on historical antecedents from state and local anticipatory democracy programs going back to the 1970s, as well as more recent or ongoing local healthy community efforts and broader initiatives like Healthy People 2020 and 2030 and the Millennium Development Goals. Health arose as the top priority as massively multiplayer online game dialogues highlighted the role of health as an input to fiscal stability, national security, and economic vitality. Many game participants volunteered to go to work right away on these priorities in their own towns and cities. In doing so, they were able to draw upon “big data” applications that aggregated data from national, community, and individual health records.
At the level of the individual, “big data” facilitated health improvement by applying the profound knowledge of systems biology, as well as massive computational utilities, to rich data clouds around each person. The billions of bits in each cloud came from inexpensive microfluidic devices enabling nearly continuous testing of blood for circulating proteins, biomonitoring devices that could interface with personal simulations to predict future wellbeing. These combined with and whole genome sequencing – the cost of which had dropped below $100 by 2020. Exploration of this data led to an explosion in understanding of genotype/phenotype relationships and of epigenetic factors, allowing the generation of personalized therapies to prevent chronic disease or to slow its progression. Recognition that the so-called “silent” regions of DNA were part of the complex control mechanisms during human development led to earlier interventions in developmental and certain neurodegenerative disorders including Parkinson’s and Multiple Sclerosis. By collecting a person’s genetic code, zip code, and everything in between, these systems offered the capacity to predict when people were likely to get major disease and to die, what level of health status they could achieve along the way, and what achieving this health status would require. Thus the individual “big data” clouds could be aggregated into community health status reports with indices to compare individuals and communities across the country.
Personal avatars (digital health coaches) helped people recognize and leverage the extent to which their health was shaped by social, psychological, and behavioral factors. This reduced the reliance on heroic medical procedures and pointed to many new opportunities to improve health and wellbeing. Clinical testing could commonly be conducted on computers or via in silica simulations. Thus, clinical trials on actual patients were primarily used to confirm what had already been observed in the simulations, which markedly reduced the time and cost for developing new drugs and therapies. Patients played an assertive role in stimulating and using these innovations. What had started decades before on sites like PatientsLikeMe.com by 2032 had become large-scale public engagement with what had previously been elite scientific domains and the esoteric knowledge of the few. SNPsLikeMe.org became one of the most popular social networks, allowing people to organize around similar genetic profiles.
Most cancers were effectively preempted and managed by 2030. In 2026, the world had cheered when a consortium of businesses, NGOs, and government scientists announced a cure for Alzheimer’s. People whose physical disabilities once placed them in care homes could be seen walking along the streets of America because of robotic walking aids. Former Type I and II diabetics now faced happier and longer lives due to the ability to grow and transplant pancreatic islet cells from pluripotent stem cells.
These advances prompted a somewhat paradoxical transformation of health care delivery during the 2020s. In 2018, a tax had been placed on all medical care expenditures to support public health. Governments recognized that expenditures in other policy areas led to more health gains than expenditures on health care. The tax on health care enables public health to play its health protection, inspection, and health advocacy roles. Health care adjusted its focus as primary care evolved from the Patient-Centered Medical Home to the Community-Centered Health Home (CCHH). These homes deploy broader primary care teams that coordinate care for the individual while they analyze community conditions and health patterns and work with their communities on improving community conditions. Healthier communities, more effective personal health care, and more sophisticated self-care decreased the demand for physician services and hospital care. And the continuous pursuit of the Triple Aim (better care, lower per-capita cost, and improved population health) by health care providers, as well as effective cost reductions by large (and in many states single) payers, led to a reduction in health care spending to 15 percent of GDP by 2032.
In the eyes of many, the revolutionary transformation in both health and health care in the decades leading to 2032 was inevitable given the rapid diffusion of knowledge to an engaged population with a deeply held aspiration to be healthy. In 2032, most Americans feel a shared responsibility for the health of all, and participate in the formulation of health policy and the expansion of health knowledge.