With more than 350 days of sunshine per year and temperate winters, the desert oasis that encompasses Tucson, Arizona, benefits from so-called "place luck." But that luck has his limits. With a fast-growing population and an economy dominated by many low-wage service-sector jobs, greater Tucson had the sixth-highest poverty rate among large U.S. metropolitan areas in 2011. Among other challenges, the rate of substance abuse is high, which many say is a byproduct of drug trafficking from Mexico.

Tucson began tackling its population health challenges in earnest in 2003, when the city's then-mayor, Robert E. Walkup, took on a challenge from U.S. Surgeon General Richard Carmona, M.D., to make the community a model of a healthy metropolis. What followed was the Healthy Tucson Initiative, which led to ongoing community collaborations that have engaged local businesses, schools, nonprofits, health systems, and public agencies in initiatives and policies to focus public attention and engage residents in healthy lifestyles, improve their emotional health, and prevent substance abuse and violence.

A symbol of the community's commitment to health is the ongoing construction of a 131-mile recreational trail known as the Loop that offers opportunities for exercise as well as a means of spurring economic development. "This kind of investment in terms of infrastructure for physical activity has been part of why we've been able to do some significant things despite the fact that we are a relatively poor community in comparison with some other jurisdictions," says Francisco A. R. Garcia, M.D., director of Pima County Health Department.

Francisco A. R. Garcia, M.D., director of the Pima County Health Department.

Providers have also played a significant role in health system improvement by pursuing innovative models of care. This may be a function of the historical dominance of managed care in the area. (Arizona was the last state to join the Medicaid program but the first to require that beneficiaries enroll in managed care plans.) Providers' experience with managed care appears to have encouraged a conservative practice style as well as programs to prevent unnecessary hospitalizations and improve coordination of care. Today, they are refining their approach to managed care to build accountable care systems using data and analytics that were not available in the 1990s.