2012–2020

In 2012, the focus of the health care discussion is on the Affordable Care Act (ACA), on which the Supreme Court has yet to rule as of the time of this scenario’s writing.

Given this major uncertainty, we have included two different Supreme Court rulings as variants A and B of this “expectable” scenario.

However, given the movement in other areas related to health and health care, we see these two variants converging later in the 2010s, suggesting that the fate of the ACA is less significant than other factors in shaping what health and health care will look like in the year 2032.


2020–2032

After 2020, the health gains from prevention became clearer; study after study showed that communities could succeed and flourish by developing environments that support health while reducing health care spending. With zettabytes of data from personal health records and community health projects, researchers showed that increasing population health could reduce the costs of care. Encouraged by these findings, communities shifted their focus from federal and state initiatives to local efforts that exemplified “health in all” policies and created conditions for health at the community level. Strikingly, those communities that paid the most attention to social health and equity had better outcomes than similar communities that focused more narrowly on physical, nutritional, and medical health. The most successful community efforts addressed all of the health domains, including environmental, behavioral, psychological, and spiritual forms of wellbeing. ACOs partnered with these community efforts, and drew from the experiences and shared learnings to continuously guide improvements in their own services and coordination.

By 2025, prevention had taken off. Fiscal pressures on the government and on employers led to new ways to contain cost by keeping people out of hospitals and away from doctors, which created a high-growth market for innovative companies launching products and services to improve health and avoid disease. People reflected on their risk behaviors and changed them with the help of personalized health informatics, games, and digital agents that drew on the clouds of health data surrounding individual patients. These clouds integrated data from new molecular diagnostics that identified biomarkers of pre-disease. Systems biology articulated how molecular disease processes affect different organs. Thus health care and supporting technologies were able to target and motivate individuals to manage and in some cases reverse pre-disease conditions. The focus on health in communities further reinforced healthy behaviors that became specifically focused on indicators of molecular, cellular, and organ-level health.

New treatments were also developed for expensive diseases like Alzheimer’s and many cancers. An emerging science that used genomics, proteomics, and metabolomics to identify the pathways that diseases take at the cellular and organ levels has provided some fully decisive cures and a host of therapies to slow disease processes. This has greatly reduced the anticipated burden of an aging population by delaying the onset and slowing the progression of chronic disease and enabling better treatment at lower cost. Digital technologies such as virtual models and simulations, social networks where patients share health data and advocate for new treatments, and surveillance systems that continuously monitor treatment safety and efficacy have enhanced this learning and have accelerated the dissemination of innovations.

At the same time, a series of disruptive innovations created opportunities for health and health care outside the formal health care system. These included individual genome mapping for under $100, biomonitoring devices that interfaced with smart phones and health records, and natural language ontologies that helped consumers directly access the best in medical knowledge. Digital health coaches integrated this knowledge and interpreted it for individuals. While most integrated systems were willing to pay for the value these technologies offered, and provided their own branded digital health coach to their members, many consumers who were not in integrated systems paid out-of-pocket for these services, which they saw as quality-of-life enhancements. Although insurance companies continued to pool risk as they had done in the past, the growing personalized understanding of health raised public debates about personal responsibility and fairness. People asked if they really should have to pay more for insurance because of another person's health behavior choices, or because of their own genetic predispositions for diseases. The questions put new social pressure on people to take care of themselves.

Also, as politics became less divisive in the 2020s, leaders at the state and national levels found common ground in the broader application of payment systems that incentivized the coordination of care through bundled payments linked to health outcomes. Tax exemption for health insurance was eliminated. Integrated health systems grew in their ability to transform care so it was safer and better coordinated. Providers had been receiving global payments from Medicare, Medicaid, and employer-based insurance for each patient with exquisitely tuned risk adjustments based on data available on every individual in the plan. In the late 2020s, most plans shifted from actuarially-based insurance to budgets and payments personalized based on predictions of individual health outcomes.

Looking back, the shift to a focus on the social determinants of health in the 2020s made the greatest difference for health. Politicians now find it popular to promote programs addressing factors like housing, employment, and community resilience, which demonstration projects had shown can significantly improve health and reduce the local cost of health care. Mayors love nothing better than to pose in photos of earlier “hotspots” of ill health that have become health exemplars. Public health officials often use an “adaptive trial” methodology to allocate new resources to interventions, and political leaders tout the results. Subpopulations that once took the lion’s share of Medicare and Medicaid spending have begun receiving targeted services that prevent hospitalizations and thus reduce costs. The positive effect on government deficits has earned bipartisan support for these measures in 2032.