Winners and Losers: Zero-Sum Thinking, Major Roadblock to Achieving Optimal US Population Health

New Nature Medicine paper details how health inequities harm everyone, counters 4 fallacies of zero-sum health thinking, urges new collective action to advance healthcare reforms

WASHINGTON, Aug. 22, 2025 /PRNewswire/ -- A new paper in Nature Medicine challenges the U.S. to overcome zero-sum health thinking to eliminate health inequities, advance necessary health care reforms and ultimately achieve optimal health for all. In "Overcoming zero-sum thinking to advance U.S. population health" (Vincent Guilamo-Ramos; Marco Thimm-Kaiser; Adam Benzekri; Daniel E. Dawes), the authors pull back the curtain on the zero-sum mindset that defines the current and dominant approach to healthcare policy making in the US, which posits "one person's or group's gain must come at the expense of another's losing," to show how it is bad for everyone's health.

"Both zero-sum thinking and health inequities are characteristic of U.S. healthcare. Today more than ever, we must overcome both, to make everyone healthier. In this new paper, we fundamentally challenge the zero-sum thinking that denies the broader, population-level benefits of eliminating health inequities," stresses lead author Vincent Guilamo-Ramos, PhD, RN, FAAN, Executive Director of the Institute for Policy Solutions (IPS) and Leona B. Carpenter Chair in Health Equity and Social Determinants of Health at Johns Hopkins School of Nursing.

The authors define health inequities as "unjust and preventable differences in the quality or outcomes of healthcare and health policy between segments of the population." Such inequities—for nearly all metrics of healthcare access, health system performance, and population health—are long-standing among ethnically and racially minoritized, socioeconomically disadvantaged, and otherwise marginalized communities.

The new paper:

• Demonstrates how health inequities harm everyone, while highlighting how reducing inequities benefits everyone.  The authors highlight that millions of people still have no choice but to receive care through the most expensive option—their local emergency room or another acute-care setting. This overburdens emergency departments, delays treatment for those in urgent need, and ultimately drives up costs for everyone.
• Identifies and counters 4 common and destructive fallacies in zero-sum health thinking—reflected in controversies about healthcare reform.
• • • Fallacy 1: Collective vs. Individual Responsibility: A common critique of proposed reforms that increase governmental or institutional investments in social care is that they reduce individual responsibility. In reality, individual and population health outcomes are significantly shaped by social, economic, political, and environmental factors beyond individual control; the paper identifies these factors as the social determinants of health (SDOH);
    • Fallacy 2: Eliminating Inequity vs. Reducing Costs: Some claim that investing more to improve outcomes for those in the worst health drives up healthcare costs for everyone. But this is a false choice. In truth, health inequities generate massive economic costs—through excess healthcare spending and lost productivity;
    • Fallacy 3: Winners vs. Losers: Zero-sum thinkers argue that improving outcomes for those in the worst health—so the fallacy goes—diverts resources from everyone else. But in reality, policies like the Affordable Care Act (ACA) show otherwise. While coverage gains were greatest among the most disadvantaged, insurance coverage rates also rose significantly for White Americans and those earning above 400% of the federal poverty level. Moreover, the ACA delivered broad benefits to the entire population—most notably by prohibiting insurers from denying coverage due to pre-existing conditions, a protection that supports the majority of adults, who live with at least one chronic illness;
    • Fallacy 4: Investments in Healthcare vs. Social Welfare: Funding for social welfare programs has long faced resistance—often rooted in zero-sum thinking. Yet, as awareness grows about the profound impact of social determinants of health (SDOH) on population health, so too does recognition of the need to better align the healthcare and social welfare systems. Integrating social and clinical care isn't just clinically necessary—it's economically smart. When these systems work together to meet both clinical and social needs, the result is better health outcomes and significant cost savings across the board.

"A reflection of the current administration's ubiquitous framing of 'winners and losers' in policymaking, zero-sum thinking and rhetoric is in danger of undermining current policy debates and health policies, including cuts to Medicaid, major public health initiatives, even at the Centers for Disease Control and Prevention and National Institutes of Health. Basing policy decisions on a framework of winners and losers will increase health inequities among marginalized communities but also hurt everyone else. Meanwhile, the deep-rooted challenges of the healthcare system, such as prioritizing diagnosis and treatment over prevention and health promotion, or misaligned payment and incentive structures, remain unaddressed," Guilamo-Ramos said. "Now more than ever, we must break free from the zero-sum mindset that stands in the way of real reform. The stakes are too high—health inequities are widening, costs are soaring, and population health is stagnating. If we truly want optimal health for all, we must abandon outdated thinking and invest in solutions that eliminate inequities, improve outcomes, and drive down healthcare spending."

Nature Medicine paper will be available here at 5AM ET August 22, 2025 

Note to editors: For more information about IPS, please go to www.ipsnow.org.

SOURCE The Institute for Policy Solutions at Johns Hopkins School of Nursing