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We'e talked about what we've learned about
the healthcare system since 1993.
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Talked about ways in which healthcare
reform is a different proposition today,
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even though it's still subject to the
fiscal and interest group, and rationing
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related concerns that it's always
been subject to in the
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post-Medicare period.
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As I've described, we've
learned how inefficient the current
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system is.
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But we also learned how unjust the
current system is.
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Because we've also come to
understand that our healthcare system
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is really not a healthcare system. It's a
medical care system.
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And health is determined by many things
other than medical care.
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This is a standard diagram. The
particular percentages vary depending
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on which version you look at, using
which statistics from which time period.
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But a constant observation is that
medical care accounts for only about
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ten percent of health outcomes.
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Everything else, genetics, behavior,
social circumstance, and environment.
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And almost all of these social factors are
highly unequally distributed in American
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society. Such that some individuals,
some families, and some communities
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have the best chance at health, and other
individual families and communities
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have far lesser opportunities for health.
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And this is reflected in the collective
statistics regarding success of our
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health system as opposed to our medical
care.
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The United States does well on only
one core indicator of population health,
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and that is tobacco utilization, something
that the current popularity of e-cigs and
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vaping is threatening to erode. But on
every other characteristic from life
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expectancy to infant and maternal
mortality, to obesity, diabetes, and other
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behaviorally related and socially related
threats to health,
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United States does very poorly.
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Obesity is a stark illustration.
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One can pull from the CDC website
maps, state by state of BMI
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greater than 30 in the adult
population.
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And here's the bottom line.
In 1990, there was not one state
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in the United States where as much
as fifteen percent of the adult population
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was obese.
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Every state was under fifteen percent
in 1990.
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Twenty years later in 2010, there is
not one single state where less than
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twenty percent of the adult population
was obese.
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Twenty years, from all below fifteen,
to all above twenty.
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This is not the result of medical care.
This is the result of social forces,
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and social inequality.
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Poverty is a tremendous driver of
ill health.
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And in all the ways in which people
might avail themselves of health related
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non medical services, people who are poor
are far less able to do so.
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And at a national level, we see this in
statistics.
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The work that Betsy Bradley,
Lauren Taylor have done on health and
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social care spending, does not show
prosperous America outspending
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every other country on every other
parameter.
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It shows that U.S. spending is
highly skewed towards medical
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uses, and significantly underfunds
non medical social services that
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are also health improving.
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Every other country, every other
developed country spends more
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than half of its health related
dollars on non-medical
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social services.
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The United States spends barely
a third of its health related
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dollars on non-medical social
services.
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And this is highly reflected
in the core performance we see on
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overall indicators of health.
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It's also severely compromised
our ability to allocate scarce
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tax dollars effectively.
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Again, this is all driven
as well, not just by sort of a
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reasonable preference among
U.S. taxpayers for a lower tax burden,
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but by those arcane and
counterproductive rules of fiscal
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accounting that we've discussed in
previous sections of this presentation.
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From the passage of Medicare
on, the federal budget has been
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using more and more of its available
resources for medical care.
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Such that non-medical federal spending
has been significantly crowded out.
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From 1965 until the early 2000s, we
were able to afford that only because
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defense spending was getting reduced.
Defense spending has not been reduced
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over the last twenty years, and possibly
can't be reduced further.
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Which means that discretionary spending
beyond Social Security, beyond defense,
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beyond interest on the national debt,
and beyond Medicare and Medicaid,
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is almost negligible. Major social
investments that the federal government
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should make, we cannot afford, because
of persistent increases
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in medical spending.
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And it's been even more tragic at the
state level.
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If you go back to the early 1990s, states
spent the most on primary and secondary
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education, followed by higher education,
followed by Medicaid and other healthcare.
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In the 1990s, Medicaid eclipsed
higher education.
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In the 2000s, Medicare -
Medicaid, I'm sorry,
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eclipsed primary and secondary education.