The celebration of a new year marks an opportunity to reflect on the past and look forward to the future. At the Commonwealth Fund, we take stock of what we observed, what we learned, and how we impacted health policy, practice, and leadership development. In 2024, as always, we worked to fulfill our mission of promoting a high-performing, equitable health care system for everyone.
It is clear that 2024 provided much to reflect on, and three themes really rose to the surface. A common thread among these themes is the need for courage — courage to implement commonsense and well-known solutions to pressing and longstanding problems; courage to challenge the deeply entrenched interests that preference the status quo to change; and courage to hold ourselves accountable to produce better health outcomes.
First, health care in this country is increasingly prioritizing revenue and profits over patients —and people are angry. Most notably, the UnitedHealthcare tragedy led to a torrent of public outrage and frustration about the business-as-usual practices of health insurers that can result in delayed or denied care, with financial and, sometimes, life-and-death consequences.
But we saw the profit motive play out in other ways: there was the collapse of Steward Health Care, the nation’s largest for-profit hospital system. This event — a quintessential case study of private equity’s extraction of financial value at the expense of quality, safety, and patient care — destabilized the care of patients in multiple states and drew the ire of state leaders, and even a bipartisan coalition of congressional leaders.
Furthermore, evidence continues to mount that consolidation of large health systems doesn’t yield improvements in quality, safety, or control of costs. At the same time, health care providers, in unprecedented fashion, are organizing and unionizing as a counterweight to what they feel has been a move to prioritize the business of health care over the importance of patient care. Given the power of these forces, it will take courage, from many stakeholders, to turn this tide.
Second, people — even many people who have health insurance — can’t get the care they need because of costs or because they simply do not have access to the providers they need in their communities. Despite more people having health care coverage than ever before, our research found that nearly a quarter of working-age adults had insurance but were underinsured — that is, enrolled in health plans with high out-of-pocket costs that make it difficult to afford care. We see people skipping needed care, avoiding specialist visits, not filling their prescribed medications, and making heartbreaking choices between needed treatments and necessities like food or rent. At the end of this chain reaction are poorer health outcomes that are completely preventable.
Strengthening the Affordable Care Act will be critical going forward, and a real reckoning and repair of employer-sponsored insurance — which provides coverage to 172 million Americans — is necessary. Our National Task Force on the Future Role of Employers in the U.S. Health System, an expert group that has been meeting for more than a year, will soon weigh in with recommendations. But again, courage will be required if we are to see real change.
And third, here in the United States we spend the most — far more than other developed countries — but somehow have the least to show for it. We have lower life expectancy, higher infant mortality, more chronic disease and health disparities than counterpart nations across the globe. In addition, we have wide disparities across states in the U.S., in terms of health outcomes, access to care, quality, and equity. Our Mirror, Mirror 2024 report, which compares the performance of the health care systems of 10 countries, demonstrates yet again that the U.S. continues to be in a class by itself — trailing other countries in almost every measure of quality.
Public policy and health policy matter when it comes to health outcomes. This is true not only in our global comparisons but also bears out when we look at our Scorecard on State Health System Performance and our State Health Disparities Report. Commitments to a strong safety net, universal coverage, and quality and equity separate the top from the low performers across the states — in outcomes, access, quality, and equity. Another key differentiator is investment in primary care. Other nations devote 15 percent of their health care spending to primary care, but we commit a paltry 4 percent. It’s little wonder we have poorer health outcomes and a crisis in primary care. These lessons have been in front of our eyes for years, and there is a clear formula for how we can do better as a nation, but we seem to be stuck, needing real courage to change it.
As we look to 2025, we acknowledge these are big problems. Changing course will require following the evidence, looking at other proven models, and ultimately courage from all stakeholders in the health care system: leaders, providers, patients. In the meanwhile, many wonder what the new administration’s health care priorities will be. Will Medicaid remain the program we know today, protecting our most disadvantaged neighbors? How will the growth of Medicare Advantage affect seniors’ access to care? Will there be fundamental changes to — or a dismantling of — the Affordable Care Act?
And then, there are forces at work bigger than the U.S. political system. For one, technological advances, including AI, remote patient monitoring, wearable health technology, and genomics are rapidly changing health care — and hold promise to make it more efficient and effective. But we must address the financing and implementation of these tools — and ensure they are not solely benefiting one group or population at the expense of everyone else. Public health, climate change, behavioral health, and maternal health remain fundamental challenges that will also require our resolute attention.
As the Commonwealth Fund moves into its 107th year, we will be supported by our newly launched values: to be bold and impactful, to center community and common humanity, to anchor equity and integrity in all we do, and to work in a collaborative and joyful environment. And we are strengthened by our Board of Directors. Dr. Margaret Hamburg, an internationally recognized authority in medicine and public health, finished her first year as board chair. We welcome her insights and expertise as we move forward. After 10 years, we bid farewell to board member Dr. Mark Smith. We benefitted greatly from Mark’s knowledge and experience in medicine and philanthropy.
So we say farewell to 2024, and welcome 2025. We’ve had an incredible year of accomplishments to build from, and I remain humbled, honored, and privileged to lead the Fund at this important time. Bolstered by our history, our values, our board, and our incredible team, we are ready to meet this moment, with bold investments, evidence, hard work, heart, and courage. We hope you will stay engaged with us as we remain committed to making the health care system work for everyone.
