If you were trying to change the way Texans think about their physical and mental well-being, you wouldn’t find a better persuader than Elena Marks, who currently heads up Houston’s Episcopal Health Foundation. Previously the director of health and environmental policy for the City of Houston—we can thank her for the city’s cleaner air—Marks has, over the course of her decades-long career, rarely strayed far from her focus on the poor and the underserved. With a toughness honed from her years as a trial and appellate lawyer, she is also eminently capable of knocking heads together when the need arises.

So when the Episcopal Diocese of Texas found itself with more than $1 billion on its hands after the sale of St. Luke’s hospital in 2013, it turned to Marks to find the best ways to improve the health of the 11 million people living in the 57 Central and East Texas counties served by the Diocese. In 2017 the foundation began placing pilot programs in community-based clinics with the goal of stopping disease before it starts. The idea is to identify the economic, behavioral, and environmental factors that are often underlying causes—and then find nonmedical “upstream” solutions. If it works, the program may inspire other such innovations throughout the state and beyond. Recently, Marks explained to me what she wants to accomplish:

“The foundation is about health, not health care. There’s zero value in health care, except to the extent it impacts your health. If you look at the entire U.S. health system, we spend $3.3 trillion every year, and 97 percent of those dollars go to clinical care. The remaining 3percent goes to public health [essentially, preventive medicine]. But if you look at our health outcomes, they kind of suck. I’d like to rebalance those numbers.

“The new movement is ‘value-based care’—basically, taking on the fee-for-service system, in which you go to the doctor, you pay ten dollars, and it doesn’t matter if he or she helped you or not. If they messed you up, you can pay them another ten dollars to fix what they messed up. That’s how the entire system has operated, and that is what has allowed the costs to get out of control and to be disconnected from the quality. That doesn’t make any sense. If you go to a mechanic and they don’t fix your car, you take your car back to them, and they don’t charge you to fix it again.

“What the foundation wants to do is pay health care providers to be accountable for outcomes as opposed to services. For instance, kids who have asthma can take medicines, inhalers, and all that, which is fine. But asthma attacks are caused by asthma triggers. Medicine can’t prevent that. Right now, our system pays the doctor to see an asthmatic kid over and over again and to tell the family to avoid asthma triggers. But we don’t pay anyone to do home remediation that would clean up the mold or toxins in the house that would stop the asthma trigger.

“So many medical problems can’t be solved in a clinical setting, and yet that’s where all the money goes. Clinical care is really important—I’m not saying we shouldn’t have hospitals and clinics. It’s just that we have become so maniacally focused on it that we have neglected things that are often cheaper and more effective.

“We keep paying for more technology, more expensive health care. Where did the opioid epidemic come from? Oh, the health care industry, hello! They’re not the solution to the problem.”

This article originally appeared in the December 2018 issue of Texas Monthly with the headline “Offering a New Prescription for the Health Care System.” Subscribe today.