 I'm Susan Collins, the Joan and Sanford Wilde Dean here at the Gerald R. Ford School of Public Policy. And we're delighted really to be able to have a special event on a book that you'll be hearing much more about in just a few moments. I do want to say at the beginning that today's event would not have been possible without generous support from the Gilbert S. Oman and Martha A. Darling Health Policy Fund. And Martha Darling is here with us today and we're delighted to have you with us. Thanks for joining us and thank you for the support. Well, thanks again for joining us today as we both celebrate and learn from the researcher of our very own Professor Jim House. It's always really exciting to be able to showcase and recognize the work of one of our colleagues and a new publication. But it really is a particular pleasure with today's book, Jim's latest book, Beyond Obamacare, Life, Death and Social Policy. Jim's research has focused on the role of social and psychological factors in health and illness including the role of psychosocial factors in understanding and alleviating health disparities, social disparities in health. And this new book, Beyond Obamacare, explores those themes making the case that effective health policy begins with comprehensive social policy reforms more comprehensively. Among many distinctions, Jim has been elected to the American Academy of Arts and Sciences, the Institute of Medicine and the National Academy of Sciences. He has been a part of the University of Michigan's research family since he graduated with a PhD in 1972, becoming one of the university's very select distinguished university professors in 2008. At the Ford School, he taught courses in socioeconomic policy and health policy. And in 2013, he delivered the Henry Russell Lecture, which is considered the university's highest honor for a senior faculty member. Jim retired in 2014, and although he's added emeritus to his title, he remains a very impactful scholar and certainly an engaged member of our extended family here at the Ford School and the university more generally. Jim, your colleagues and I are so proud of your book and of our continued engagement with you, so thank you very much for being here for this book release. Well, before Jim begins, I'd like to briefly introduce our moderator, Paula Lance. Paula is professor of public policy. She joined the Ford School faculty this year as our very first associate dean for research and policy engagement, and we're delighted to have her here back at Michigan and in particular moderating this special panel. After Jim's remarks, Paula will introduce our discussants, Helen Levy and Richard Lichtenstein. We're delighted to have both of them here with us today, so a very big thank you for joining us. So just a quick note before we get started about the format. Jim will provide just an overview of his book and some of its major points. He will then join Helen and Richard for a moderated conversation, and then there'll be time for questions from the audience. So as you came in, you should have gotten a card around 4.40 p.m. or so. Our staff will be walking up and down the aisles to collect cards for questions, and they'll continue to do so. And we welcome your questions for that session. If you're watching online, please tweet your questions to us and use the hashtag policy talks. So it is after the program, I should mention that in our great hall we are delighted to host a reception, and there will also be copies of the book Beyond Obamacare available for purchase and for signing by Jim House. And so we invite you to stay to continue the conversation at that point and to get your own book signed. So with no further ado, it is my great pleasure to welcome Jim House to the podium. Jim, the floor is yours. Everybody hear me okay? It's not one of my strong points. But let me thank Susan for the kind introduction. And I guess my role today is at least initially to offer a brief overview of the book as a context for both the discussions, comments, and the questions that you, the audience, may have. And hopefully perhaps to entice you to invest in an inscribed copy of the book. Let me also just start briefly with some, a few thank yous. There are really many that are represented in the book. But I particularly want to thank the people who the book is dedicated to. Several of them are here. My wife, Wendy, Bob Kahn, my longtime mentor and colleague, and Bob Cheney, who as a colleague has helped to bring me into the realm of public policy. Since she's also here, I just want to acknowledge Rhea Kish, who is like Bob, a nonagenarian going on Centenarian, who gracefully edited the entire first draft of the manuscript. And it was a bigger mess then that it is now. So also thanks to Paula and Helen and Rich for their willingness to join in today. I'd also just briefly like to acknowledge the various educational and research contexts that have trained and supported me over my career in leading up to this book. And especially to thank the Ford School for providing me a late career opportunity to focus more on public policy implications of my work. And for sponsoring today's event with the support very kindly of the Oman and Darling Fund and with arrangements today by Cliff Martin, who's been exceptional in that regard. And also I should probably give special acknowledgement to the Russell Sage Foundation, which enabled me to begin the book as a visiting scholar in 2010-11 and to actually get it published four years later. Let me just offer to start with a brief disclaimer and emphasize that the goal of the book is to get us to move beyond what has been the core of American health policy, but not to undo or leave that policy behind. The book's table of contents give a sense of the territory that it covers and which I'll try to go over briefly today. You'll generally be able to tell which chapter I'm talking about at a given point as the first number in each table or figure indicates the chapter that it appears in. So let me begin with just where I started from in thinking about this book. For over a century, I think one could say American health policy has become increasingly what I have called a supply side policy with three major components. One, enhancing biomedical research and training of health practitioners, expanding availability of and access to biomedical health care insurance, and thirdly, trying to keep both of those processes as cost effective as possible. And this concern has become increasingly front and center since the 1970s, as you're well aware. For the past century, the major basis for evaluating health policy has been the health of the American population, which generally improved enormously in the 20th century, with life expectancy increasing from 45 to 50 years around 1900 to over 75 years by the dawn of the 21st century. For the first two thirds or so of the century, American spending on health was among the highest in the world, but it was not exceptional compared to other comparable countries. And about the same could be said about our health outcomes. Thus, America's supply side health policy seemed to be working well with a major continuing goal of expanding availability of and access to health as other nations were doing even more rapidly than we. However, since the 1970s, America has been confronting a growing paradoxical crisis of health care and health. That has two components. The spending side of the crisis is well known and increasingly acutely felt by individuals, families, organizations, and governments. Figure 1.1, and in all of the figures you're going to see of this type, the white line, tracks the U.S. performance and compares it to a select but broadly representative group of other developed nations, two relatively low spenders on health, the U.K. and Japan, who spend in the range of 8 to 10 percent of GDP on health, and the next highest spender after the U.S., Switzerland, and the country that is most similar and nearest to us, Canada. In 1960, as you can see, the U.S. was among the several biggest spenders on health in the world, but not highly distinctive. Since 1980, however, the U.S. has increasingly diverged from these and all other nations, currently spending almost 18 percent of our GDP on health, projected to grow to over 20 percent in the next decade. To put these figures in another context and perspective, U.S. spending on national defense, aside from World War II, peaked at 13 percent of GDP at the height of the Cold War in the 1950s when President Eisenhower warned against the power of the military industrial complex. Today, spending for health increasingly dwarfs current and past defense spending, and we have what could be called a medical biotechnology complex that is larger and arguably more powerful than the military industrial complex ever was. These trends have broadened health care reform goals to increasingly make controlling spending equal rival of expanding access. One might expect and many believe that our higher spending level gives the U.S. comparably high returns in terms of population health. Paradoxically, and not yet quite as widely recognized, the reality is quite to the contrary, especially for Americans, women, and children. Figure 1.6 shows that U.S. infant mortality has gone from one of the lowest among developed nations in 1950 to among the highest since 1970. More strikingly, and this is a process that is ongoing, American female life expectancy in the 1950s was the equal of any other nation. Since then, and especially since 1980, American women increasingly lag precipitously behind women in virtually all other developed nations, now by two years, for example, compared to women in the United Kingdom and up to six years compared to women in Japan. American women have also lost almost three years of the nearly eight-year advantage in life expectancy that they held relative to American men in 1980, and those men have themselves been increasingly lagging behind their male counterparts in comparably developed nations. For some health indicators and more disadvantaged parts of the population, women's mortality experience is actually worsening absolutely and a relatively unprecedented phenomena in a highly developed and wealthy country. So between 1980 and 2008, advances in women's life expectancy actually were diminished for all less educated women, and among the least educated, there was a decline of almost five years as shown in the left side of the figure you're looking at. In 43% of U.S. counties, by a recent analysis, female life expectancy is actually declining, a pattern that could characterize almost all American women within several decades, unless current trends are reversed. One small contributor to this declining female life expectancy is an absolute increase in maternal mortality. Oops, getting ahead of myself here. In the U.S. as shown in figure 1.7, which is again unprecedented in highly developed countries. Thus, America's current health policy problems and indeed crisis go far beyond just increasing access to health care and insurance, and increasingly are simultaneously trying to reduce spending for health care and insurance while at the same time improving population health, and those may sound almost contradictory. Reform of the American health care and insurance system has been elusive and partial due to the particularly and peculiarly fragmented nature of American government and our social welfare system, which assigns to the private sector major responsibility for programs, especially pensions and health insurance that are almost entirely in the public sector in comparable nations. After repeated failures to achieve comprehensive reform of health care since the creation of Medicare and Medicaid in the 1960s, the Patient Protection and Affordable Care Act of 2010, a.k.a. Obamacare, was a notable political achievement with at least four major goals as shown in table 2.1. The prognosis for achieving most of these goals, however, remains quite guarded. While substantially expanding insurance coverage and access to care, Obamacare will likely have its best marginal success in either controlling health expenditures or ameliorating the worsening of Americans' population health. This somewhat dour assessment reflects the range of projections being made for the impact of the law, including quasi-experimental and experimental evaluations of the Massachusetts Health Care Reform of 2006 and an early reform of Medicaid expansion in Oregon in 2008, respectively. In addition, we have seen increasing evidence that the Obamacare's potency has been and is being greatly diminished by the political compromises made to achieve its passage and by the opposition and obstacles it has faced since and continues to face. More fundamentally, Obamacare, like all prior health care reforms, is largely a supply side policy focused on expanding and managing the supply of health services and the pricing of them, rather than on altering the major driver of the demand for health services, which is the health of the population itself. If Obamacare and health care reform more broadly cannot solve our current health policy crisis, then what can? My answer is a new demand side approach to health policy grounded in the science of social determinants and disparities in health. The fundamental source of America's paradoxical crisis of spending more and more on health care and getting less and less in terms of health outcomes is the seemingly intuitive but unfortunately erroneous assumption that health care is the primary determinant of individual and population health. While health care is important to health, it is much less so than we customarily think. Logically, this reflects the fact that health care most often comes into play after we are already sick or injured, often seriously slow, and health care frequently cannot cure our illness or injury, but only help us to manage its further course. Empirically, multiple estimates suggest that health care accounts for probably only 20% or so of the variance and change in population health and certainly less than the assumed 50 to 100% that underlies our current supply side approach to health research, education, practice, and policy. This estimate reflects but goes beyond the important shift over the last century from infectious diseases to chronic diseases as the major sources of morbidity, disability, and mortality. For example, historical demographers and epidemiologists discovered that modern medical health care had not actually been the major determinant even of the decline of infectious disease mortality from the mid-18th century through the mid-20th century as had previously been assumed. Most striking was the work of the medical demographer Thomas McCune. We're looking at the decline of tuberculosis mortality in England and Wales between 1838 and 1960 as shown in Figure 3.3, and tuberculosis has been referred to by Susan Sontag as the cancer of the 19th century. TB mortality declined from relatively epidemic proportions in the mid-19th century when it accounted for 20% of all deaths to almost nothing by 1960. However, 50% of this decline occurred before Robert Koch had even discovered the tubercle bacillus, and 80 to 90% occurred before the development of effective pharmacological treatment and vaccination against TB. Others produced similar analyses of the decline of many other infectious diseases over this period, with vaccination proving the major determinant of such declines only for three diseases, smallpox, whooping cough, and polio. Another perspective on individual and societal health has existed since ancient times in the antinomy between the Greek goddesses, hygia, and panacea, and later in the 19th century, beginning in the 19th century, between the traditions of social medicine and biomedicine. In this alternative view, the health of individuals and populations is primarily a function of their ability to adapt and thrive in relation to the environments and conditions in which they live and work. It is these conditions of life and work that mainly shape health with health care more a response to health problems than a primary determinant of health. To understand chronic diseases, biomedical research had to move outside of the laboratory and clinic and develop a new conception of the etiology of disease and a new research design for studying it, the long-term population-based perspective study, which sought to identify characteristics of people that predicted onset of major morbidity or mortality in persons free of disease at entry into the study. Studies in places like Framingham, Massachusetts, Tecumseh, Michigan, and other communities identified first physiological variables like blood pressure and cholesterol as major predictors of cardiovascular morbidity and mortality. These were not, however, the necessary and sufficient causes that bacteriology and virology had discovered for infectious diseases, but rather what came to be termed risk factors that increased the likelihood of disease onset acting multifactorially with a range of other factors. Through these and other methods, the adverse health effects of environmental toxins and pollutants became increasingly well-recognized beginning in the middle of the 20th century or even a little before that. In the 1960s, it became clear that risk factors were not only physical, chemical, or biological, but also behavioral. As can be seen in figure 3.1, the 1965 Surgeon General's report on smoking and health showed that the emergence and growth of the production and consumption of cigarettes in the early 20th century led with a lag of 20 to 30 years to a mid-century epidemic of lung and other respiratory cancers while also contributing to increases in cardiovascular disease and non-respiratory cancers. By the 1980s, a major public health effort, most importantly increased taxation of cigarettes and major restrictions on where they could be smoked began to achieve a substantial and continuing reduction in smoking and declines in cancer and cardiovascular disease have followed by the end of the century again with a 20 to 30 year lag. The range of behavioral risk factors expanded beyond cigarette smoking to include lack of physical activity and immoderate levels of alcohol consumption and eating or weight. From the 1960s through the 1980s, I and others sought to identify through similar perspective epidemiologic research major social and psychological risk factors for morbidity and mortality. By the mid-1980s, stress and work and other aspects of life, a number of psychological traits and perhaps most striking lack of social relationships and supports had been shown to be risk factors for health comparable to blood pressure, cholesterol, smoking, and other behavioral risk factors. In a 1988 article in Science, I and my colleague showed the congruence as in figure 3.2 of our own and other research in the U.S. and Europe indicating that a low level of social integration or relationships produced a doubling or more in the risk of death from all causes, which is exactly the same thing that cigarette smoking does. Unfortunately, both medical care and non-medical risk factors for health are often quite unequally distributed by race, ethnicity, socioeconomic position, gender, and combinations thereof, perhaps especially and increasingly so in American society. During the first decades after World War II, social inequalities or disparities in health were curiously ignored even as research on social determinants of health moved ahead. Things changed markedly in the 1980s. The seminal document and event was the report of a commission established by the labor government of the United Kingdom in the late 1970s to investigate how the first quarter century of operation of their national health service had affected socioeconomic disparities in health. The commission's report, known as the Black Report after its chair, Sir Douglas Black, who is the U.K. equivalent of our Surgeon General, surprisingly showed that socioeconomic health disparities were still large in the U.K. in the 1970s and virtually undiminished by a quarter century of universal access to health care through the NHS. The report was delivered to the new conservative government of Margaret Thatcher in the beginning of the 1980s, which proceeded to issue 250 copies of the report on a bank holiday with a preface by the Secretary of Health essentially saying that we're not sure we believe your findings and even if we did, we could do nothing about them. Reissued by Penguin Press, the report ultimately became a sensation in social epidemiology and certain areas of public policy in both the United Kingdom and internationally. Research in other Western European and North American countries, including Canada and the U.S., replicated wide socioeconomic disparities in health little changed by the spread of systems of national health care and insurance. The 1980s saw a similar rediscovery of racial ethnic disparities in health. Evidence since then suggests that social disparities in health, both socioeconomic and racial ethnic, have generally increased further over the past quarter century. In the late 1980s, my own research group had a similar epiphany regarding socioeconomic disparities in health. In 1986, we launched something called the American Changing Life Study, or ACL, a long-term national prospective study of the role of social, psychological and behavioral factors in the maintenance of health and effective functioning over the adult life course. It was conceived and fielded before the widespread rediscovery of socioeconomic disparities in health, so this was not initially our central concern. However, our first analyses of our 1986 survey focused on how the relation of age to health varied as a function of a wide range of social, psychological and behavioral risk factors. As it turned out, socioeconomic position as indexed by education and income proved most powerful by far in shaping these relationships. Slide 4.4, or figure 4.4, graphs by age and for different levels of education, the proportion of people who in 1986 reported no functional limitations. That is, they said that they could do heavy work around the house such as shoveling snow. As you can see at the age of 25, few people manifest functional limitations. But functional abilities declined linearly with age among people with less than high school education, while the college educated continued to show almost no limitations until somewhere between their mid-50s and mid-60s, and those with intermediate education lie in between. These are large differences, 20 to 30 percentage points in middle age. I'll use the arrow here for a second if it works. If you look across here, it were conceived another way, 20 to 30 years in difference in the age of onset of substantial or significant limitations. As the end of life, where as John Maynard Cain said, in the long run we all are dead, socioeconomic differences again narrow. One cannot be sure from cross-sectional data that these patterns are a product of the way health changes with age as a function of education. However, we now know from our longitudinal data through 2011-12 that this is the case. We have seen similar results by income, and we and others have also shown similar socioeconomic differences in mortality over the life course, and have also analyzed racial ethnic disparities in conjunction with socioeconomic ones. These social disparities in life expectancy range up to 10 to 15 years. We now understand, as shown in this table, for example, that socioeconomic factors can account for 50 to 75% of racial differences in mortality, especially for men, so if you see the overall racial difference is 4.9 years as of this particular population and time, and that difference is essentially cut in half when you start looking within particular income groups. Further, the income difference that you observe both within the white and particularly in the black population is even larger than the racial difference that you observe. However, it's also the case, as you can see, that there remain racial ethnic differences at all socioeconomic levels, and factors such as discrimination and segregation, we now know, have significant adverse effects on health over and above those from socioeconomic position. We now understand that socioeconomic position, which is here, which is itself a function of age, gender, race, ethnicity, and broader social, political, and economic conditions and policies constitutes what some have termed a fundamental cause that shapes individuals' exposure to any and all risk factors for health, medical care, psychosocial risk factors, environmental risk factors, and the like. Our ACL study has been, we've also documented and others have socioeconomic disparities in medical care and insurance and exposure to environmental hazards and in health behaviors from smoking, through eating, drinking, and exercise to obesity. Our study has been more uniquely able to show similar results for social and psychological risk factors, and for virtually every risk factor that we can measure and that we and others have shown to predict adverse health outcomes, there's a marked gradient by education and also by income. We've also shown that if education and income did not produce such pervasive differences in exposure to and experience of these risk factors, socioeconomic disparities in health would be commensurately reduced. In our original cross-sectional data, statistically adjusting for income in a set of 11 behavioral, social, and psychological risk factors, reduced educational disparities by 70 to 80%, as shown by the dotted lines here, which are superimposed on the figure that you just looked at. All that we and others have done longitudinally produces results consistent with these data. Thus these socioeconomic factors are particularly important and potent for health science and policy because of their wide-ranging impact on virtually all health or risk or protective factors, including new ones as they arise. And because they show us where in the population are the greatest opportunities for improving health. Given the relatively modest relation of healthcare and insurance to health and the large impacts of social determinants and disparities on health, it's not surprising that there is essentially no correlation across countries, as shown in figure 3.4, between spending on medical care and insurance here as a percentage of GDP and life expectancy. Or there is actually a decidedly negative one if we include the egregiously outlying point of the United States. Little wonder that spending more and more on medical care and insurance has not produced commensurate gains in population health. Over the last decade, culminating in my book, I've increasingly focused on the implications of all of this for current debates on health policy and broader social and fiscal policy. There are several implications from what I've said thus far. First, America is paradoxically paying more and more for healthcare and insurance, but getting less and less in terms of population health outcomes. Second, this paradoxical crisis derives from the understandable but unfortunately mistaken belief that healthcare and insurance are the major determinants of health and hence the only proper domain of health policy, including Obamacare. Third, there's little reason to believe that Obamacare or any other proposal for supply-side healthcare reform will more than marginally either improve population health or restrain the growth of spending for medical care and insurance. What is required is essentially a demand-side policy that reduces expenditures by first improving population health via a broad range of public and private policies outside the domain of current supply-side healthcare and insurance policy. That is, we need to use what we've learned about the nature and sources of social determinants and disparities in health to promote public and private policies that enable more and more people, especially disadvantaged socioeconomic, racial, ethnic and gender groups, to live and work under conditions that protect and promote their health. Let me just, in interest of time, skip over a couple of things. All of this further means that virtually all social policy is in fact health policy, and just as we evaluate the environmental impacts of a wide range of seemingly non-environmental policies, we need to evaluate the health impacts of seemingly non-health policies and to consider the results in our analysis of the costs and benefits of those non-health policies. So let me close with two related points. First, we now know that we can improve health through a very broad range of public and private policies. Second, we also know, all that we know, I'd say, indicates that a healthier population spends less and less rather than more and more on healthcare insurance. Most widely recognized and discussed at this point and probably also most intuitive are the ways that agricultural, transportation, housing, urban and land use policies have adversely affected patterns of smoking, eating, drinking and physical activity and hence body weight, and the ways that these policies we now know can be modified to improve patterns of health behaviors and hence health. We've similarly recognized the potential adverse health impacts of physical, chemical and biological environmental conditions and increasingly have found ways to mitigate at least some of these. In addition, however, both prospective epidemiologic data that we've already discussed and field experimental research in the U.S. and other countries has now documented substantial health impacts from a wide range of socioeconomic policies. Let me briefly note newer experimental data in the five major areas shown here. For example, when states in the U.S. or nations across the world increase the number of years of compulsory schooling, people affected by those changes live longer than people who just missed falling under the new compulsory schooling policy. Similarly, children randomly assigned to receive enhanced preschool education have better health, well into adulthood than those who randomly did not receive that enhanced education. And $10,000, this partly comes from the work of one of our colleagues here, Sue Donarski, in financial aid to a post-secondary student results in 1.6 years of additional education, which in turn translates from other knowledge that we have into anywhere between a third and a full year of additional life expectancy. In contrast, economists estimate that it takes $30,000 to almost $150,000 in health expenditures to yield an additional year of life expectancy, depending on the point in the life course that these expenditures are made. Experimental studies in the U.S., Latin American countries in South Africa, have shown that increasing the income of individuals and families is beneficial to their health at points from early life through old age. And job loss during major economic downturns produces a reduction in life expectancy of 1.5 years or more due largely to attend to $15,000 permanent loss in annual income. Laws that broke down de jura and de facto segregation in schools, housing, and access to medical care have now been clearly shown to have improved the socioeconomic and health levels of African Americans. And a major experimental study has just shown that moving people out of public housing into socioeconomically better neighborhoods reduced levels of obesity and diabetes among those randomly assigned to move compared to those who randomly were left in their original poor public housing neighborhoods. All of these socioeconomic policies impact a wide range of risk and protective factors for health, and they also have other non-health benefits. Thus, a wide range of social and economic policies affect health, perhaps most notably education income and employment policies, ranging from support for public education to student financial aid to social security, earned income tax credits, the minimum wage, and employment and unemployment policies. We have yet to planfully evaluate the health effects of such policies on a large scale, but it's plausible that since the 1970s the U.S. has been running a perverse national experiment in moving many of these policies and consequent levels of education, income, and employment in directions adverse to health. Trends in education and income are perhaps clearest in these regards. As many of you may know, from the 1970s through the end of the 20th century at least, levels of high school and college graduation essentially plateaued in the U.S. After having written steadily between 1900 and 1970, as seen here in Figure 1 for high school graduation in Figure 2, 9.2 for college. And the current U.S. ranking on educational, intergenerational educational mobility, that is, do children do better than their parents, as seen in Figure 2, 9.3, eerily mirrors our rankings on population health outcomes. We are 23rd in this list of, or 20, I think out of 23 in this list of OECD countries. Similarly, growth in earnings has plateaued since the 1970s, as seen in Figure 9.4, and the real value of the minimum wage has steadily declined. These changes have arguably driven declines in health with a consequent rise in health expenditures, which I must say this is all still a hypothesis, but worthy of more research. Finally, do healthier people really spend less on medical care rather than spending more in order to make themselves healthy? Maybe happy, maybe happy too. Recent research indicates the answer is yes. On an annual basis, people in better health, including those from more advantaged racial, ethnic or socioeconomic groups, utilize less health care and spend less on it. And projections that are much more solidly based on past empirical evidence than those regarding the hope for economic savings from health care reform show that healthier people spend substantially less over their lifetimes, even though we all make most of our medical expenditures in the final years and even months of our lives. For example, as shown in Figure 8.1, simply being obese at age 50 results in 15,000 more in lifetime health expenditures compared to the non-obese. This differential would be much larger if conditions often associated with obesity, such as hypertension, diabetes, or musculoskeletal problems were also considered. Returning to where we started today, suppose that the population of the United States had levels of population health comparable to other highly developed nations instead of our relatively worsening population health parameters, what would be the implications for health care spending. We now have a first estimate from a micro simulation model of the American population age 50 and over using parameters drawn from the National Health and Retirement Survey done here at the Institute for Social Research. If the U.S. population age 50 and over came gradually over a period of 25 years to have the same average level of serious diseases and health risk factors as those in major European countries, this would first erase the 1.2 year gap in life expectancy between us and those nations at age 50. More importantly, there would come to be savings of 60 billion current dollars annually in public spending for Medicare, Medicaid, and disability benefits, or over half a trillion current dollars over a decade, analogous to the projected savings from Obamacare and other health care reform proposals, the impacts of which remain uncertain at best. These spending trends can be seen in the next figure, and here just focus on the blue, which is the spending for health expenditures as essentially each new age group, 51-year-olds, 52-year-olds, as they come in the population have health that matches the European numbers. By the time you go out 20, 25 years, you're saving 60 billion dollars a year, and those savings continue pretty much indefinitely. Equally large savings would occur in private spending on health, which does not necessarily happen under health care reform proposals that focus on the public sector and may merely shift costs from government to private organizations, families, or individuals. All of these savings would be larger still if people below age 50 are also included, or if the US's health is allowed to improve beyond the average of major European nations, or if these changes occurred more rapidly than over 25 years or extended beyond 25 years used in this projection. The potential total savings would then be in trillions of current dollars in the range of the expenditure reductions currently seen as necessary to create more sustainable overall budgets for government at various levels, not to mention organizations and individuals suffering under the burden of rising health care costs. Efforts such as Obamacare to reform health care insurance cannot and should not be abandoned as we need to do all we can to achieve universal access and to make the soon to be 20% of the GDP spent on health as cost effective as possible. But in addition, we need a demand side policy that improves levels of population health via broader social policies and determinants of health, especially at middle and lower socioeconomic levels and for disadvantaged racial and ethnic groups where the opportunities for health improvements are greatest. Improved population health decreases the need, the demand, and hence the expenditures for health services. Just as deescalating the Cold War did more to shrink our spending on national defense than efforts to make the military industrial complex more cost effective. So this demand side approach to health policy is likely to have larger and more certain effects in both improving population health and reducing health, spending on health care and insurance than Obamacare or any alternative proposals for health care reform on the supply side. Thank you. Good afternoon. It's really an honor to be part of the event this afternoon for many reasons. But the most important of which is that I came to the University of Michigan in 1994 to do a postdoctoral fellowship in health policy. And Jim was my main mentor. I have been privileged to learn from and worked with Jim for over two decades now. I can't begin to express my gratitude to Jim and his wife, Wendy, for how wonderful they've been to me all this time. And again, how much I've learned from Jim over the years. He's had a tremendous impact on my own career. And I'm delighted this afternoon. We also have two terrific people who are going to provide some comments and reactions, first of all. And then we're going to turn it over to all of you. And I do want to remind the people who are joining us online that if you have a question you want to ask, so please tweet that using the hashtag policy talks. So today we have with us Helen Levy, who is an economist and a research associate professor at the Institute for Social Research at the Ford School of Public Policy here and also the School of Public Health. Her research interests include the causes and consequences of lacking health insurance, evaluation of public health insurance programs, and also the role of health literacy and explaining disparities in health outcomes. And we also have with us today Professor Richard Lichtenstein, who is the SJ Axelrod Collegic Professor of Health Management and Policy. Dr. Lichtenstein's research interests include community-based participatory research, racial and ethnic disparities in health, and barriers to health insurance coverage for low-income children. You can read more about their terrific interests and also some of their side projects and activities in addition to their academic ventures, but I'll turn it over to them right now. Helen will lead us off and then Rich will follow up. So let me start by congratulating Jim on his book, which represents the remarkable synthesis of facts and ideas. Jim, I learned so much from every conversation with you, and the book was a very forceful reminder of that. The book is Distilled Essence of Jim House, and as such it is wonderful. The connections across disciplines, across policy domains, across areas of human activity reflect a remarkable depth and breadth of intellect. Now, depth and breadth of intellect are not necessarily the things you think of if you hear the words Washington DC, and I want to talk a bit about some of the things that lie in the space between the vision that Jim's book lays out for a more enlightened social and health policy and some of the immediate concerns that are part of the implementation of the Affordable Care Act. So you can think of my comments as a much less visionary beyond Obamacare. And I'm going to come back to the issues raised in Jim's book, but I want to start by talking a little bit about the Affordable Care Act itself. The Affordable Care Act is often described as having had two goals. Jim said four, but I only have five minutes, so I'm going to say two. One of those was to cover some of the approximately 50 million people who were uninsured at the time that the law was passed, and the other goal was to try to do something about controlling the growth rate of health spending. And these are quite different goals from each other in a number of ways. An important one is that for the first one covering the uninsured, this was not a difficult problem from a policy perspective. So there were lots of policy proposals that had been sitting around for literally decades for how you could do this. You could expand Medicare and Medicaid. You could have tax credits. You could have an employment. There are lots of ideas for how to do this. And the hard thing about covering the uninsured was getting the political will and the political coalition to make it happen. And conditional on having that, pick any one of these policies off the shelf and it's going to work. And in fact, that is what we're seeing because the fraction of the population that's uninsured dropped from 13% to 10% as soon as the law was. The coverage provisions of the law went into effect in 2014. So that part of the policy wasn't hard from a policy perspective, and it seems to be working. Now, the second goal of the Affordable Care Act had to do with slowing the growth of healthcare spending and getting more value out of the spending that we do, and that's much harder to do because we don't really know how to do it. There's also questions about the political will to do it, but we actually don't have a bunch of great ideas about how to slow spending in a way that preserves the things we spend money on that are valuable and selectively cuts out the spending just on stuff that's wasteful. So what the Affordable Care Act did on this front in light of this sort of gap in our knowledge about how to solve this problem was try a bunch of different things. So some examples of the, I'll call them experiments in the Affordable Care Act of how to get more value out of health spending. Some examples of these are instead of paying doctors in Medicare which thing they do pay them more if they do less but keep their patients healthy. It's so crazy, it just might work. Another example is instead of paying hospitals more when their patients acquire infections while they're in the hospital to actually penalize hospitals for that. And another example that's actually been in the news lately is imposing a tax on very, very generous health insurance plans. This is sometimes called the Cadillac Health Insurance Tax. It's been in the news for the past couple of weeks and even just this morning was in the New York Times both because there's a move in Congress to repeal this element of the Affordable Care Act and then today because Hillary Clinton came out and said yesterday that she supports the idea of repealing it. The idea of repealing it is not a popular idea with economists. Probably yes. In any case, what these and other things in the Affordable Care Act are essentially doing is we're bumbling around trying to find different ways to reduce spending in ways that don't harm health. Now coming back to Jim's book, the vision that he lays out in the book is that if we spent more on basic things like quality education and social programs like food stamps or the EITC or SSI people would ultimately be healthier and in the long run would need less medical care and so they'd spend less. So in a nutshell he's arguing that these social policies are a very cost-effective way to deliver better health. And the economist in me says that even if we did these things we're bumbling around with these other attempts to cut costs in the system for a number of reasons. The first of which is that the social determinants approach doesn't do anything to distinguish between the medical care that's useful and the medical care that's wasteful that we pay for even if it improves the profile of population health. It also takes a long time relatively speaking and my reading of the numbers is slightly different from what Jim said. My reading was that it wasn't actually saving enough money to actually ensure that Medicare will still be there for me, let alone for my kids. And those are the kinds of numbers I'm looking for when we talk about reducing health spending. Now I don't mean to suggest that Jim argues in the book that the social determinants approach ought to replace other approaches. He's quite up front about that. These two types of policies, the sort of grab bag of cost control efforts that I've talked about and the more coherent vision that Jim lays out in his book, they're compliments not substitutes. It's not an either or situation. And so I think that even as folks in Washington continue to experiment with ways to try to turn off the spigot of healthcare, especially federal and state healthcare spending a little bit in ways that don't harm health, I think the value of Jim's book will be to add to those debates a longer term and broader perspective that suggests we need to think outside the healthcare for other solutions to this problem. Thank you. Good afternoon. I appreciate the invitation to speak here. Let me just start by saying that Jim has had a very big effect on my career. Also, he was on my dissertation committee, which was chaired by Bob Kahn long ago, so I appreciate that very much. And I've read what he has written and have really incorporated into a lot of the teaching that I do at the School of Public Health. So let me start by saying that I am a total adherent to the idea of the demand side that Jim is talking about. I also run into the same problem I think he had writing this book, which is I teach kind of aspiring health administrators, hospital administrators, policy people and health physicians about the healthcare system. And they're very committed to it and they have a lot at stake in the health system. And I also try to tell them that the healthcare system is not the only way to create health. In fact, as Jim described beautifully in his book, it doesn't even make a big difference on the margin anymore. So I'm interested in racial and ethnic and socioeconomic disparities. I'm interested in inner cities. It's very important for me to tell people that just providing more healthcare is not going to end those health disparities. The inequalities in health between the poor and the rich, between blacks and whites, Latinos and whites, it's just not going to do it. So one of the things I try to do when I teach people, especially physicians who work in inner cities, is to tell them that you're not going to make a difference in health just working hard all day inside your office, treating patients exactly the right way. Because think about it, somebody comes into an office with diabetes in Detroit. The things that a physician is going to tell that person is. First of all, I want you to start eating fresh roots and vegetables. And second, I want you to get exercise. I want you to go out and jog. I want you to walk a long way. And if you've been in parts of Detroit where I work, you know that there's no fresh roots and vegetables available. And you know that it's not safe to walk and most times people can't do it. I'll tell you an example of how we've enabled people to walk. But the point is just going with the medical care side doesn't really solve the problem. You really need to think more broadly. You have to get outside the walls of your office or your hospital. And you have to really get involved in population health, which is what the Obama administration tried to do in the Affordable Care Act by trying to give hospitals incentives to improve population health. It's very hard to tell hospital administrators you've got to serve the community because you're not going to get reimbursed for that. But that's something that I think is really important. So let me give you a case study about how Barbara Israel, who is kind of the leader of a big effort we work, she wouldn't use that term. She would say the facilitator. But she's a colleague and she and Paul actually was involved in this and several faculty at the School of Public Health at the nursing school and public policy and social work and medicine. We went into Detroit in 1995 to try to really do something about health inequalities in Detroit. We got a bunch of community-based organizations to agree to partner with us on an equal footing. That's a whole other story, really changing the way we do research in Detroit. But we got eight different organizations to sign on with us. And we sent in the proposal to David Satcher, who is the head of CDC. Later he became the Surgeon General. And a couple of months later, we found out we got funded and we had to go back and talk to these organizations that we had talked to and say, now we're ready to do it. So I just want to tell you, first of all, the nature of the organizations that we partnered with to improve the health of people in Detroit. And then I'll tell you what their reaction was. So I'm just going to list a couple of the sectors in which they were active. So one was dealing with housing in a low-income housing neighborhood. Another was doing job training and economic development work. Another was doing education in the public schools. One was dealing with youth violence on the east side of Detroit. Another was community center that tried to provide activities, healthy activities for kids on the east side of Detroit. A behavioral health organization dealing with substance abuse and mental health problems. An environmental justice organization, which deals with some of the terrible pollution that it goes on in parts of Detroit. And then finally, a federally qualified community health center. So only that last one is a real health provider. All the others deal with the social determinants of health. The funny thing was when we went back and these organizations that signed on with us found out we got the grant, they said, why do you want to partner with us? We have nothing to do with health. We provide jobs for people. We do education. And that's the whole point. That's how you improve health. You upgrade people's education, their income. You get them physically active. You, you know, all these other things that really don't have much to do with clinical work is really the way we saw improving health. And we've been quite active for 20 years now doing projects with community members, not on communities, but with community members. And let me just give you a sampling of the kind of things that we've been dealing with. So first of all, that whole issue of they're not being fresh fruits and vegetables in Detroit. I don't know if you know this, but up until a few years ago, there were no national grocery stores or supermarkets in the city of Detroit. So you had to go to party stores to get fruits and vegetables, and you can imagine the quality of those fruits and vegetables there. Very hard to get wholesome food, be nutritious. People eat bad foods. You get, you know, obesity is something that's going to arise out of that. So we tried to deal with that problem. Lack of places in which to be physically active. We have a project that works. It's about heart health, and they actually have developed several different walking groups around Detroit where people get together and they have charted out safe areas to walk in, and they met two or three times a week and they walked quite a long distance. They had a really great time interacting with each other. They really enjoyed doing it, and they lost weight and their blood pressure went down. So these are things that can be done without a clinician and a stethoscope. To try to improve people's health. We work on youth violence, gang violence. It's kind of hard stuff to deal with, but that's how you try to improve the youth health in Detroit. And the quality of the public schools. We actually tried to work with that. That was very hard to do in Detroit because they're closing schools every time you turn around, and that was kind of the issue. And we also tried to work with community partners to talk about how do you approach policymakers and get them to change health policies. Or some of the other policies, like air pollution in Detroit is a big health issue. How do you deal with that as a community resident who doesn't want another bridge span coming through your neighborhood, which is what's going on in Detroit right now? So I can't tell you that we solved the problems of Detroit. I can't tell you that people are by and large much healthier than they were 20 years ago. But I do know that we have made really good inroads into the health of many of the people that we work with. And that despite the fact that I teach about health care and the health care system in my classes, I really believe that the way to go about improving health, especially in places like big inner cities, is through working on the social determinants. So thank you. So we're going to give Jim a moment to respond to some of the comments of our discussants, and then we're going to turn to audience questions. I'll try to be brief. You all have been very patient. Just in general, I thank Helen and Rich for relatively kind comments. On the one point that Helen raised, we all want to be able to preserve Medicare and preserve other programs. What's not clear at this point in time is whether health care reform can produce enough savings to allow that, or whether I won't claim that it's a guaranteed from a micro simulation model that the actual policies will produce the same thing. But I'd say at this point in time, there's at least kind of an equal chance on both sides. And as she started off with it, as I feel, this is not an either or situation, but it is a situation where we need to restore kind of balance to thinking about health policy and not treat it as entirely a problem of health care and insurance. Rich's comments reflect that. And again, there's nothing that I'm saying when I focus a little bit more on broader national policies that contravenes the idea that one should be doing things in the community. I would only say that it would be a lot easier in communities if the national policies were flowing in the same direction rather than communities trying to work against the tide of a national policy that's going in other directions. Can you hear us? Okay. Well, first of all, thank you all for being here. It's been really interesting to hear all your comments today. My name is Danielle Farrow. I'm a second year MPP here at the Ford School. And I'm Dennis Jane. I'm a senior studying political science. Okay. So to start us off on the Q&A, one of the first questions that we got, which is a big one, is single-payer system the way we must go? I think I'll yield to Helen for the best part on that. All I guess I would say, again, what I find when I talk about these things is that the questions come back to questions about health services and healthcare and insurance. And what I'm trying to do is move the conversation beyond that. That's not to say that that other conversation is not important. I would say that the evidence indicates that, yes, a single-payer system from my perspective probably could get better control of healthcare costs. On the other hand, the evidence we have from other countries is they're not absent the policies that we have. The development of universal insurance in Canada did not solve all the problems. So that is not a panacea for everything. But I'd say Helen's much more qualified to talk about this. I mean, you know, I think we do have single-payer for people over 65. And it works well in some ways and has problems in some other ways. And I don't think that that is the only way to achieve equitable and efficient outcomes. And certainly there are the examples of, say, Germany, the Netherlands, and Switzerland, all of which have universal coverage built around employer-based systems more or less like we have for people under 65. And those systems seem to work pretty well, too. So no, I guess I don't think that single-payer is the only way to go, which is good, because I don't think we're going to get there. The next question is, does enactment of the Affordable Care Act make progress on population health more or less likely going forward? So to rephrase that, can the inadequate quality measures in the Affordable Care Act serve as a foot in the door towards substantial improvement, such as mental health treatment policy? You know, again, I would say, you know, there's nothing, I think the Affordable Care Act includes a lot of good ideas about both dealing with health services and trying to expand things to think more clearly about population health. But if you continue to restrict the discussion to things that are mostly centered within the health care and insurance system and those kinds of ideas, I don't think you're going to get very far. So I just want to make a point that Jim makes several times in the book and said it right at the beginning here and that I always try to make this point, too, which is this, that you can talk about the inadequacy of the health care system improving everyone's health, but that does not mean that the health care system and that health care itself is not important. You know, there was a time in the 70s, I remember, when people were saying, you know, health care doesn't matter, so what difference does it make if people don't get Medicaid? You know, it's not going to help them. There were sort of medical nihilists. And sure, that's easy for people with insurance to say, but you know, I think the issue is we need to have everybody insured, so whether it's, you know, I'm not sure a single payer system is possible, whether that's the right way to do it. I do think we have to get everybody insured so that when all those decades of problems, in terms of social problems that they've lived with cause health problems, people will be able to get treated for them. But I definitely think we have to fix upstream, you know, the things that people live with during their whole lives as a way of trying to improve health. We can't just rely on rescuing people after they've gotten sick by living a lifetime in deprived conditions. Okay. The next question is, how do we incentivize the government and investors to budget more money toward social services and other forms of prevention? And also thinking about the prospect of a potential Republican president and Republican Congress. These are easy ones. I'll start. I spend some time in the book and I get this response all the time. I got it in reviews. Well, this is all very, sounds all very nice, but it'll never happen. Nobody wants to do this. I mean, we just watched over the last year a substantial change in both public and private thinking about the minimum wage that I think two years ago people would have said, nothing's going to happen to improve the minimum wage. Now something's going to happen. That's not just coming out of, solely out of the Democratic or the more progressive side. There are people, other people on the Republican side are doing that. Similarly, earned income tax credits are things that have been done generally in a bipartisan way and even people like Paul Ryan continue to support that. So I don't think, you know, my view on public policy has been shaped a lot by a book by a guy named John Kingdon who used to be in the Political Science Department here and is now in the Brookings Institution. And he says you get policy change when you've got three things, three streams coming together. One is a problem stream. People have got to believe there is a problem that needs attention. Secondly is a political stream. You have to have the conditions to make things happen. But the third one is that there has to be a policy stream that points you in the direction that is actually really going to make a difference. And so it seems to me that, you know, our role in policy is not to necessarily say what is politically palatable at the given moment but to say what we think is actually going to make a difference and hope that at some point things are going to come in that direction. And we've seen that happen in the past in a wide range of areas. And I think we're going to start to see that happen with respect to some of the kinds of socioeconomic policies that I'm talking about. There's also a follow-up question of that. And I think some people in the back are having trouble hearing. So if you could all speak into the links. So in consideration of the multitude of and continuing challenges to health care reform, could you assume that large-scale population health initiatives at the national level will face opposition or will continue to face opposition? I mean, there are lots of opposition. Health care reform continues to face huge opposition. There's always, you know, political disputes about things. But there are moments when we have been able to and, you know, I think to be able to enact both positive changes in terms of health care and insurance policies and positive changes in terms of social policies that impact health. And, you know, as I say, you can't, I think, to go away. And I think that's been a tendency in some parts of the health policy community. As I understand it, the Robert Wood Johnson Foundation set up a group that was supposed to produce by the people who initiated the idea something like the Black Report from Britain. And they essentially start off by talking about social determinants and particularly social disparities in health. And then they almost entirely dropped the subject. And I am told in, you know, this may or may not be true, that this was largely a result of not the Republicans on the committee. It was the result of the Democratic co-chair of the committee who said, oh, we've been there and done that and tried to do stuff here and we can't do it. And, you know, I think, you know, that kind of approach, I think, in the long run isn't going to get us anywhere. That's not to say that you're going to make, you can say exactly when the change is going to occur. But changes like this are going to happen. They have happened and they will continue to happen. Even if you listen to Donald Trump, he talks some of this kind of stuff. Right, so we have a very specific question from a person in the audience. In 1968, Dr. Jack Geiger argued a similar demand-side approach to improving population health in rural Mississippi. He created a community health center but also spearheaded many social improvements in the area to improve health. How would you assess his efforts and why are we still proposing his policy in 2015? So I know a little bit about this. So Jack Geiger was the sort of the grandfather of the community health center movement in the United States. And it turns out that he was trained by two South Africans, Sydney Clark and Emily Clark, who created this movement called Community Oriented Primary Care, which was basically that, as I was saying before, you can't just treat people in the four walls of your clinic. You really have to go out and deal with the issues that are causing them to have health problems. So Jack Geiger studied with them, came back to the U.S., got the Johnson administration to actually create a community health center. They were called neighborhood health centers. This started in 1966. And the first ones were in Mount Bayou, Mississippi, which is what you were talking about. And the other one was in Columbia Point in Massachusetts in Boston. And their whole emphasis was to go beyond just treating people, but to actually, like Jack Geiger was talking about the population in very fertile areas of Mississippi where people were starving because they used to be sharecroppers and they couldn't work the land anymore. So he created prescriptions for food. That was one of the things that the health center did. In other health centers over the years, they've done things like train people to become health workers. They've done things on housing. I worked at a health center in 1968 where they had a legal staff and landlords to try to improve conditions in housing. So I think getting outside the walls and doing that is a great idea. There are now 1,500 community health centers, so that movement has gotten bigger. It's the one thing in the Obamacare legislation and after that, just recently, that got funded with billions of dollars more because that's the groups that's going to take care of the new Medicaid patients. So I think that was a very positive movement. I don't think it's blossomed or anything, but I think that was a very positive thing and there are lots of communities where there's healthcare now where there wouldn't have been before and some of the other issues that are addressed in social factors, too. I want to chime in on that. I've actually met Jack Geiger. He's an amazing person and his legacy is just tremendous as is the legacy of community health centers. However, I've spent the last four years on the board of a federally qualified community health center in Washington, D.C. and on the board, we had to be worried about what are the finances of the health center and the money comes in to cover medical care. I think one of the big problems we have right now is insurers and including Medicaid, a lot of people who go to health centers now do have coverage through Medicaid, which is great. Medicaid per law and regulation doesn't cover non-medical care. It's very hard to get Medicaid to cover non-medical care things like housing, supportive housing and employment investments and even food. So I think until we really kind of change policy at the federal level in terms of what Medicaid and other programs can cover, it's going to be really hard to move off and have health centers move off of their primary business, which is to provide health care. I think we have time for two or three more questions. So the next question is depending on your presentation is how strongly social relationships affect health. Is this finding true among disadvantaged groups? How would demand side policies address this issue? I should probably be better prepared to answer this than I am. As far as I know, there's no major difference socioeconomically in the impact of these kinds of relationships. They're beneficial at all levels. It is a complicated issue, a very complicated issue and people have tried various small kinds of things to affect relationships. Part of it again is you have to look at that in a broader context and I think we need to think about how do socioeconomic policies, employment policies, work family policies, how do they affect social relationships, the ability of people to have them and not personally I'm interested, I'm not going to do it myself, but I'd love to see people doing more on what's the impact of digital, the digital age on social relationships. There are many ways in which that could be helpful and there are other ways in which it could be very adverse. At the time that I wrote and did most the research on this, the evidence was very clear. It was very clear to me that there was a lot of career rating in some aspects of social relationships in terms of people's organizational involvement. Certainly you were seeing marital and family break up and all of those things. Those are fundamental things that social policy has to think about and address and they're broad. It's not a fix to go with marital or partner relationships which are one of the fundamental types of social relationships that matter for health. I know we have many more questions that you've all put forth and I'm so sorry we don't have time to get to all of them. I think we do have time for one more question. The last question is what can healthcare centers do to move into social health? For example, social workers in the ER and providing breast feeding classes. Can you take the last word? Again, I think clearly health centers and the healthcare system can play a role in doing things to promote larger things. They cannot in and of themselves make the kinds of policy changes, the full range of policy changes that are necessary. There is a need for coordination there. I do worry at times when I was on a panel that was looking at the issue of how to include social determinants of health in electronic health records. It was composed of a large number of people who I would say were pretty enlightened physicians and healthcare administrators but to some degree they had a very hard time getting past things like smoking, drinking, physical activity and so forth to see that the kinds of factors that affect the health of people coming in is different. I must say I have some hope that there may be gradual generational change occurring. We get a fair number of younger physicians who come to our training programs on psychosocial factors in health and sometimes I ask them why the Robert Wood Johnson program used to have several programs among the ones that Paula mentioned but also one that they've had for a very long time called the clinical scholars program which was specifically targeted on physicians. I would ask these people why are you coming to our program on social factors in health or social policy in health rather than the clinical scholars program who would say basically when we see people in our practice, in our office, in our clinics we can do something to help those people but we increasingly recognize that we could so much more could be done if we could reach people earlier and prevent or at least ameliorate the onset of disease and the kinds of problems that they have and therefore we recognize we've got to start thinking more broadly about the kinds of things. Great, well thank you to Helen and Rich for their comments and provocative reactions. Thank you to all of you for your comments and questions thanks to the students for their role today but most importantly thank you so much Professor Jim House for your amazing scholarship and this wonderful book that really I think represents a pinnacle of what's been an amazing career so thanks for sharing this with us today. And I just wanted to say that this has been a very important informative conversation I hope you will stay and join us to continue it out in the Great Hall and also have your book signed by Jim House. Again thank you very much for joining us and again thank you to our panel and especially Jim House.