Aaron E. Carroll, a pediatrician, is president and chief executive of AcademyHealth, a nonpartisan organization that advances evidence-based health policy.
Every few years, American politics rediscovers chronic disease. Leaders point to rising rates of diabetes, heart disease and depression. They say people are sicker because they eat the wrong food, exercise too little and make poor choices. Fix your diet. Avoid the additives. Move more. And if you still get sick, that is on you.
That story is appealing because it’s simple. It flatters the healthy and shames the sick. It also lets policymakers claim they have diagnosed the problem without building anything, paying for anything or changing the health system at all.
Researchers studying how health systems and policy shape health have spent decades showing the story is more complicated.
One major reason more people have long-term conditions today is that they’re living longer. Chronic disease is more common in older adults. As America ages, the number of people with chronic illness will rise even if risk factors stay the same.
An analysis published in Frontiers in Public Health in 2023 projects that Americans over 50 with at least one chronic disease will nearly double by 2050, from about 72 million to 143 million. That projection sounds frightening until you remember what it reflects: More Americans are living long enough to accumulate diagnoses. That’s not a moral failure; it’s demographics.
Age-adjusted heart disease mortality fell 66 percent from 1970 to 2022. Mortality from heart attacks fell 89 percent. Cancer mortality has dropped 34 percent since 1991, averting an estimated 4.8 million deaths. Americans are not falling apart. The challenge is how to help millions of people live well for decades after these advances.
Measurement also matters. When the 2017 blood pressure guideline lowered the threshold for hypertension, the share of adults in the United States classified as hypertensive jumped from about 32 to 46 percent. No one’s arteries changed that day. The definition just changed. When the U.S. switched medical coding systems in 2015, about 1 in 6 diagnostic categories saw immediate shifts of 20 percent or more. When the categories change, the counts can jump. Same bodies. Different buckets.
This does not mean chronic disease isn’t real or that we shouldn’t care. But the leap from “rates are up” to “Americans have failed” is sloppy. Age-adjusted diabetes prevalence among adults rose from 10 percent in 1999-2000 to 14 percent in 2021-2023. That’s not an artifact of aging. It reflects a real shift in how many Americans are getting sick. But these trends aren’t random. They track with income, geography and race: the footprints of systems, not the failures of individuals.
The numbers that should make policymakers most nervous are those related to young adults. An analysis in 2025 by the Centers for Disease Control and Prevention found that among 18- to 34-year-olds, the prevalence of one or more chronic conditions rose 7 percentage points over a decade, with especially big increases in obesity and depression. Better screening doesn’t explain it. What does is the environment young people are coping with: spikes in food and housing costs, a collapse of mental health access and the daily grind of getting by in a system that was not designed with their health in mind.
I work in health services research. I also have ulcerative colitis, and my brother has Crohn’s disease. We were diagnosed while young, active and otherwise doing everything right. Neither of us ate our way into autoimmune illness. When chronic disease becomes a referendum on virtue, it doesn’t just misrepresent the science. It isolates people who are already dealing with hard diagnoses and doing everything they’re supposed to do.
This is where the blame narrative does the most damage. It takes trends shaped by commercial food environments, economic stress and inadequate mental health access, and reduces them to “try harder.” That makes for good speeches, but not good policy.
Blame is cheap. System change costs money and effort.
The U.S. has used the blame strategy for decades while also running the most expensive health system in the world: almost $14,800 per person in 2024, far above the average for nations in the Organization for Economic Cooperation and Development. When it comes to supporting health outside the health care system, though, we’re cheap. The Brookings Institution has noted that OECD countries spend about $1.70 on social services for every dollar on health, while the U.S. spends 56 cents. We invest heavily in medical rescue and lightly in the conditions that make chronic disease more likely.
Diet matters. Smoking still kills. Exercise helps. But when leaders frame chronic disease as a failure of will, they avoid harder questions about how the U.S. pays for care, where people live, which food is marketed to whom, and whether preventive services reach the people who need them. A serious response would mean building a health system that manages chronic illness over decades, not just acute episodes. It would mean investing in housing, food access and mental health care, the factors that determine whether people get sick.
The choice isn’t between personal responsibility and policy. It’s whether the country will keep using one as an excuse to avoid the other.
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