In many communities across the U.S., poverty is a depressingly reliable indicator of health outcomes and health system performance, in part because access to care tends to be more limited in impoverished areas while socioeconomic challenges associated with poor health—low education levels, homelessness, and mental illness—abound. But there are some fascinating exceptions to this general rule, as The Commonwealth Fund’s 2012 Scorecard on Local Health System Performance revealed.

Among them are communities with significant poverty that nonetheless perform in the top tier on a composite measure of health care access, quality, efficiency, and outcomes. Our goal was to explore—to the extent possible from qualitative research—what might be contributing to their performance. We interviewed local business leaders, insurance company executives, health care providers, and the heads of community-based organizations and philanthropies.

In gathering insights on these three communities, all notably different in terms of demographics, historical legacies, and local culture, we saw several patterns emerge. Some of the most important may seem obvious, like the fact that community leaders in each area set ambitious goals for improving population health and health system efficiency and viewed achieving those goals as key to revitalizing their local economies and attracting new residents, as well as new businesses. For example, in 2003, the mayor of Tucson declared his intention of making the city the healthiest in the U.S.

Community leaders also placed high value on social capital and social ties, and relied on the latter to bring providers, payers, and community organizations, among many others, together. Many said that this collaboration (one called it “coopetition”) was a prerequisite for change as no individual effort by payers, providers, or patients would be strong enough to overcome the perverse incentives and fragmentation of services that contribute to the dysfunction of U.S. health care.

A commitment to careful stewardship of health care resources was another common theme, likely contributing to below-average health care spending in all three regions. This may be a function of conservative social or medical culture as well as the smaller size of the communities; each has barely more than 1 million residents, making it easier for local leaders to interact and hold one another accountable for upholding community values. The most striking example of this was in Grand Rapids, where employers and other community leaders came to the conclusion that building and sustaining world-class health care facilities would require reining in spending on inappropriate and duplicative care.

These communities also placed a heavy emphasis on identifying and addressing the needs of the underserved, reflecting both a sense of social responsibility and a pragmatic awareness that this could lead to savings downstream. Among the populations they targeted for better care were substance abusers and the mentally ill, women at high risk for adverse birth outcomes, and frequent emergency department users, including patients with significant dental problems who lacked access to dentists. In Tucson, funding for two state-of-the-art behavioral health centers came from local voters who approved bond initiatives.

Local and national foundations and state and federal government grants were other key sources of funding in these areas. This money has been used to foster collaboration and build capacity for improvement, which local leaders hope will be sustained over time. Among many diverse programs there was a focus on training lay health educators or hiring community health workers to find and assist residents who could benefit from health coaching and better chronic disease management, two strategies proven to reduce poor health outcomes and associated health care spending.

These and other findings are described more fully in the accompanying case studies, but we would be remiss if we didn’t highlight two additional themes.

1. Payment models: in each of these communities managed care contracting and performance incentive programs were common, providing significant support for primary care physicians to adopt best practices and improve the quality of care.


2. Each displayed an openness to innovation involving social change, which put them at the forefront of the nation in introducing models of care that change the way patients interact with the health system.