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We'e talked about what we've learned about
the healthcare system since 1993.

Talked about ways in which healthcare
reform is a different proposition today,

even though it's still subject to the
fiscal and interest group, and rationing

related concerns that it's always
been subject to in the

post-Medicare period.

As I've described, we've
learned how inefficient the current

system is.

But we also learned how unjust the
current system is.

Because we've also come to
understand that our healthcare system

is really not a healthcare system. It's a
medical care system.

And health is determined by many things
other than medical care.

This is a standard diagram. The
particular percentages vary depending

on which version you look at, using
which statistics from which time period.

But a constant observation is that
medical care accounts for only about

ten percent of health outcomes.

Everything else, genetics, behavior,
social circumstance, and environment.

And almost all of these social factors are
highly unequally distributed in American

society. Such that some individuals,
some families, and some communities

have the best chance at health, and other
individual families and communities

have far lesser opportunities for health.

And this is reflected in the collective
statistics regarding success of our

health system as opposed to our medical
care.

The United States does well on only
one core indicator of population health,

and that is tobacco utilization, something
that the current popularity of e-cigs and

vaping is threatening to erode. But on
every other characteristic from life

expectancy to infant and maternal
mortality, to obesity, diabetes, and other

behaviorally related and socially related
threats to health,

United States does very poorly.

Obesity is a stark illustration.

One can pull from the CDC website
maps, state by state of BMI

greater than 30 in the adult
population.

And here's the bottom line.
In 1990, there was not one state

in the United States where as much
as fifteen percent of the adult population

was obese.

Every state was under fifteen percent
in 1990.

Twenty years later in 2010, there is
not one single state where less than

twenty percent of the adult population
was obese.

Twenty years, from all below fifteen,
to all above twenty.

This is not the result of medical care.
This is the result of social forces,

and social inequality.

Poverty is a tremendous driver of
ill health.

And in all the ways in which people
might avail themselves of health related

non medical services, people who are poor
are far less able to do so.

And at a national level, we see this in
statistics.

The work that Betsy Bradley,
Lauren Taylor have done on health and

social care spending, does not show
prosperous America outspending

every other country on every other
parameter.

It shows that U.S. spending is
highly skewed towards medical

uses, and significantly underfunds
non medical social services that

are also health improving.

Every other country, every other
developed country spends more

than half of its health related
dollars on non-medical

social services.

The United States spends barely
a third of its health related

dollars on non-medical social
services.

And this is highly reflected
in the core performance we see on

overall indicators of health.

It's also severely compromised
our ability to allocate scarce

tax dollars effectively.

Again, this is all driven
as well, not just by sort of a

reasonable preference among
U.S. taxpayers for a lower tax burden,

but by those arcane and
counterproductive rules of fiscal

accounting that we've discussed in
previous sections of this presentation.

From the passage of Medicare
on, the federal budget has been

using more and more of its available
resources for medical care.

Such that non-medical federal spending
has been significantly crowded out.

From 1965 until the early 2000s, we
were able to afford that only because

defense spending was getting reduced.
Defense spending has not been reduced

over the last twenty years, and possibly
can't be reduced further.

Which means that discretionary spending
beyond Social Security, beyond defense,

beyond interest on the national debt,
and beyond Medicare and Medicaid,

is almost negligible. Major social
investments that the federal government

should make, we cannot afford, because
of persistent increases

in medical spending.

And it's been even more tragic at the
state level.

If you go back to the early 1990s, states
spent the most on primary and secondary

education, followed by higher education,
followed by Medicaid and other healthcare.

In the 1990s, Medicaid eclipsed
higher education.

In the 2000s, Medicare -
Medicaid, I'm sorry,

eclipsed primary and secondary education.