In a small town, Sarah, a single mother of two, struggles to access reliable health care through her local community health center. Limited resources and long wait times leave her feeling frustrated and helpless.

Meanwhile, in a large city, David, a father of three and a Medicaid recipient, faces similar challenges. Despite living near top hospitals, he encounters long wait times, difficulties finding providers, and limited access to specialists.

Though Sarah and David live in different settings, their experiences highlight a common issue: skepticism around the phrase "all health care is local."

For communities to be healthy, there’s no choice but for health care to be local.

However, when access is compromised, health care is no longer effectively local—even if care facilities are geographically nearby. This disconnect is seen in the experiences of individuals like Sarah and David.

There are two key points I want to make by the end of this article. 

First, a community needs the ability to respond to health care needs in a way that enables healthy local market dynamics and regulations for accessible and affordable health care.

Second, I argue that it's not enough to focus solely on local health care; we must prioritize local population health.

The Push Back Against Health Care Being Local

Let me first address the claims you may have heard—that health care is no longer truly local. Several key factors contribute to this perception, including the rise of telehealth, price transparency, the appeal of destination hubs, and broader systemic challenges.

Each of these points has merit and reflects significant trends in the health care landscape.

I've broken it down into three key points below.

1. Telehealth

Claim: The growing demand for cost-effective and convenient health care has fueled a rapid rise in virtual care, with many patients turning to telehealth services for their accessibility and potential cost savings.

My view: I agree that telehealth is here to stay. However, despite its growth, most patients still prefer in-person visits with health care providers at least some of the time.

A 2023 study of 1,226 participants found that 71% favored face-to-face appointments, compared to 29% who preferred virtual care.

This preference is consistent even among Gen Z. Research by Springbank Collective and Able Partners shows that Gen Z "actually prefers convenient in-person health care within the four walls of brick-and-mortar clinics."

Additionally, as more telehealth companies evolve, integrating in-person visits is becoming a critical part of the patient journey.

I also think there's something valuable about connecting with clinicians and staff who live within your community. Loneliness is a significant challenge, and having local, personal connections can make a difference.

2. Destination Hubs and Specialized Care

Claim: The perception that health care isn’t local is partly due to the growing trend of patients seeking specialized care in destination hubs, often far from their immediate communities.

The reputation of renowned specialists and cutting-edge technology can overshadow local options, reinforcing the idea that comprehensive care isn't available nearby. This trend is exacerbated by rising medical debt, prompting patients to explore more affordable out-of-market options.

My view: There is definitely validity to this claim. Especially with highly specialized conditions, destination hospitals can offer a level of care that local general hospitals cannot match, potentially at more affordable prices. As highlighted in the book The Innovator’s Prescription, specialized care centers have a competitive edge, leaner and can be hyper-focused.

3. Affordability

Claim: As medical costs rise, many consumers face significant financial burdens, prompting them to seek lower-cost alternatives outside their local health care systems. The prevalence of medical debt forces patients to prioritize affordability over proximity, contributing to the perception that local health care is inadequate.

My view: The current health care system often doesn’t function as it should.

However, I don’t agree with the notion that patients are always in a position to be conscious consumers. While potential opportunities exist to compare prices and quality for elective procedures, it’s unrealistic to expect this in urgent situations. For example, if someone needs an emergency appendectomy, they can’t “shop around” for the best deal.

Patients should have access to local health care without fearing that a procedure down the street—or across the state—might cost significantly less.

The solution isn’t to ask patients to navigate a convoluted system; it’s to ensure the system works for us as patients.

A Path Forward For Health Care

For health care the real issue lies in the complex financial models that dominate our health care system and its fragmented structure. Fundamentally, these systems often prioritize profit and revenue generation over patient well-being, focusing on treatment rather than prevention.

To achieve both affordability and accessibility in health care, we must first address these underlying problems.

A key driver is that provider consolidation leads to higher health care prices, as payers lose leverage to negotiate favorable rates. As a result, patients bear the financial burden through increased premiums and out-of-pocket costs.

To address this, we need stronger measures to prevent large health care mergers and to support independent providers.

Current regulations, such as Certificate of Need (CON) laws, the Stark Law, and restrictions on physician-owned hospitals (POHs), protect incumbent providers and stifle competition. CON laws limit new facilities, allowing existing providers to block competitors, raising prices without improving care.

The Stark Law, while preventing self-referrals, favors large systems over independent practices. The ACA's ban on new POHs reduces competition and raises costs.

These regulations, driven by regulatory capture, benefit established providers at the expense of patients and innovation. Repealing or reforming them could lower health care costs and improve access.

On a similar note, we see comparable trends with Pharmacy Benefit Managers (PBMs), which have been criticized for their lack of transparency, potential conflicts of interest, and their role in driving up drug prices and limiting patient access to necessary medications through restrictive formulary practices.

Additionally, the growing trend of Direct Primary Care (DPC) offers a promising alternative to traditional models. DPC allows patients to pay a monthly fee directly to their primary care provider, enhancing personalized care and reducing administrative burdens.

This model can improve patient satisfaction and potential health outcomes by allowing providers to focus on preventive care without the constraints of insurance billing.

Shifting our focus briefly to value-based care (VBC), I believe it represents a positive step forward; however, substantial barriers persist, including the foundational issue of excessively high health care prices and administrative inefficiencies.

I’ll delve deeper into these challenges in a future article, but I’m currently less optimistic about VBC compared to the initiatives mentioned earlier in this section and the upcoming section.

As I conclude this section, I want to express my skepticism that market dynamics alone will adequately reduce health care costs in a meaningful way. I believe we also need regulations to control for greed.

Thinking at the Population-Level for Community Health

Local health systems should partner with community-based organizations (CBOs) to implement programs that address the social drivers of health, particularly for high-cost Medicaid and Medicare patients.

Take, for example, the case of high-cost patients, especially those experiencing homelessness. These individuals often turn to emergency departments for a wide range of issues because they lack access to alternative care options.

Although CBOs provide substantial benefits, their impact can sometimes feel ephemeral.

While Medicaid and Medicare can and should be enhanced to support interventions addressing the social drivers of health, significant improvements can also be achieved through population health initiatives in local communities.

I’d like to discuss where individuals are in their health journeys, referencing Maslow’s Hierarchy of Needs. This framework is important because 80% of health outcomes are influenced by social drivers of health.

When individuals are at the “Basic Needs” level, they struggle to maintain their health and often cannot travel long distances for care or shop around for services. This is not a niche problem; the Medicaid and uninsured populations total around over 100 million Americans—about a third of the country.

The majority of these Americans are lower-income, and as economic inequality continues to rise, it’s crucial to address these systemic issues. However, these social needs should not fall solely on the health care system. We don’t want to turn Medicaid into "medicalized poverty."

And addressing social drivers of health isn't just about targeted interventions; it's about broader, community-wide changes that affect the overall health of the population, even when access to health care is available.

And broadly speaking, are we misunderstanding the social drivers of health by focusing too heavily on individual solutions rather than addressing systemic, population-level issues?

While increasing, for example, financial security for certain individuals can be beneficial, does it truly address deeper, more complex problems like poor education, unsafe neighborhoods, or the daily encounters with racism?

These challenges aren’t simply personal failings; rather, they often reflect broader policy failures.

Shouldn't we approach social drivers of health with a more comprehensive, sociological perspective? How can we ensure Americans have not only financial security but also access to education that includes practical skills like budgeting, meal planning, and navigating essential services? 

This is the heart of public health. These efforts reflect the core responsibilities of Local Health Departments.

Now, from a health care perspective, part of what I’m getting at here is that chronic diseases, when they are preventable, cause significantly higher costs for our health care system.

Personal responsibility is certainly important—eating better and being more active are essential steps. However, relying solely on these individual choices, even with well-meaning public health campaigns, is not enough to create lasting change.

It’s superficial.

The real issue lies in the environments that shape our decisions. Without transforming the physical spaces, food options, and social settings where people live, those healthier choices remain out of reach for many.

Why?

Because the environments around us—our neighborhoods, stores, and restaurants—still promote unhealthy behaviors. People will naturally choose what's accessible, and right now, what's available is often not what's best.

By offering these opportunities within our local communities, we can make a significant impact on health outcomes and reduce future health care costs. Investing in preventive measures at the community level will lead to healthier populations.

Population Health Value-Based Care

Housing should be accessible to all, not just because it may lead to better health outcomes, but because it is a fundamental right that every American deserves.

And as mentioned earlier, value-based care (VBC) in health care has its limitations, particularly in a non-single-payer system where we are currently unable to capture true long-term savings effectively.

What if, instead of focusing solely on VBC in health care, we adopted a value-based population health model for each county?

For example, a chronically homeless person costs the taxpayer an average of $35,578 per year. This study shows how costs on average are reduced by 49.5% when they are placed in supportive housing. Supportive housing costs on average $12,800, making the net savings roughly $4,800 per year.

This is something I’ll be reflecting on more, and I would love to hear your thoughts if you have any.

Conclusion

For communities to be healthy, health care must be local, with a focus on affordability and accessibility.

The federal government must acknowledge that unchecked greed in the American health care system harms Americans. In conjunction, healthy communities require fundamental tenets such as affordable housing, fair wages, and access to nutritious food.

Unfortunately, local health systems often profit when more patients get sick. Making this is not solely about changing health care to be more aligned with social drivers of health; it’s about incentivizing local governments to make it much easier to be healthy in this country.

Ultimately, health care in America should be a right, not a privilege. Patients should not have to navigate a complicated system; rather, the system should intrinsically work for us.

I am optimistic we can get there.