The most significant discussion of health care reform in the United States in nearly two decades has reached a critical stage with the focus of attention on expanding access to care while at the same time reducing costs and improving outcomes. Ensuring access to care through workable, comprehensive insurance reforms is indeed a worthy goal. But lost in the policy discussion is how best to improve the overall health of Americans.[IMGCAP(1)]If the U.S wants to achieve the health indicators of other nations, we need to have an honest discussion about what would get us there. As a nation, we spend far more of our gross domestic product (16 percent) on health care than any other country. Yet we lag far behind in health outcomes. Why?Let’s start with that data from the Organization for Economic Cooperation and Development. International comparisons of developed nations show that the next-highest investment in health care is by Norway, which devotes 9.1 percent of its GDP once all payers are considered. In real U.S. dollars, that’s less than $5,000 per person, per year. Hardly a bargain, but consider what they get for that spending: Better life expectancy at birth, lower infant mortality, lower obesity rates. But is it Norway’s health care spending and what it buys that leads to better health? Obesity has a stronger link to education than it does to health care spending. If education affects health status, what about other factors? Accounting for such spending yields a very different picture of return on investment by nation; when other public spending is added to health care spending, the U.S. investment in building health falls far below that of Norway and other OECD countries. The same variations can be seen within the U.S.America is far more heterogeneous than most other developed nations, which also plays a role in health and health care. Significant variations in Medicare spending exist per capita by state, particularly at the end of life. But these simple comparisons hide the variations in total health spending and social factors across American communities.Poverty, which greatly increases the chance of illness, plays an important role in these variations. According to the Census Bureau, 13 percent of Americans (children and adults) live in poverty. In Louisiana and Mississippi, where poverty rates are 19 percent and 21 percent respectively, both states spend less on health care per capita than the U.S. average, while spending more on Medicare beneficiaries than the U.S. average of $7,439. Why is it then that the health of citizens in these two state lags far behind the nation as a whole? Could it be that once given health insurance and other benefits — by way of reaching the dual entitlements of Medicare and Social Security — when they turn 65 years of age, Louisianans and Mississippians must eventually pay a heavier price for a lifetime of neglected health needs?In Texas, 16 percent of the population lives in poverty, and per capita health care spending is far below the U.S. average ($4,601 vs. $5,283). Yet Medicare per capita spending in Texas is far greater ($8,292) than the U.S. average.Babies in all three states have among the lowest life expectancy at birth — not because of what’s invested at the age of 65 and beyond, but rather because of what is not invested in children and young adults all of their lives. States that have low poverty rates and relatively stable investments in health care throughout the lifetime of their citizens often show a very different picture. Vermont, smaller and far less diverse than its southern counterparts, has a poverty rate of 10 percent and spends about $6,000 a year on all patients, including Medicare beneficiaries. Consider again how all of this matches up against the comparisons to other developed nations. On average, child poverty in OECD nations is 13 percent compared with more than 21 percent in the U.S. (and 5 percent in Norway). In single-parent households in the U.S., child poverty rates come close to 50 percent. While most discussions in the current debate have focused on the cost of clinical care, insurance rates and primary vs. specialty care, we may be missing the bigger picture. Consider the classic epidemiologic example of matches and lung cancer. People who carry matches are far more likely to develop lung cancer than those who don’t. Similarly, nations with mechanisms to ensure access to health care have better health status. However, in both cases, elements may be necessary but not sufficient to lead to the conclusions in question. None of this argues against reducing waste, expanding insurance coverage or building a system with more primary care providers, all of which are characteristics of healthier nations. What it does indicate is the fallacy of looking at Medicare data as a proxy for health and the importance of a sustained investment in health throughout one’s life, not just beginning at age 65 to improve health outcomes. Whether looking within the U.S. or across OECD countries, the focus of our discussion must go beyond the narrow focus of health care spending in the last decades of life and more closely examine the relationship of health status indicators against investments in health over the lifetimes of individuals. If “reform— ignores these facts, and we only improve access and reduce costs, we are likely to look back in another 20 years and wonder why our nation hasn’t become healthier.Atul Grover is chief advocacy officer for the Association of American Medical Colleges. Michael Johns is chancellor at Emory University.