And even as we compensate for services, we pay a lot more for some services — like expensive, high-tech tests and procedures — than for others — like the time it takes a clinician to think, evaluate, come up with a plan, and help a patient follow it.

The healthy housing program we had set up had helped thousands of children and adults like Veronica. We had worked with a community partner to set up a produce stand and resource guide to help families experiencing hunger and food insecurity. A medical-legal partnership we had created shortly after I started at the clinic was blossoming. Thousands

from David M. Lawrence, former chairman and CEO of Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals:

For those interested, a more comprehensive list of policy solutions and opportunities to advance an upstreamist approach can be found at healthbegins.org

Third and finally, it’s urgent that we go beyond utilitarian arguments to continue to stake moral claims for improving access to quality health care for all. Increased efficiency and lower costs, though important, are not the alpha and the omega of health care improvement, and they are still less of a factor in the improvement of health itself. The

Mitch Katz directs the Los Angeles County Department of Health Services, the second-largest county health care system in the country. He described to me how economic incentives can stack up against upstream care. “Because there’s been little money toward prevention, there’s no payer or mechanism for prevention research like there is for medical res

California, for instance, recently launched a Health in All Policies initiative to factor health into a wide swath of state decisions.

As a result of regulatory, cultural, and financial obstacles, doctors and nurses who aspire to be upstreamists on the front lines face challenges in five key areas. To remember these, think of the acronym TRIDNTT (pronounced “trident”): 1. Time and Resources (both human and capital) 2. Incentives (at individual and system levels) 3. Data that’s acc

*For more insight on this type of model, I recommend two articles published in 2010: “A Framework for Public Health Action,” by Thomas R. Frieden, in the American Journal of Public Health, and “A Conceptual Framework for Action on the Social Determinants of Health,” by the World Health Organization.