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This paper looks how health systems can go beyond clinical care to address the social determinants of health and considers why this approach might be particularly relevant for Accountable Care Organizations (ACOs) touted by the Affordable Care Act. ACOs make profits by reducing the medical expenses of patient populations. The leading causes of death in the United States are tobacco use, insufficient physical activity, and an unhealthy diet. These risk factors are linked to increased incidence of a wide range of chronic diseases, the treatment of which places a tremendous financial burden on our health care system. Health care delivery and access are just a small part of the solution to our chronic disease crisis. Increasingly, strategies that address the social determinants of health--"the conditions into which people are born, grow, live, work, and age"-- are the ones that hold the most promise. In Massachusetts, Steward Health Care System supports a number of initiatives to address the social determinants of health in its patient population. Steward provides an example of how a hospital system can address the health of its patient population by moving beyond clinical care. The varied initiatives have also resulted in cost savings for the system.

Someone once said that if two people with the same idea get together in America, the result is an ORGANIZATION. Run your finger down the list of names of associations and societies in any almanac or directory and you will find Eagles, Owls, Elks and Moose, Dragons and Druids, National Associations of Manufacturers of everything from abacuses to zithers, but you will find very few groups whose work lies in the protection of the consumer or the advancement of his interests. Consumers in America (120,000,000 of them) are notoriously unorganized. This places them in a tremendously disadvantageous position in a democracy such as ours, where legislation is enacted in response to the demands of articulate groups capable of exerting economic and political pressure where it is most needed. It is estimated that there are well over iooo trade associations ever active in Washington to give force and directness to the opinions and wishes of business. Yet there is probably no economic group in the country which is less adequately represented in the lobbies of our legislatures than the consumers. The passage of the Food and Drugs Act in 19o6 can be attributed to the efforts of certain public-spirited and fearless friends of the consumer such as the late Dr. Wiley and Professor Ladd, and the self-interest of farmer's organizations rather than to any organized activity on the part of consumers. The timely publication of The jungle by Upton Sinclair did much to arouse public opinion, while the lobbies of the American Medical Association and the National Association of State Dairy and Food Departments were fighting the stand-patters in Washington. The crusade of the muckrakers against false and fraudulent advertising left a passing impression upon the public, soon to be forgotten as the great "Ballyhoo Age" descended upon us and muckraking was no longer profitable. In 1927 the apathetic public was again aroused when Your Money's Worth by Stuart Chase and F. J. Schlink described the waste of the consumer's dollar which resulted from his ignorance in purchasing goods in the new jungle of 'competitive advertising and powerful sales pressure, where the skillful * B.S., 1925, College of the City of New York; M.A., 193o, New York University. Instructor in economics in a New York City high school. Assisted in the preparation of a prospective syllabus in Vocational Civics for New York City schools. Now engaged in the preparation of a study of consumption problems and their relation to education, and is collaborating on a new high school economics text emphasizing the development of social control.

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