The failings of the U.S. health care system — and the institutions and structures that perpetuate them — are the subject of a new report from the Lancet Commission on Public Policy and Health in the Trump Era.

In a commentary appearing in the journal today, Commonwealth Fund President David Blumenthal, M.D., and Margaret Hamburg, M.D., a Fund board member and former head of the U.S. Food and Drug Administration, ask how the nation can overcome those failings to achieve a health care system that works well for everyone. The obstacles are not only substantial, they say, but also deeply rooted in our political system and culture.

Ultimately, the path to health reform will require “political activism of the most basic kind” to address the roots of our health care crisis, they write. These include inequalities in income, education, nutrition, housing, justice, and employment opportunities.