The Hypertension Control Paradox — Why Is America Stuck?

· by · in Healthcare. ·

This article first appeared in The New England Journal of Medicine. It is co-authored with Sandeep P. Kishore, M.D., Ph.D.

Published January 24, 2026 | N Engl J Med 2026;394:417-420 | DOI: 10.1056/NEJMp2515023

Although controlling blood pressure with medications is one of medicine’s simplest and most effective interventions, the U.S. health system’s efforts to combat hypertension population-wide have stalled — in stark contrast to the remarkable progress in so many other areas of medicine. Guidelines exist and clinicians are trained, yet hypertension remains uncontrolled in half of Americans who have it. Fortunately, advances in technology, artificial intelligence (AI), and health system design offer the opportunity to reverse this trend.

When the National High Blood Pressure Education Program launched in 1972, only 10% of U.S. adults with hypertension had a blood pressure below 140/90 mm Hg. The control rate peaked at 54% in 2013–2014, fell to 44% by 2017, and now hovers near 50%.1 When the Centers for Disease Control and Prevention’s newer (2017) hypertension threshold of 130/80 mm Hg is applied, only one in five U.S. adults (20.7%) meet the target, with just half of adults with hypertension taking medication; 40% of those with hypertension remain unaware of their condition. Each 10% improvement in hypertension control could save 14,000 lives per year,2 yet national efforts such as Million Hearts and Target:BP have not resulted in sustained progress. Meanwhile, Canada raised its control rate from 13% to 66% within a decade,3 and Kaiser Permanente Northern California reached a 90% rate by using protocolized, team-based care.4 Clearly, high control rates are achievable.

So why is the United States still failing? It’s no secret that hypertension prevalence has increased in parallel with broader societal shifts — toward more sedentary lifestyles, greater consumption of ultraprocessed foods, higher salt loads, and higher rates of obesity and metabolic dysfunction. The risks are compounded by financial strain, poverty, insufficient housing, psychosocial stress, food deserts, and pharmacy deserts. Such structural and behavioral drivers may thwart even the most effective interventions and require deep and serious attention. But as a starting point, we focus here on the role of health systems in aligning incentives, providing information, and delivering care (see table).

Barriers to and Solutions for Effective Hypertension Control.

Blood-pressure control can become a success story if incentives are realigned to reward prevention and sustained control. We believe that even without incentives, frontline clinicians act professionally and ethically, driven by intrinsic motivation. But the systems in which they work often direct investments away from critical, underfunded areas.

A first step is for the government to extend payer time horizons (by extending insurance policies) to 3 to 5 years — by means of congressional or regulatory action — so that savings from prevention accrue within meaningful time frames. Because patients often change health plans before complications of hypertension can arise, most insurers never realize cost savings within typical 12-to-24-month horizons, which makes sustaining hypertension control economically irrational.

Second, regulators and health plan leaders can redesign quality-improvement efforts to focus on fewer, higher-impact measures. Although Medicare Advantage includes blood-pressure control as a star ratings measure that is triple weighted, most clinicians do not receive direct incentives to meet this goal. Medicare Advantage plans receive a 5% premium bonus for aggregate four-star performance, yet few such incentives exist for commercial, Medicaid, Affordable Care Act, or fee-for-service plans. Meanwhile, blood-pressure control competes with dozens of other metrics for clinicians’ attention. Streamlined quality-improvement programs — perhaps modeled after Covered California’s Quality Transformation Initiative5 — could reduce the number of measures and emphasize (by providing larger incentives) a small set of high-impact outcomes that truly matter.

Third, payers could reorient reimbursement toward outcomes rather than visits. In many regions of the country, Medicare reimbursement for level 1–2 visits for hypertension is only a fraction of that for encounters for more severe conditions (e.g., $69 to $109 vs. $152 to $213 for level 3–4 Medicare visits in San Francisco), and remote patient-monitoring services barely break even once patient attrition and billing costs are considered. Moreover, long-term sequelae of hypertension lead to profitable procedures.

Finally, health care organizations should make incentives team-based. Sustained blood-pressure control depends on dieticians, psychologists, pharmacists, nurses, and digital care coordinators working in concert with physicians. Aligning rewards for the whole team can transform hypertension care from a low-margin obligation into a shared success for clinicians, patients, and payers.

On the information front, timely and trustworthy data are the cornerstone of blood-pressure control. Yet today, many quality dashboards, which rely on claims data, lag 6 to 12 weeks behind blood-pressure measurements, and home blood-pressure readings rarely appear in electronic health records (EHRs). Unlike the glycated hemoglobin level in diabetes, blood pressure is more volatile and often judged by a single, nonrepresentative measurement. In addition, remote monitoring still faces challenges. Data feeds are often incomplete or buried deep within the EHR, hidden in flowsheets that many clinicians never check (or know about). Without clear incentives, many clinicians don’t want blood-pressure data streaming into their inboxes, especially in clinics with high turnover where continuity of care is poor. When frontline clinicians can’t trust the numbers they see, can’t see them at all, or don’t want to see them, the net result is inertia rather than action.

AI can now transform this landscape. Machine-learning algorithms can synthesize readings from validated home blood-pressure cuffs and flag patients whose trajectories signal increasing risk. AI-supported remote-monitoring platforms may be able to triage patients for outreach or medication adjustment, reducing clinicians’ burden and permitting speedier responses. In addition, makers of current wearable and sensor technologies claim they are as accurate as blood-pressure cuffs. But to make real gains, health systems will have to move from retrospective reporting to real-time data integration. Data from validated home readings and wearable devices capable of continuous blood-pressure monitoring should flow into the EHR, with automated averaging and alert thresholds. Such integration will require interoperability standards and, ultimately, a national patient identifier system so that data can be linked across payers, clinics, and consumer devices. Connecting EHR and wearable data would further enable longitudinal tracking of blood-pressure control across fragmented systems.

On the care delivery front, clinicians currently fail to intensify treatment in as many as 80% of visits with patients with uncontrolled hypertension. Protocolized, team-based care is a proven antidote to therapeutic inertia, but it remains rare. Health systems could adopt protocol-driven medication-adjustment algorithms — standardized approaches that specify drug sequence, dosing, and escalation thresholds. Such protocols enable delegation of medication-adjustment authority to trained nurses, pharmacists, or community health workers, dramatically accelerating progress toward blood-pressure control. Decades of evidence shows that such task shifting results in equivalent or better outcomes than solo-physician care, with high patient satisfaction. Embedding these decision tools into care teams’ workflows, supported by technology, prevents overload and ensures continuity.

Improving access, continuity, and medication adherence requires structural changes in care delivery and coverage. Expanding digital-first and retail-based hypertension programs that help patients and clinicians track blood pressure with devices and personalized coaching could close gaps for the one in four U.S. adults who lack a usual source of care — if paired with payment models that reimburse for patient engagement and monitoring rather than only for visits. Coverage reforms that eliminate patient copayments for essential generic medications and favor fixed-dose combination pills — which have been proven to enhance adherence and blood-pressure control — could result in immediate population-level gains, even as national targets shift toward lower blood-pressure goals (<130/80 mm Hg). Finally, a unified patient-education system established by payers and health care organizations would reduce fragmented information and close knowledge and awareness gaps that undermine blood-pressure control.

At root, the failure to control hypertension is a failure not of science but of system design. Proven solutions already exist that harness protocol-driven algorithms, empowered teams, and current and emerging technology. Over the longer term, payers should extend insurance policies to make prevention and sustained control financially viable. These steps require policy alignment and leadership more than new discovery.

References

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