 Thank you very much and so our second speaker is Albert Huang who was a professor of medicine Here at the University of Chicago a general internist and he's one of the I think most thoughtful people here at the University of Chicago And he has he again, it's like a Paul Farmer He has the ability to sort of integrate sort of understanding of individuals and people with macro health policy He is an international leader in terms of geriatric diabetes policy cost policy analysis for diabetes and spent a year in the Obama administration After the Affordable Care Act he was one of the people that wrote the regulations for many affordable care act So Albert geographic disparities and diabetes and obesity in the long arc of health policy Good morning so I'm gonna Talk about two things you probably already know, but To two long-term trends that are happening and I'll try I think what I'll be enlightening is talking about the intersection of how The diabetes and obesity diabetes and obesity epidemics are clashing with what's happening in health care policy And actually it relates to environmental policy And I didn't realize until afterwards that my talks really about what's happening with the Trump administration both health care policy and environmental policy I did not intend that to be the case, but Nevertheless, thank you for having me. So you know when we talk about the long arc of Civil rights, but also the long arc of health care reform One basic point is that a health care reform in the United States However, you view it Each incremental change that's happened in our health care system has taken decades or has taken a long time it's certainly beyond the my own lifetime but You know, you had to realize that health insurance itself was not a normal thing until after World War two Employers did not provide health insurance Until it became a need to incentive to encourage To attract employees in fact physicians in the American Medical Association opposed the health insurance itself and for many decades opposed the adoption of something like Medicare and Medicaid for for several decades with President Truman failing to pass Universal health insurance and it was not until 1965 that we had Medicare and Medicaid and I don't know who knows who was the last state to to actually have a Medicaid program in the United States Arizona, right? So it wasn't until the early 1980s So Medicaid was passed in the mid 60s But it wasn't until the early 80s that all states in the United States had adopted a Medicaid program So it just takes a long time for any program even after legislation has passed takes a long time for implementation And you can see all the various things that happened in between We didn't have M. Tala until the mid 18th 1980s People could be refused care at insurance at a hospital emergency room if they had no health insurance until I'm tall was passed The Clinton health reform effort failed in the early 1990s. I was in medical school by that point We didn't have health prescription drug coverage for Medicare recipient beneficiaries until 2003 passed by a Republican president Bush and we didn't have the Affordable Care Act until 2010 and we had to elect our first African American president in more to pass the Affordable Care Act and that was the first that since from 1965 to 2010 it takes that long for the next major expansion of insurance coverage an over 40 year 40 year period So this is just some some pictorial Illustrations of the long arc of health care reform United States. Does anybody know who the older man is on the right? So it's Harry Truman. He had the first red white and blue card and you can see the best he Truman behind him vice president Humphrey and It was not until and from 1965 to 2010 is when we next have the next major expansion of insurance coverage in America at least sponsored by through expansion of Medicaid, but also the creation of insurance exchanges and Does anybody know the older white man sitting next to President Obama to the left to the right? Anybody from Michigan John Dingle so John Dingle was an early champion of health care reform and so you always you what you always want one of the old the People fighting the good fight along the way To be present for The passage of major legislation. That's right. So that just reemphasizes again the intergenerational time it takes to Bring about health care reform So what's happening at actually a blistering fast pace compared to reform of the health care system is our concurrent obesity and diabetes epidemics. I know that the opioid epidemic is Very very important and is killing people at an incredible pace But this epidemic is happening also and is generally gone unnoticed over the last couple of years We've been distracted by many things in in the political discussions, but this epidemic is happening this is the picture of obesity prevalence in 2011 and We had to create new colors by 2016 to reflect the rising prevalence of obesity These are this is the picture the geographic map of obesity prevalence across the United States You know, I've actually never thought this would happen. I remember being interviewed ten years ago about obesity prevalence around 30% I said it's not really possible for the whole country to be obese But it turns out that there are some states with obesity prevalence now now close to 40% which And actually we are really losing the battle in terms in terms of combating the rising prevalence over obesity You can see these concentration of dark purple states that have obesity now over near 38 39%. It's incredible and The same thing is happening with the related condition of diabetes So this is the this is prevalence of diabetes diabetes by counties in the United States Overall in the United States we have a prevalence of around eight or nine percent But you can see that there are some pockets of the country that have counties with prevalence rates over eleven percent This is the picture in 2004 and this is the picture in 2009 It's really a quite devastating and we are approaching a world where we're gonna have to be all in mobile devices with little Joysticks to move around while sipping soda And so it's a really canister you know catastrophic epidemic. It's not got not gotten much attention. It's not very sexy It's not cancer It's not the opioid epidemic, but it's causing devastation In terms of health care outcomes and health care costs and likely to be a bigger driver health care costs than any of the other epidemics we've talking about So why is this geographic disparity you can see that some parts of the country have less obesity some have less Diabetes than others and why is that the case and this is a beautiful? Graphical depiction of the complex relationship between demographics social environment and the built environment our relationship between race place and poverty and you can imagine an individual is somewhere in this three-dimensional space and those differences between the social environment and built environment coupled with our Ethnic and racial differences our differences by age all lead to difference rate different rates of these chronic conditions of obesity and and Diabetes and I have to properly attribute this to this was created by one of our research fellows Liz tongues beautiful graphics showing this complex relationship between these different Exposures that increase our risk of chronic conditions and if you think and this is a Classic model of social determinants of health that links all these factors together At the macro level the meso community level to the interpersonal level down to the individual you can see how the built environment and the social context Can facilitate it can increase our exposure to stressors in our environment in our local environments the state of our public health systems are The availability of of health care services are affected by policies within the social context and And so on and eventually all this flows down into the creation of health That manifests in obesity and diabetes is just one example of health outcomes that matter to us So the other dimension I just show you that three-dimensional space of the built and social environment But the other big factor that is ignored by policy makers It is really about timing at what point in the time of a person's life. Are they exposed to this world and This just goes this is just a this is a graphic from a the landmark randomized controlled trial of diabetes Of diabetes care. It's actually a trial called the United Kingdom prospective diabetes study It's one of it's a study that will never be repeated again because it took 20 to 30 years to conduct Actually ran out of funding at various times But it's the trial that basically justifies are the way we treat people with diabetes It's the one that justifies the lowering of blood sugars and people with type 2 diabetes And it turns out that they have Enrolled people who were newly diagnosed with diabetes in their 40s and 50s Treated them intensively with multiple medications in the first 10 years of their diabetes And then they the trial actually ended but they continued to follow the people over time Works And you can see here. This is the trial end. The two arms were already separated in terms of events Basically, if you had lower sugars, you did better than if you had higher sugars This justifies our use of a lot of diabetes medications Despite the conclusion of the trial the differences between the two arms persisted this is what we call the legacy effect and a legacy effect of glycemic early glycemic control Meaning if you treat people at the right time of their lives if you address health chronic health conditions at the right time There'll be benefits for those people and benefits for the health system decades later So if you were to go back in time and Revisit health care reform in America You would never start with the creation of Medicare and Medicaid. You are missing the you're not ensuring Health health insurance for the people between the ages of 40 and 64 and it wasn't really the until the Affordable Care Act that we were able to Have Health insurance for that populate that demographic So when health when the Affordable Care Act was passed we wrote this Need a light terrifying and I wrote this thought paper that sort of anticipated the health consequences for chronic diseases related to health care reform That the Affordable Care Act created opportunities to maximize health of a population and based on the UK PES And we really thought and this actually has partially happened Rates of uninsurance have declined dramatically for people who were uninsured And the idea is that if you're insured you're more likely to get diagnosed And you're more likely to be treated at the right stage of your life And this could reduce delays and treatment this graphic just shows that the longer your delay is in terms of treating blood pressure Interperson with diabetes the the greater the risk of future events such as amputations renal failure heart disease The problem is Depends on how you view this the the role of the Affordable Care Act has been completely Detended on the state so a key landmark decision by the Supreme Court in 2012 allowed states to expand Medicaid If they wanted to and this is the orange states are the ones that have have declined to expand Medicaid but the blue states have expanded Medicaid and so Medicaid expansion for the low-income individuals is variable across the country and So I want you to think about how this will intersect with the obesity and diabetes epidemic and remember the graphics I showed you earlier. Where is obesity and diabetes most prevalent? It's actually where the orange states are so what's happened? What do we actually know has happened? This is a study that I've done with a recent graduate student Rebecca Meyerson from the Harris school but we've taken a look at prescription drug claims related to diabetes and Basically, what's happened is in states that expanded Medicaid rates of prescribing for commonly used diabetes medications have shot up and are Significantly different from states where they haven't expanded Medicaid so you can draw your own conclusions But likely these this is a mixture of people with newly diagnosed diabetes or now treated diabetes That was previously untreated so people in the medic in the Medicaid expansion states are getting exposure to these glucose lowering medications So there is in you can imagine so what will if you connect this with what we know from the clinical trials You can anticipate the likely health outcomes that will happen by states another thing another part of the Environment is of course our public health systems and public health systems are quite variable and this is a typology created by Glenn May's to describe health systems that are comprehensive Conventional and limited and basically the ideal system is one that is comprehensive that has a broad scope of recommended population health activities Supported through dense networks of contributing organizations and sectors. This is one where the public health Public health departments work in concert with hospitals clinics and so on and are well integrated and and basically carry out the activities of normal population health and What he's found is that if you compare counties that have Comprehensive health systems versus those that are not comprehensive that there's a difference in mortality rates across these counties So even if you don't adopt Medicaid expansion, there is something that one can do locally to have a more comprehensive health system even with constrained budgets and The other thing that's happened is of course environmental policy has changed a great deal with the new Trump administration And there's a separate line of work around environmental exposures. It turns out that air quality is a predictor of diabetes risk water quality is a predictor predictor of Diabetes risk including potentially pesticides in the water and some farming communities may be increasing the risk of diabetes and Our counties this is a county level picture of the quality. This is a bio If you look at the counties that have darker colors the darker the the color the healthier the overall environment is in terms of air water quality and Unfortunately, there's a lot of pale colors again in the deep south So again, this is another factor another policy tool another policy that is affecting our overall obesity and diabetes epidemics So if we don't make significant changes and I don't know when this will happen State disparities and diabetes outcomes are gonna widen due to variation in Medicaid expansion So I am expecting something fairly catastrophic in the next two decades in the southern states that did not expand Medicaid with far they're gonna have a If you want to invest in dialysis centers the time is now Obesity and diabetes disparities within states I think unfortunately, I'm gonna widen because of cultural changes. There's increasing co-location of the exposures policies and people And this is part of a you know the worsening Divide between different kinds of people who live different ways and Educate by education race and by policies But you know the silver lining might be that there may be ideas for change that may come from identifying communities within Non-expansion states with low obesity and diabetes prevalence and maybe state and local experimentation with limited resources might provide some Some opportunities to make a difference and this is a graphic from the state of Georgia This is the diabetes prevalence across Counties and there are you can see there are a few counties with lower rates of diabetes and The question is why and could they potentially provide us some roadmap to better health? so I hate to be kind of a downer but We have to keep our eyes on the ball on this really important epidemic which is contributing to Geographic disparities, but health disparities in general the diabetes and obesity epidemics have not stopped You just we've just stopped paying attention to it the public health and health care environmental policies that are Intersecting to cause what we see today This within generation change in our health status We are doing some work that I want if you're I'm happy to talk to you about we have a Medicaid working group You know Chicago is now investing in national purchase of in the entire country's Medicaid claims data, and we are hoping to make this place a major epicenter of Medicaid research and If and we also happen to have on campus The Center for Spatial Data Science, which is led by Luke Ancelin. He's essentially the best spatial Geospatial statistician in the country So more to come more that we can do to highlight this this convergence of policy and health epidemics Thank you very much in light of the problems that Are developing at a at a upper policy level in the government? Do you know of any work with? grocery store chains or any of the private sector for example at least When it comes to climate change some businesses are saying to hell with Trump and his administration We're gonna stick with all the regulations that Obama Was trying to promote Have you been able to in other words? stir up any interest in the private sector grocery stores, etc. who will have some effect on the food that people have and Potentially lead to the diabetes you're concerned about It's a great question. It's really a question about you know, can we can things be done? locally despite Federal policy and the answer is actually yes and actually one of the following speakers Monica peak is probably the best model of this where she's been able to collaborate with local grocery stores and Walgreens And I mean you'll and you've noticed probably the movement of Whole Foods into the Englewood neighborhood There are things under way that they can be done to incentivize better food a better built environment for people to encourage exercise and So yes, I think that there is a lot and so that's the that that's what I wanted to end on is it Hopefully a little more hopeful note that there are little local was local experimentation. I think that can make a difference Bob shun from here in Chicago. My question is what do you think makes the South different? So I did not I did not say this directly, but it is really I think it's amazing the legacy of old of history and of older policies and It's probably linked to you know Slavery racism the Civil War I wanted to actually find show a map of the Civil War the Confederate States But they those states were the states that will some of the last to adopt Medicaid those were the states that actually have they actually have some of the smallest of state contributions to the Medicaid program itself and and so it's We're repeating many of the things many of the things that are happen that happened in the past are repeated again and again and I don't know if it's a it's cultural or historical, but the long legacy of old policies is with us today Thank you