Leaving a Healthier Legacy

by Shu-Ling Zhao and Kate Behan

Healing the System That’s Supposed to Heal Us

Most people think of healthcare as what happens in the exam room. But for millions of Americans, the most damaging interaction comes afterward—when the bill arrives.

The Better Ancestors in Healthcare initiative is built on a simple idea: medical debt is not just a financial problem. It is a health problem.

Research across nearly 3,000 U.S. counties shows that communities with higher levels of medical debt experience higher rates of premature death. Individuals carrying medical debt are five times more likely to skip mental health care and face increased risks of housing instability. In many cases, the bill that follows treatment can be as harmful as the condition that led to it.

At the same time, nonprofit hospitals receive billions of dollars in tax exemptions each year in exchange for a commitment to serve their communities. Better Ancestors asks a straightforward question:   Are hospitals fulfilling that commitment all the way through—not just in care delivery, but in billing practices as well?

Rethinking Healthcare’s Role in Our Communities

As major employers, purchasers, and investors, hospitals influence economic opportunity, housing stability, and overall quality of life. Increasingly, leaders across the field recognize that improving health requires going beyond hospital walls.

Efforts like the Healthcare Anchor Network and the Lown Institute’s Most Socially Responsible Hospitals Index reflect this shift toward broader accountability.

At We in the World, the Mission First Initiative builds on this momentum—connecting and strengthening work that is often fragmented across silos into a coordinated, strategic approach.

The core insight is simple:
Doing right by communities does not undermine financial performance; it strengthens it. Reducing harm, simplifying systems, and proactively managing risk improve both outcomes and sustainability.

Mission and margin are not in conflict—they reinforce each other. 

What does this look like in practice? The work begins at the points where harm is created and can be prevented. 

How It Works

The Three Pillars (“3 C’s”)

• Care — Stop the harm
  End billing and collection practices that deepen financial distress for vulnerable patients.

• Civic Life — Fix the system
  Advance policies that protect communities and hold healthcare institutions accountable.

• Community — Build upstream
  Invest in the social and economic conditions that create health in the first place.

Care

Financial vulnerability directly affects health outcomes. This is not just a social issue—it is a system design problem.

The Mission First Initiative creates a national model that allows hospitals to identify financially vulnerable patients before debt is generated.

Instead of the traditional approach—“bill everyone, collect what you can”—the model uses automated, address-based relief. At registration, patients are screened based on whether they live in a designated Mission First Zone, enabling intervention before any bill is issued.

This approach shifts resources upstream:

• From collections to prevention
• From reactive write-offs to proactive support

The result is lower administrative waste, reduced compliance risk, and stronger patient trust.

Civic Life

Hospitals are not only care providers—they are civic institutions with significant influence over local conditions.

This pillar focuses on leveraging that influence through:

• Policy engagement
• Cross-sector partnerships
• Community-centered leadership

Several states demonstrate what this can look like:

• North Carolina links Medicaid payments to hospital financial assistance practices
• Arizona in partnership with Undue Medical Debt has used federal funds to eliminate medical debt for qualifying residents

The opportunity now is to move from reactive solutions to system-level prevention.

Community

Trust between healthcare systems and communities has eroded due to rising costs, inequities, and long-term disinvestment. Rebuilding it requires investment beyond clinical care.

Many hospitals are already acting as anchor institutions—leveraging hiring, purchasing, and capital investments to strengthen local economies.

Examples include:

• Cleveland Clinic supporting worker-owned businesses that create living-wage jobs
• Bon Secours investing in housing and neighborhood revitalization in West Baltimore
• Rush University System for Health partnering with Filmore Linen Service to create neighborhood jobs and build community wealth through local procurement in Chicago’s West Side.

These efforts reflect a core principle of Mission First:
health systems improve health not only through care, but through how they invest.

By directing resources upstream—into housing, employment, and community wealth—organizations can rebuild trust and create lasting impact.

The Only Thing That Ever Has 

At its heart, the work of being a better ancestor in healthcare is rooted in combining systems thinking — mapping the system to understand how it works — and sensemaking — seeing why the system moves the way it does. Then using both lenses to build an understanding of where the opportunities for generational healing may be.

With $194B of medical debt in active collections, we know there is ample opportunity for repair and for reimagining how money moves in healthcare. Ample opportunity to stop the bleed of predatory practices that harm patients. And ample opportunity to heal as a community, and as a community of care.

The Better Ancestors in Healthcare framework is what systems thinking merged with sensemaking looks like in practice. It looks at the bill-generation workflow, identifies where we can make an impact, and then changes the flow so that a bill is never generated. Harm is stopped before it starts. And it happens using direct power and control that people within a system already have — better ancestors within the system who want to see change.

Medical billing may seem like a sprawling system. But within one healthcare organization, it takes a handful of people to make a change. A catalyst willing to reimagine and to inspire others to implement. Key leaders aligned with that catalyst. When Margaret Mead said never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has — she was right.

Healthcare, like all systems, is designed, implemented, and upheld by people. Its practices and policies are made by people. And that means this work is transferable to other systems, other sectors, anywhere people inside an institution are ready to become ancestors the next generation can be proud of. The model scales because the conditions are the same: a system causing harm, people inside it with power to catalyze change, and a question of whether they’re willing to use it differently.

by Shu-Ling Zhao and Kate Behan