 Hi, I'm Christine Mitchell from the Center for Bioethics at Harvard Medical School. I'm here today with Lauren Taylor, who is the co-author of this book, The American Health Care Paradox, which she wrote with Elizabeth Bradley. I'm going to start by asking you first how you got interested in health care spending. As I heard you talk about this book, the extent to which you wrapped your mind around and made understandable the numbers in American health care policy was just incredibly impressive. How'd you get there? That's nice of you to say. I think it's the classic things that you're not naturally great at, you become a good teacher of. So I remember this, I was a lacrosse player once and I was not at all a good defender, but now I love to coach it because I had to learn it. And so that's the same thing with the health spending numbers, right? I'm not naturally even quantitatively inclined. I would say I'm not an economist, but I felt like the numbers were a really, really important way to make concrete and measurable the attention that we in the United States spend both on medical care and other social determinants of health. And the way we did that, of course, was to use spending, almost as a proxy of attention paid to these different determinants of health. And so, yeah, we spent a lot of time trying to understand them and understand them well. What's the public-private breakdown? What's the ratio between these two spending buckets? And I think it comes through as clear because we were using that as a means to an end, right? We were trying to communicate something larger about the American public's relationship to the health care industry and our relationship to the social service industry and the numbers or the spending was really just a means to an end. So what is the American health care paradox? Yeah. So the American health care paradox is this idea that we spend an enormous amount on health care, primarily medical care. We're up around 18% right now and we've been in that neighborhood for a number of years. And yet if you look at the population health outcomes that we get compared to our OECD peers, the OECD being the Organization for Economic Cooperation and Development, we do lousy. So when I say population health outcomes, I'm thinking about infant mortality, life expectancy, maternal mortality, the big markers of how healthy a population is if you grow up in a school of public health. Of course, there are things we could always point to and say the U.S. does well at. And those are usually high volume, very medically complex things like organ transplants, knee replacements. But I maintain, and I think I know Betsy would agree, these maternal mortality, life expectancy type outcomes are really the ones that give us a better indication of how healthy the population is on the whole. And so it's that mismatch between huge spending, which I think we have historically thought, oh, more health care spending will get us a better population. And yet it's the large spending, but not great health outcomes that was what we were trying to get at with our title, The American Health Care Paradox. So the paradox is that the United States spends more money on health care than anyone else and gets far less. So many other countries do better than us. And then you, too, really looked comparatively at the numbers across the United States and in other countries. And you had a big surprise in doing that as you looked at what counts as health care. Can you explain that a little? Yep. So the kind of summary statistic, if you will, from all of our work is this. In the average OECD country, for every $1 spent on health care is matched with $2 in social service spending. In the United States, for every $1 spent on health care, we match that with about 90 cents of social service spending. So what you see in that kind of ratio is a really different pattern. In other OECD countries, there is, of course, an emphasis on health care, but there's much more so on what we would now call the social determinants of health, right? The quality of the housing, the quality of the water, people's social relationships, access to healthy food, transportation. Here we have really strongly emphasized the health care and really put much less emphasis into those other social determinants of health or social service spending buckets. And I think that's been to our disadvantage, because this ratio, which I was just describing, we found to actually be more predictive of health outcomes, the infant mortality, the life expectancy, than just the health service spending alone, which was the real revelation. Because historically we've thought, as I said, you want better health, spend more on health care. And yet, quantitatively and through the modeling, we were able to show that may not actually be right. It may be more about the ratio and how you allocate scarce resources. That's what gets you better health outcomes instead of just spending more and more on medicine. And then you spend a little time looking at the history of health care spending in the United States. So I was really fascinated by the work you did on the neighborhood health centers and the differences that made embedding health care within a setting where broader definition of health was used. And yet that fell by the wayside. Can you describe, not so much what happened to the neighborhood health centers, but this evolution that's brought us to where we are and where you think we need to go? Yeah. I'm so glad you picked up on that, because I think it's so important, and it's especially timely right now, the neighborhood health centers were this incredible little experiment run really as part of the war on poverty in the late 1960s and early 1970s. And the idea was, we'll create one-stop shops that can do both the medical care, the health care provision, and the social service delivery. So for instance, you would have one in Mississippi, they started often in the Mississippi Delta, and you could have team-based health care where you could see a nurse, you could see a doctor, you could bring your child for a well-baby check, get them weighed and measured and all those things. There would also be a pharmacy. They could do some small kind of day of surgical work. And so it was a real clinic in the same sense that we would think now of an FQHC and maybe even some higher acuity facilities. But then they also did incredible what we now call wrap-around services, but I think that even diminishes the importance of them. The social service delivery side was core to what the neighborhood health center was, and so each neighborhood health center could decide what kind of services they thought their community needed. So again, in the Delta, it may be a farm cooperative or it may be digging wells, a rural community. In New York City, you would have the same model, a neighborhood health center, but they may be focused more on English as a second language classes or rodent remediation in the homes, things like that. So it was very, very contextually aware, really before its time, very locally driven. So local folks from the community had to serve on the governing boards and serve in real proportions. It wasn't kind of a tokenization of their participation, but they had to be there really deciding what kind of services should the center offer. And the only way to make that decision was what kind of services do we think the community needs to be healthy. So I think it was just a really different model, and they were able to achieve that because they were essentially block grant funded. And so there was not, historically in the United States, we've now separated out, this is the health service spending, and this is the social service spending, and it's in fact often very difficult to braid those two things together or even coordinate them in a meaningful way. And yet this moment in history of the neighborhood health centers was a rare one where the federal government was able to say, here's a set pot of money, local constituency, you decide what the local community really needs to be healthy, and you pursue those ends however you think best. And so I think it's indicative of this larger thread in the American health care historical narrative which is we really always want to maintain a lot of control over our health care spending, and we want to know exactly what's inside the lines and what's outside the lines, what's the cost effectiveness of everything in the health care industry. And we really want to just maintain a great deal of control over the administration and financing of that. And this was again the neighborhood health centers a rare moment where the funds came to the local group and they were able to have their own degree of control and spend those funds really with a tremendous degree of flexibility that we have not really seen I think since that moment in time in the late 1960s and early 1970s. And they were phenomenally successful, right? So I think this is the big system tension that we're always struggling with, how to build a system that's predicated on control and you know accounting for every P and Q and exactly who's going to get what in terms of the health care delivery and yet also allowing for enough flexibility so that recognizing the enormous variation in what people need to be healthy they can get that, right? Everyone doesn't need the same things to be healthy and yet we need to build a system predicated on control when people are incredibly different in their needs and communities are incredibly different in their needs. So then the funding for that program moved into the Department of Health and Human Services? Yes, it went exactly to the health education and welfare at the time. Right. And so that was a big deal because it meant that what had started as a program to really boost economic growth in low income neighborhoods, it originally was in the Office of Economic Growth, OEO, then got transferred over to health education and welfare where it fell under the purview of doctors, right? And health care professionals. And so when it went to their shop, they said, okay, well, you know, it's nice that you've been doing all these other things, the farm cooperatives and the digging of the wells, but we don't really see that as essential. And so we will continue to pay for and fund these neighborhood health centers because we know they're popular and well received, but we're only going to fund them in so much as here's the money for the medical services and everything else, you know, you're on your own. Good luck. You can keep doing them if you want, but you need to locally fundraise. So of course the bottom fell out of all of those social services. And we have now I think a much more medicalized version of the neighborhood health centers and the federally qualified health centers. They do great work, but it's a very different vision from what the original kind of Jack Geiger, Count Gibson inspired neighborhood health centers were to begin with. So now that you have a deep view of not only the history, but also the numbers around how the United States delivers health care, what do you and Dr. Bradley recommend as, you know, what did you see as something that would be a more successful way to deliver services to the population of the United States in a way that would improve health outcomes and bring them more in line with other countries' successes? Yeah. So I think there's two points here. One is a conceptual point and another is more operational. Conceptually, we have always said the first step is to reconceptualize what we mean by health. And I think distinguish it very, very clearly from health care. For too long, we've used those terms synonymously. And I think that has led us down the path, the errant path of, oh, you want better health, just spend more on health care. Those two things are different, right? Health care is one means to try and achieve health, but it's not the only means. And in fact, it's probably not the highest leverage means, if you will. And in our travels to Sweden and Denmark and Norway, which are really the stars of the OECD, they get the best health outcomes often for the same amount of spending or less than we do. They just had a very different attitude towards health. Health was a means to an end, but they hadn't medicalized the idea of health to the same extent. And in fact, they had kind of instrumentalized it. It was, yeah, your health is important in so much as it allows you to spend time with your family or do good work professionally. You know, it was an input to a good life, but it was not the end all be all of a good life. And I think that's resonant with what we are just talking about in terms of the neighborhood health centers being born in the OEO, the Office of Economic Opportunity. There, too, it was this idea that we need to create health and communities in order for these communities to prosper, but not just because we think health is some kind of ultimate good in and of itself. And I always just think that's so different than how we generally think and talk about health in the United States. And I think the most emblematic example was once I was driving on I-95 through Connecticut, and there was a big billboard for a hospital system. And it just read in these really stark letters, because your health is everything, period. And it struck me because we were doing this work at the time that, wow, that's just so different, right? When you think your health is everything, you will spend any amount to achieve perfect health. And we've learned, like, that's just an endless treadmill. No one is perfectly healthy. And we can always go down a rabbit hole of just enormous spending to try and achieve that elusive goal. So I think our relationship to health and trying to understand what we mean by health really still has some changing to do. And that's been some of the work we've been out talking about vis-a-vis the book. On the more operational side, what we've really recommended is trying to be creative and braiding together and knitting together these enormously distinct health and social service sectors. And so you're seeing a lot of that happening now. And I think it's really exciting where health care providers are starting to step outside the four walls of the hospital or the clinic to think really deeply about what do patients need to be healthy. And in many cases, it's not more medicine. It's not another pill. It's access to healthy food. It's clean air in the home. It's transportation to and from work or seeing relatives. It's some kind of company or social relationship so that especially our elders are not incredibly lonely and becoming depressed. And so you're seeing really innovative work. You know, BMC here in Boston has a food pantry on site. All sorts of hospitals are starting to run medical-legal partnerships where legal aid societies are really becoming kind of part of the care team and addressing things that are non-medical in order for people to be healthy. There's a ton of examples. And so we are continuing to work on what are the right ways for these two sectors to come together because it's by no means easy. There's all sorts of cultural and professional differences. There's lots of challenges related to HIPAA and information sharing. It's not easy work, but I think that's where our focus has been and we've been really happy and excited to see how well received that core message of the book has been. So we've just had a presidential administration in which the Affordable Care Act was revised and amended and compromised but eventually passed that enabled at least some of these somewhat more creative approaches to help. And we've just had a presidential election in which we now have a Republican president and Congress. Do you anticipate that? What do you anticipate for changes in the next political scene around which these health care policy decisions will be made? Yeah. I think it's really hard to say. Who can say they know what's coming down the pike politically because there really hasn't been a lot of policy proposals that have come out in great detail about health care or anything else to date. But I think one thing that we have heard is some talk about block granting Medicaid. And so this is actually a really interesting proposal because if you talk to people in state government, they hate this idea. It's very frightening to think that Medicaid would become block granted because there's always a fear that if we hit a financial recession, the federal government will not continue to support as the ranks of the Medicaid population grows. People become unemployed, they go on Medicaid, and there's this fear that the state is going to be essentially left out to dry. That's the fear. I think it's a valid fear. It's one we need to come to terms with. But the idea of block granting Medicaid also raises some I think potentially interesting opportunities to do more of this creative braiding between health and social service delivery. Traditionally Medicaid, because it has not been block granted, it's paid essentially as a fee for service, has been very clear about what counts for Medicaid spending and what doesn't count for Medicaid spending. And yet we know a Medicaid population is one where people often have enormous social complexity underlying the medical presentations. And so lots of states have been fighting for a long time to try and get Medicaid just to pay for some parts of housing or pay for some parts of nutritional assistance. And it's been a back and forth, back and forth between the state and the federal government. So in fact, if we go to a block granting of Medicaid, I think there could be some real opportunities to say, okay, the feds have given us the funds. We know what we have to work with and states could decide, you know what we are going to pay for parts of housing or we are going to pay for transportation or we are going to pay for the home air filters. And so in an odd way, I think there is some real opportunity there or there could be. Again, I'm not one to prognosticate too far into the future, but I think that could be a real area of innovation if that is the path we go down. So you are now actually pursuing your PhD in at Harvard Business School, which in retrospect, looking back at your book and the way in which you got involved in looking at the numbers for healthcare spending and thinking about the organization of the delivery of healthcare, go back and fill in the gaps for us. What did you do that led you to where you are now? Yeah, it's funny how looking back, things make more sense than they ever feel in the moment. I've been a real academic journey woman, if you will, and people have always thought, well, I imagine some people must have thought like, oh, she's such a lost soul. She's just kind of traveling all around. I started in history of science, history of medicine department, studying public health history and eradication of yellow fever at the Panama Canal. And I just thought that was the most interesting work. Then I stayed at Yale. I did my undergrad at Yale and I stayed for a master's of public health. Then I studied mostly global health, but was staying in the kind of infectious disease realm, really tried and true global health work. Then I went to work for my now co-author, Elizabeth Bradley, at the Global Health Leadership Institute at Yale and also was doing monitoring and evaluation and kind of relationship management with different partners we had. Then I came to Harvard and went to the Divinity School for a master of divinity. As a presidential scholar. As a presidential scholar, thank you, and studied ministry and ethics, trying to understand what is the nature of people's obligations to one another and what is the nature of institution's obligations to the public. So if we think about a hospital, what is the nature of a hospital's obligation to the surrounding community? And so, had a great time. And then while there did that program, that research study in Ghana? Yep, I then wrote a master's back in global health, looking at organizational partnerships between Pentecostal faith healers and psychiatrists and psychologists, which was fascinating. Worked with you at Boston Children's Hospital in the Office of Ethics and did some chaplaincy. And now I'm in the PhD in health policy and management. And it's just, you know, life is funny. There is both an ethics and a management track in this PhD. And I applied to both thinking ethics would make the most sense, coming out of a divinity school. But there's always been something about me that likes management. I like the idea of structure. You can point to it. You can, there's just something really appealing. I came from a leadership institute. Betsy has always been a professor of management. So I applied to both. And the head of the ethics track, Norm Daniels, was retiring. And so they said, we're shutting down the track, but we'd love to have you in management. So that decision was kind of made for me. But I had equal interest in both of those tracks because I think they are deeply, deeply related fields. How we organize systems, how we organize service delivery, people can think, oh yeah, it's just about org charts and it's just about, you know, finance. But all of those decisions have ethical ramifications, right? And so increasingly what I'm trying to do is bring to light the ethical dimensions in all of these seemingly technical system design organizational design choices. So there may have been things I didn't ask you that you wanted me to ask you. Let me give you a chance to offer one of those. I think you did a great job. Thanks, Christine. Well, thank you very much. Thank you.