WEBVTT 00:00:00.773 --> 00:00:06.961 We'e talked about what we've learned about the healthcare system since 1993. 00:00:06.961 --> 00:00:12.608 Talked about ways in which healthcare reform is a different proposition today, 00:00:12.608 --> 00:00:16.832 even though it's still subject to the fiscal and interest group, and rationing 00:00:16.832 --> 00:00:21.434 related concerns that it's always been subject to in the 00:00:21.434 --> 00:00:22.347 post-Medicare period. 00:00:22.347 --> 00:00:27.010 As I've described, we've learned how inefficient the current 00:00:27.010 --> 00:00:28.802 system is. 00:00:28.802 --> 00:00:32.298 But we also learned how unjust the current system is. 00:00:32.298 --> 00:00:38.811 Because we've also come to understand that our healthcare system 00:00:38.811 --> 00:00:41.792 is really not a healthcare system. It's a medical care system. 00:00:43.998 --> 00:00:49.535 And health is determined by many things other than medical care. 00:00:49.535 --> 00:00:54.922 This is a standard diagram. The particular percentages vary depending 00:00:54.922 --> 00:01:01.402 on which version you look at, using which statistics from which time period. 00:01:01.402 --> 00:01:09.337 But a constant observation is that medical care accounts for only about 00:01:09.337 --> 00:01:12.658 ten percent of health outcomes. 00:01:12.658 --> 00:01:20.507 Everything else, genetics, behavior, social circumstance, and environment. 00:01:20.507 --> 00:01:27.091 And almost all of these social factors are highly unequally distributed in American 00:01:27.091 --> 00:01:32.618 society. Such that some individuals, some families, and some communities 00:01:32.618 --> 00:01:38.111 have the best chance at health, and other individual families and communities 00:01:38.111 --> 00:01:42.158 have far lesser opportunities for health. 00:01:42.158 --> 00:01:49.498 And this is reflected in the collective statistics regarding success of our 00:01:49.498 --> 00:01:52.922 health system as opposed to our medical care. 00:01:52.922 --> 00:01:59.968 The United States does well on only one core indicator of population health, 00:01:59.968 --> 00:02:07.255 and that is tobacco utilization, something that the current popularity of e-cigs and 00:02:07.255 --> 00:02:12.207 vaping is threatening to erode. But on every other characteristic from life 00:02:12.207 --> 00:02:18.332 expectancy to infant and maternal mortality, to obesity, diabetes, and other 00:02:18.332 --> 00:02:24.155 behaviorally related and socially related threats to health, 00:02:24.155 --> 00:02:28.085 United States does very poorly. 00:02:28.085 --> 00:02:31.258 Obesity is a stark illustration. 00:02:31.258 --> 00:02:41.514 One can pull from the CDC website maps, state by state of BMI 00:02:41.514 --> 00:02:45.423 greater than 30 in the adult population. 00:02:45.423 --> 00:02:50.365 And here's the bottom line. In 1990, there was not one state 00:02:50.365 --> 00:02:55.851 in the United States where as much as fifteen percent of the adult population 00:02:55.851 --> 00:02:56.772 was obese. 00:02:57.845 --> 00:03:02.589 Every state was under fifteen percent in 1990. 00:03:02.589 --> 00:03:11.325 Twenty years later in 2010, there is not one single state where less than 00:03:11.325 --> 00:03:15.534 twenty percent of the adult population was obese. 00:03:15.534 --> 00:03:22.350 Twenty years, from all below fifteen, to all above twenty. 00:03:22.350 --> 00:03:29.391 This is not the result of medical care. This is the result of social forces, 00:03:29.391 --> 00:03:30.537 and social inequality. 00:03:32.503 --> 00:03:36.504 Poverty is a tremendous driver of ill health. 00:03:36.504 --> 00:03:43.478 And in all the ways in which people might avail themselves of health related 00:03:43.478 --> 00:03:49.564 non medical services, people who are poor are far less able to do so. 00:03:50.933 --> 00:03:55.006 And at a national level, we see this in statistics. 00:03:55.006 --> 00:04:00.170 The work that Betsy Bradley, Lauren Taylor have done on health and 00:04:00.170 --> 00:04:05.512 social care spending, does not show prosperous America outspending 00:04:05.512 --> 00:04:08.093 every other country on every other parameter. 00:04:08.093 --> 00:04:15.057 It shows that U.S. spending is highly skewed towards medical 00:04:15.057 --> 00:04:24.025 uses, and significantly underfunds non medical social services that 00:04:24.025 --> 00:04:25.340 are also health improving. 00:04:26.221 --> 00:04:28.710 Every other country, every other developed country spends more 00:04:28.710 --> 00:04:32.891 than half of its health related dollars on non-medical 00:04:32.891 --> 00:04:34.008 social services. 00:04:34.008 --> 00:04:38.563 The United States spends barely a third of its health related 00:04:38.563 --> 00:04:41.615 dollars on non-medical social services. 00:04:41.615 --> 00:04:45.632 And this is highly reflected in the core performance we see on 00:04:45.632 --> 00:04:48.351 overall indicators of health. 00:04:48.351 --> 00:04:55.421 It's also severely compromised our ability to allocate scarce 00:04:55.421 --> 00:04:56.984 tax dollars effectively. 00:04:56.984 --> 00:05:01.036 Again, this is all driven as well, not just by sort of a 00:05:01.036 --> 00:05:05.712 reasonable preference among U.S. taxpayers for a lower tax burden, 00:05:05.712 --> 00:05:09.851 but by those arcane and counterproductive rules of fiscal 00:05:09.851 --> 00:05:15.072 accounting that we've discussed in previous sections of this presentation. 00:05:15.072 --> 00:05:24.108 From the passage of Medicare on, the federal budget has been 00:05:24.108 --> 00:05:29.410 using more and more of its available resources for medical care. 00:05:29.410 --> 00:05:34.427 Such that non-medical federal spending has been significantly crowded out. 00:05:34.427 --> 00:05:39.638 From 1965 until the early 2000s, we were able to afford that only because 00:05:39.638 --> 00:05:44.081 defense spending was getting reduced. Defense spending has not been reduced 00:05:44.081 --> 00:05:47.749 over the last twenty years, and possibly can't be reduced further. 00:05:47.749 --> 00:05:53.946 Which means that discretionary spending beyond Social Security, beyond defense, 00:05:53.946 --> 00:05:58.194 beyond interest on the national debt, and beyond Medicare and Medicaid, 00:05:58.194 --> 00:06:03.112 is almost negligible. Major social investments that the federal government 00:06:03.112 --> 00:06:06.774 should make, we cannot afford, because of persistent increases 00:06:06.774 --> 00:06:08.444 in medical spending. 00:06:08.444 --> 00:06:11.564 And it's been even more tragic at the state level. 00:06:11.564 --> 00:06:18.396 If you go back to the early 1990s, states spent the most on primary and secondary 00:06:18.396 --> 00:06:25.064 education, followed by higher education, followed by Medicaid and other healthcare. 00:06:25.064 --> 00:06:35.068 In the 1990s, Medicaid eclipsed higher education. 00:06:35.068 --> 00:06:38.448 In the 2000s, Medicare - Medicaid, I'm sorry, 00:06:38.448 --> 00:06:41.277 eclipsed primary and secondary education.