If the quality of health care was the only major determining factor of health outcomes, then the healthiest cities in the United States would simply be those with the best health care facilities. Recent national rankings of city health status based on composite measures of health care access, food environment, physical activity, and built infrastructure reveal a different reality. The cities that perform best are those where health is structurally supported, while the lowest-ranking cities face overlapping deficits that extend far beyond clinical care. The implications are significant; modern medicine is operating downstream of the most powerful drivers of health.
A clinical reality that the data is now confirming
Consider a common scenario: A middle-aged patient with poorly controlled diabetes presents for follow-up. Medications have been optimized. Education has been reinforced. Yet glycemic control remains suboptimal. On further discussion, it becomes clear that the patient lives in a community with limited access to fresh food, relies on inexpensive processed meals, and has no safe or accessible space for regular physical activity.
From a clinical standpoint, the treatment plan is sound; but from a population health perspective, it is incomplete. This disconnect, long observed in practice, is reflected at scale in national data.
The structural pattern behind city-level health disparities
Across U.S. cities, clear patterns are emerging. Higher-ranking cities consistently demonstrate the following:
- greater access to healthy food options
- higher levels of physical activity
- more walkable environments
- increased availability of green space
In contrast, lower-ranking cities are characterized by
- limited access to nutritious food
- reduced opportunities for physical activity
- socioeconomic constraints
- under-developed infrastructure
These findings align closely with the framework of social determinants of health, defined by the Center for Disease Control (CDC) as the non-medical conditions in which people are born, grow, live, work and age, that influence their health outcomes. The CDC emphasizes that these factors exert a substantial influence on health outcomes, often exceeding that of clinical care.
Health care is not the primary differentiator
One of the most important insights from the data is that health care access alone does not explain variation in health outcomes. Some higher-ranking cities do not lead in health care metrics alone, yet perform well overall due to stronger environmental and behavioral support. Conversely, cities with reasonable access to care may still rank poorly when social and environmental conditions are unfavorable.
A couple insights can be derived from this reality. It suggests that
- health care functions as a necessary but insufficient condition for population health, and
- upstream factors determine baseline risk before clinical intervention occurs
For health care systems, this has direct implications for performance under value-based care models where outcomes are increasingly tied to factors outside traditional clinical control.
Implications for clinical practice and health systems
The persistence of these patterns highlights a structural misalignment between health care delivery and health outcomes. Clinicians are trained to manage disease at the individual level; however, the data demonstrate that disease risk is often established at the community level. This creates a recurring cycle. I refer to it as the Community Risk-Clinical Care Cycle. This occurs when
- environmental conditions increase baseline risk
- clinical care attempts to mitigate that risk
- patients return to the same environment
- disease progression continues
Without addressing upstream drivers, this cycle is difficult to break. For health systems, this translates into higher chronic disease burden, increased health system utilization, elevated readmission rates and persistent cost pressures.
Reframing the role of health care
The findings call for a broader conceptualization of the role of health care. Rather than viewing health care systems solely as providers of care, there is a growing need to position them as participants in health creation alongside sectors such as urban planning, food systems, and public policy.
Practical implications include integrating social risk factors into routine clinical assessments to better capture upstream drivers of disease, leveraging geospatial data to identify and prioritize high-risk communities for targeted interventions, and developing cross-sector partnerships that address critical needs such as food access and preventive infrastructure to improve long-term health outcomes.
Advances in data analytics and artificial intelligence (AI) further enable the incorporation of non-clinical variables such as environment and access, into predictive models. This creates opportunities for more targeted and effective interventions at both the individual and population levels.
A systems-level challenge
Importantly, these disparities should not be interpreted as failures of individual behavior, as they reflect system-level conditions that shape available choices. The reality is that patients do not choose food deserts, they do not design transportation systems, and they do not control the availability of safe recreational spaces. As such, improving health outcomes requires interventions that extend beyond the health care system itself.
Conclusion
The variation in health across U.S. cities underscore a fundamental reality that health outcomes are largely determined before patients enter the health care system. For clinicians and health system leaders, this necessitates a shift in focus from optimizing care delivery only, to understanding and addressing the broader conditions that drive disease. Pending that shift, health care will remain highly effective at treating illness, but limited in its ability to reduce disease incidence.
Jalene Jacob is a physician-entrepreneur.
