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.