Here is the central paradox of American healthcare. We spend nearly twice as much per person as any other developed country. We have the most advanced hospitals, the most innovative drugs, the most sophisticated medical technology on earth. And yet the average American dies younger than the average person in Canada, the UK, Germany, France, Japan, Australia, or a dozen other countries that spend half what we do.
This is not a partisan talking point. It is a documented, consistent, multi-decade finding. And understanding why it is true — really understanding it — leads to conclusions that are uncomfortable for everyone: for the healthcare system, for public health authorities, for policymakers, and for our community directly.
The answer is not what most people expect. And the solution is not primarily more healthcare spending. It is something harder.
Where America Wins and Where It Loses
The life expectancy gap between the US and peer nations has a specific shape. And that shape tells you exactly where the problem is.
Between the ages of 60 and 75, the United States is the best in the world at extending life. If you make it to 65 in America, your odds of living well through your 70s and 80s are better here than anywhere else on Earth. The combination of access, technology, pharmaceutical sophistication, and specialist capacity that defines American medicine produces genuinely superior outcomes in that age window. We have built the best system in the world for extending life when disease is already established. When the house is on fire, American firefighters are the best.
The problem is everything that happens before age 65.
Infant mortality in the US runs two to three times higher than in peer nations. Drug overdose mortality — driven primarily by fentanyl — kills over 100,000 Americans per year, a number with no parallel in any other wealthy country. Homicide rates are approximately seven times higher than in peer countries. And obesity affects roughly 30% of American adults, with all of its downstream consequences — diabetes, heart disease, joint disease, and increasingly, cognitive decline.
These are the forces that drag down our average life expectancy. Not a failure of medical care for people who are already sick. A failure to prevent the conditions that make people sick before age 65 in the first place.
“Somewhere between age 60 and 75, we go from dead last to first. The medical system we’ve created that optimizes for access, quality, sophistication, and technology is actually quite effective at creating longevity from that standpoint.” — Saum Sutaria, CEO, Tenet Health
This Is Not a Healthcare Access Problem
The US today covers the vast majority of its population through some form of health insurance — Medicare, Medicaid (now covering 90 million Americans), ACA marketplace plans, and employer-sponsored coverage. The uninsured rate has never been lower.
The people who are dying younger in America are not primarily dying younger because they lack insurance. They are dying younger because of gun violence, drug overdoses, infant mortality tied to prenatal access and socioeconomic stress, and chronic disease driven by obesity and metabolic dysfunction that starts in childhood and is fully established by middle age. These are not conditions that better insurance coverage would have prevented. They are social, environmental, and behavioral problems that sit upstream of the healthcare system.
The healthcare system can treat the illness once it arrives. It cannot prevent the conditions that generate it. And on those upstream conditions — nutrition, physical activity, substance abuse, violence, prenatal care access in underserved communities — the American public health model has been, by almost any honest accounting, a failure. The same public health apparatus that effectively controlled infectious disease over the 20th century has been unable to bend the chronic disease curve.
That is a hard thing to say. But it is accurate. If we continue to frame the primary problem as healthcare access or drug pricing, we will keep investing in those solutions while the actual drivers of our mortality deficit go unaddressed.
Oregon’s Dirty Secret and Southern Oregon’s Specific Burden
Oregon has a brand problem. The state markets itself — successfully, nationally — as a health-conscious outdoor paradise. Active, sustainable, progressive on public health.
The data does not support that brand. OPB’s analysis of Oregon’s chronic disease burden found that southern Oregonians live shorter lives and have lower quality of life than Willamette Valley residents. Oregon’s obesity rate runs around 30%, compared to 26% in Washington and 24% in California. More than half of Oregon adults are living with some form of chronic disease. Chronic disease costs Oregonians an estimated $8 billion a year. Oregon consistently ranks near the top of western states for smoking, substance use, and high blood pressure.
Southern Oregon is worse than the state average on most of these metrics. We have higher tobacco rates, fewer physicians per capita, lower median household incomes, and a demographic profile that skews older — which means more Medicare-eligible residents, more chronic disease burden, and more demand on a healthcare system already operating at high cost.
The intersection of these factors creates a specific regional economic consequence. Higher chronic disease rates generate higher healthcare utilization. Higher utilization in a market with limited competition — where Asante holds roughly 78% of the regional market share — means costs are set through negotiation rather than competition. Those rates flow to local employers as premium increases. Workers whose employers cannot afford coverage become uninsured or underinsured. They defer preventive care. Their chronic disease worsens. They arrive in emergency departments. That uncompensated care gets absorbed — partially through Asante’s community benefit spending, partially through cost-shifting to commercial rates. And the small business owner’s premium increases again next year.
It is a regional feedback loop running in the wrong direction. Without structural change, it accelerates.
What Actually Works — And It Is Not What Most People Assume
The evidence on what would actually move the outcomes needle in Southern Oregon is reasonably clear. The frustrating answer is that most of it is not primarily the responsibility of the healthcare system.
Nutrition and physical activity. The single largest driver of the US health outcome deficit — relative to peer nations — is the chronic disease burden driven by poor nutrition and physical inactivity. Countries with better outcomes have, in many cases, structured their physical environments differently: more walkable cities, food systems where ultraprocessed products do not dominate by default, cultures of active commuting. Southern Oregon has genuine assets in this regard — trails, parks, outdoor recreation culture, farmers markets. What we lack is a coordinated strategy to connect those assets to the communities with the worst health outcomes. The environmental assets exist. They are not reaching the people who need them most.
Mental health access. Mental health disorders are powerful drivers of chronic disease management failure, substance use, and healthcare cost. Southern Oregon has a chronic shortage of mental health providers. AllCare Health has been working to expand mental health access through value-based payment structures, including efforts to align mental health incentives with primary care. This is the right direction. The gaps remain large.
Prevention-oriented primary care. The most cost-effective moment to intervene in almost every chronic disease is before it becomes established — or very early in its course. Our system is organized around the sick visit: the 15-minute acute encounter, reimbursed for managing an existing problem. It is not designed, financially or logistically, to deliver sustained, longitudinal, prevention-focused care. That requires different payment models, longer visits, and team-based care structures. Asante’s AHNPlus value-based care model for employers is one attempt to build something different locally. Oregon’s CCO structure is another. Neither has yet achieved the scale to meaningfully shift the population’s health trajectory.
The Sustainability Math, One More Time
Healthcare is nearly 20% of GDP and growing at 2% faster than the economy every year. The aging pressure — the peak baby boomer Medicare wave — crests around 2032. After that, the demographic driver begins to ease.
But the chronic disease driver does not ease. Obesity and metabolic disease rates have been climbing for 50 years. Type 2 diabetes has gone from roughly 1% of the population in the early 1970s to 12 to 15% today. GLP-1 drugs may slow that trend — but only if they are accessible to the people who need them at prices the system can sustain. The ratio of economically productive working-age Americans to Medicare beneficiaries is declining toward 1:1.
The goal is not a catastrophic 25% cut to healthcare spending — that would be economically devastating and is not a serious proposal. The goal is to bend the trend: to bring healthcare cost inflation closer to overall GDP growth, instead of consistently running 2% above it. Over 20 years, that difference is the difference between a manageable system and one that is not. Getting there requires simultaneous action on drug pricing reform, administrative simplification, shifting more care to lower-cost settings, and most critically, reducing the chronic disease burden that drives the majority of healthcare utilization.
A Direct Call to Action for Our Region’s Institutions
Reimagine Healthcare is a platform for informed community conversation. But conversation that leads nowhere is just noise. Here is where the evidence points for our region.
- Asante Health System should publish a ten-year chronic disease strategy for Southern Oregon with specific, measurable outcome targets. Not community benefit reporting that documents spending — outcome metrics that track whether chronic disease prevalence is actually declining in the region it dominates. A $1.3 billion health system with A+ credit and 78% regional market share has the resources and the responsibility to lead on this. The community benefit infrastructure exists. The chronic disease strategy does not.
- AllCare Health and Oregon’s CCO system should set and publicly report specific outcome targets for chronic disease prevalence reduction in Jackson, Josephine, Curry, and Douglas counties. The CCO global budget model is one of the most structurally sound frameworks for population health management in the country. What is needed now is public accountability — not process measures, but outcome measures. Did diabetes rates in the covered population go up or down this year?
- Southern Oregon’s business community — the Rogue Valley Chamber, SOREDI, the Southern Oregon Business Alliance — should organize explicitly around healthcare cost as an economic development issue. Every premium increase local employers absorb is, in large part, the consequence of national policy decisions: the 2003 prohibition on Medicare drug price negotiation, the PBM rebate structure, the absence of price competition in the regional market. That is an advocacy agenda with teeth, and regional business organizations have the standing to advance it.
- Local governments and regional planning organizations should integrate health outcomes into land use, transportation, and food access planning. Walkability, food environment, and active recreation access are not soft quality-of-life amenities. They are, on a population basis, among the most cost-effective health interventions available. Jackson County’s health outcomes will partly be determined by planning decisions made in the next five years.
- Oregon’s congressional delegation should hear directly and repeatedly from Southern Oregon constituents on pharmaceutical pricing reform. The Inflation Reduction Act’s partial opening of drug price negotiation is a start. Extending it further is politically possible — if there is organized demand for it.
The machine is running. It has been running for 70 years, built through well-intentioned decisions whose compounding consequences nobody fully anticipated. It is expensive, unequal in its benefits, and on a trajectory that raises serious long-term questions about fiscal sustainability.
None of that is going to be fixed quickly or easily. But it can be understood. It can be engaged. And in a region like ours — where the health system, the employers, the community organizations, and the public institutions are all local enough to know each other, to sit in the same rooms, and to be accountable to the same community — understanding it clearly is the necessary first step toward doing something about it.
That is what reimagining healthcare looks like.
This series was produced by Reimagine Healthcare for educational purposes. It is based on analysis of publicly available research, a conversation between Dr. Peter Attia and Saum Sutaria, and publicly reported data on Southern Oregon’s health system. It is not intended as medical or financial advice.