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Policy Points    Interventions in a regional system with intertwined threats and costs should address those threats that have the strongest, quickest, and most pervasive cross‐impacts.  Instead of focusing on an individual county's apparent shortcomings, a regional intervention portfolio can yield greater results when it is designed to counter those systemic threats, especially poverty and inadequate social support, that most undermine health and well‐being virtually everywhere.  Likewise, efforts to reduce smoking, addiction, and violent crime and to improve routine care, health insurance, and youth education are important for most counties to unlock both short‐ and long‐term potential.Context  Counties across the United States must contend with multiple, intertwined threats and costs that defy simple solutions. Decision makers face the necessary but difficult task of prioritizing those interventions with the greatest potential to produce equitable health and well‐being.    Methods  Using County Health Rankings data for a predefined peer group of 39 urban US counties, we performed statistical regressions to identify 37 cross‐impacts among 15 threats to health and well‐being. Adding appropriate time delays, we then developed a dynamic model of these cross‐impacts and simulated each of the counties over 20 years to assess the likely impact of 12 potential interventions—individually and in a combined portfolio—for three outcomes: (1) years of potential life lost, (2) fraction of adults in fair or poor health, and (3) total spending on urgent services.    Findings  The combined portfolio yielded improvements by year 20 that are considerably greater than those at year 5, indicating that the time delays have a major effect. Despite the wide variation in threat levels across counties, the list of top‐ranked interventions is strikingly similar. Poverty reduction and social support were the most highly ranked interventions, even in the shorter term, for all outcomes in all counties. Interventions affecting smoking, addiction, routine care, health insurance, violent crime, and youth education also were important contributors to some outcomes.    Conclusions  To safeguard health and well‐being in a system dominated by tangled threats and costs, the most important priorities for a county cannot be simply inferred from a profile of its relative strengths and weaknesses. Two interventions stood out as the top priorities for almost all the counties in this study, and six others also were important contributors. Interventions directed toward these priority areas are likely to yield the greatest impact, irrespective of the county's specifics. A significant concentration of resources in a regional portfolio therefore ought to go to these strongest contributors for equitable health and well‐being.

the milbank quarterly

Which Priorities for Health and Well‐Being Stand Out After Accounting for Tangled Threats and Costs? Simulating Potential Intervention Portfolios in Large Urban Counties