kool-aid. this is absolutely crazy, so i don't really know where the story's going, and my sense is that some heads roll in miami, and i wonder -- you know, incognito was a great player, but how can he be a great teammate after what you saw? how will anyone bring him on when he, you know, is that kind of a teammate. football's a team sport, and so i think he could maybe worry about his job process. [laughter] next question. >> hi. you mentioned numerous times that football is regarded as evolutionary sport. i mean, we see this even down to the wall of choice, oblong shape

against a round ball, sharp contrast to every other sport. >> sure. >> but having the spirit means that is subject to change, and change is not always good, so is not the evolutionary spirit of football is gift and curse? >> well, i think it's a gift because there's always these controversies about the sport of football, and football's able to reagent. if you play baseball a hundred years ago, if you were ty cob and you were to appear through time travel on a baseball field today, you'd know how to play the game. the game has not changed. it's a stat tick game. soccer's the same way. if you try to change a rule in baseball, you know something like instant replay, the traditionalists scream bloody murder. you can't do that. i think so it. baseball is different. baseball is a tray -- traditional game. football is not. you have the ball that they play with, and that came about

because harvard was playing a canadian university, and mcgill wanted to use the rugby ball, harvard with the round ball, and harvard liked the rugby ball and forced anyone playing harvard to, hey, play with the rugby ball. rules change in that way. you can tell a harvard man, but can't tell him much; right? they had to do it. when football started, the first intercollegiate game between princeton and rutgers, at rutgers, in new brunswick, new jersey in 1969, they kicked the ball into the goal like soccer. they kicked a round ball in the goal. within a few years, players decided it's more fun to kick the ball above the goal than beneath it. that's where you get goalposts, the ball elongated over time, rule changes like the forward pass and the neutral zone. you know, we talked about the fact that the touchdown, you had to touch the ball down

physically. they didn't have end zones, and there's innovations in equipment in rules, in the field of play, and that's changed. no different now. you know, the point i think i made in the speech is that if you're able to change the size of the ball, if you're able to add end zones and say, hey, kick the ball beneath the goalpost rather than above it, add a forward pass, that no game ever did, you don't pass forward in rugby, but you do it in football. they complained that this is grass basketball. there were purists screaming bloody murder at that time. if you are able to do that, if you are able to introduce a running game and pass the ball and negotiate kicking, but still call the game with "football," e okay if ncaa officials kick out defensive players who put on hits on defenseless offensive

players. we're okay with that. those are minor tweaks to the bigger picture. what the question may be getting back, the nightmare scenario for football fans is one day we wake up and the players are not wearing pads. they are wearing flags. this is already happened. this happened in a school in new jersey, lawrenceville prep, where the head mistress decided football was too dangerous, and so they got rid of the old tackle football league in the country, and they replaced it with a flag football league. in massachusetts in newton, every year there was a powder puff football game that's a flag football game, it's out of hand, but it is flag football, and the principal of the school decided to ban it because flag football was too dangerous. it's not going to stop with football.

it's not going to stop with flag football, and if you like some other sport better, they may come after that one next. let me just close with this. football has not grown too rough. the message of the book, "the war on physical" is that society has grown too soft. thank you so much for coming out tonight. i appreciate it. [applause] >> thank you, all. closing notes, visit the following website, our sister group, accuracy in media, www.aim.org, and our website accuracy and academia, academia.org. mr. flynn's website,

flynnfiles.com. there's a variety of cultural, political observations on there that are well worth reading, and, of course, check out the book. again, this meeting was brought to you, as all our sites are, from a generous grant from the frank day fresco and nelly fresco foundation sponsoring the cop servetive university series that we run every year. thank you, all, for joining us. have a good night, and stay in touch. [applause] [inaudible conversations]

>> hi, everybody, and welcome. so welcome to the special event hosted by the institutions for social and politic study new health care center. we're here to have a conversation about bradley and lauren taylor's book, the american health care paradox. there's no shortage of government health care in the news right now. you know, we've got democrats defding the act, and republicans attack it, and i think we would

all argue they miss what very little might be the key point, which is that the health care system's broken. we spend more, and we get less than virtually every other country, and that neither party are talking about what we would do about it. you know, i would argue that our ability as a country to reign in health care spending is going to determine our physical future. this is the largest single factor that is driving our debt. quite literally, health spending is bankrupting the country. if it's not under control, there's not a lot of money to spend on anything else. this is the sort of underlying rationale for health. we firmly believe that evidence should be what's driving health care policy, and public policy in general. we got three goals for this term. the first is to link extraordinary resources at yale together and produce

psychological lores from the medical school together with economists, political scientists, cosh sociologists, and come together to produce interdisciplinary scholarships. the second is to get students involved. the students here, the future healthcare leaders, and talk about these issues, talk about what's happening, why we care about this, why it's so challenging. the third is to connect what we do here at yale to the outside world. there's no better example of this than the two of you and what you're doing. you know, bradley is a professor of public health here at the university, director of the global health leadership institute, the master of the beautiful college. i live in davenport, and, you know, she -- i think more than anybody else personifies these three aims. you know, extraordinary scholar who has done leading work

looking at why there's variation in hospital performance, one of the most popular teachers at the university, which was pretty amazing thing in and of its own right, and a solar who is not only producing research, but translated it into practice, improving the way hospitalling are managed across the globe. lauren's a presidential scholar at the harvard divinity school, and they came up with the book, the american healthcare par paradox. there's a lot of explanations why spend more and get less. economists say the reason why the health care system is expensive is because of technology, the fancy kits in the hospitals. doctors say it's because of malpractice. you two have a different explanation, something where you argued the causes of why the u.s. health care system is expensive might be outside of the health care system. it's an extraordinary book. we're going to talk for hopefully 20-30 minutes now and open up for discussion with the

audience about the book, what it means to the u.s. health care system, and what we should do. i guess we'll start with the first question. why is the u.s. health care system so expensive? why is it that -- why do we spend more and get less? >> thank you so much, zach, a wonderful introduction. our thesis is that we are depending on a medical system that address social, behavioral, and environmental challenges that are really detouring us from being a healthy population. look at the most common causes of illness, colon cancer, heart disease, adult onset diabetes, and 70-90% of the cases are related to social and environmental, economic determinants. exercise, sleep, nutrition, stress at work, our occupations, what our housing is like, and yet we expect a medical model of physicians, medical treatments, procedures, surgeries to fix this. we spend an enormous amount op

the medical side and don't spend as much as other countries on services that really support the more fundamental determinants of health. that results in an expensive system that does not really confer the health we deserve. >> and why? why have we evolved in this way? why is scandinavia, as you talk about in the book, look so different? >> i think what we found is there's a strong historical press in the united states for letting the system grow organically. health care in the u.s., as it did in many places began as a cottage industry. doctors were entrepreneurs, put a plaque outside the house saying, i'm open for business. we have continued down that path of an entrepreneurial free market health care system because we feel that's the american way to approach the system. scaped knave ya really movedded, and much of europe moved in the

beginning of the 20th century for a more kind of centralized and budgeted system where they decided that health care was not something in the market but socially good they wanted to ensure for people, and i think those are different approaches and tell us a lot about how we arrived where we have. >> so how do you articulate the paradox, you know, the title of the paradox, how do you frame it? >> i think it's straightforward. it is we're spending more and getting less. you usually expect when you buy more, you buy a cadillac, you spend more money on it, you get a better car, but you don't expect -- it's paradoxical to anticipate you'll spend $8,000 per capita in the united states whereas the next most expensive country would be two-thirds of that. you would expect you should have better health outcomes, longer life, less infant mortality, less heart disease, less disability. we don't have any of those

things, not really. >> is the research community missing the point? why don't we have an answer, you know, ten years ago? why is it taking this long? >> yeah, a good point, but this is a historical problem. what is amazing about the paradox is it's not the paradox itself, but that we had it for decades, and other authors wrote about it, but why have we not addressed it? that, you have to step back as lauren began to step back and look back at what is the history of the way americans relate to their health care and their health, and who is benefiting from a very large medical system. it is the largest industry in the globe, 18% of the u.s. economy. this is a system that's benefiting many, many people. it just may not be conferring the health we want, but it makes a lot of profit for our country, and it's really set up that way. >> do you think profit is the reason we have this paradox? >> i do think that's part of the reason. ic that's undenial.

i think, you know, the system growing in such an unplanned way is a big part of it also, and the lack of attention to kind of equity and making sure everyone is getting resources in a fairly evenly districted way. .. things that respond to medical intervention so we have more people living with new replacements in the united states than anywhere else in the

lead -- and kidney dialysis. it's that we don't do well on these broad population health outcomes where health outcomes were we compared industrialized countries. >> so this gets at the heart of the issue. if you look at the differences in health care spending costs, countries spend more and then you factor in social care. when you look the the collective pie we end up spending i think less than a lot of other countries. how do you define health care wax what is a health care system and how do we think about it, what should a health care system do? shouldn't it just be for heart attacks? should it be for population math and. >> i do think many people run hospitals and many physicians in the united states probably do see their job as fundamentally, i get medicine, medical care. i maybe operate and i have medical treatments but we also have to look at who is paying

from the health care system. 50% of the revenues of the hospital typically and sometimes more than that is actually paid for by medicare and medicaid. that's the public dollar and the question has to be then what is that public dollar dying -- eyeing? should it be buying helper health or should it only be buying medicine and the two are really different. when we visited different countries there is a different conception of health and other countries. where health is rob andrew's did his medicine is one input but so are many other things. it's also clear in united states we have that integrated view. i think we have a much more separated view it as this is the medical care center and it has a whole different revenue screen and there's education and housing and nutrition completely separate. we don't always do that in this country. >> so health care's and the key input to health. >> i agree. what is an example? what's an example.

talk a little bit more about that. i found that one of the most powerful examples in the book. >> do you want me to read it? >> sure. i didn't get a copy of the book. >> it's a passage that we have gotten a lot of feedback on its 100% true story so i will read it and it's meant to illustrate as he suggested this kind of power social determinants of health and the way they can drive help their expense. joe is a 28-year-old man with type one diabetes living in the united states. he lost permanent housing and has been saying in a friends condemned boarded up house to avoid being seen near joe interest to the marshlands behind the house. issues are full of holes but he cannot afford to replace them. joe's diet has similarly suffered from his lack of

income. he sometimes go several days without fresh food which negatively affects his diabetes. also after lifetime of poor insulin control he is starting to lose circulation. last year to show head to toes removed on his right foot to save his life at a hospital with the cost of $7132. still drop if he continues to cause decreased sensitivity and increased risk of trauma to his feet. the doctor alessa emphasized the importance of keeping his feet dry and taking proper medicine all of which joe is eager to do. since that appointment joe has been diligent in taking his insulin but dry feet remain difficult to achieve. his doctor is raise the issue of having to more toaster madonnas photo a cost of $14,000 without immediate changes joe will need to have it below the knee amputation in the years ahead at a cost of over $17,000. he will also likely need a wheelchair.

the estimated cost of his estimated expenses will easily top $30,000 paid by state medical assistance programs funded a taxpayers. meta-system marked by the most advanced medical treatment in the world joe is dying a slow painful and expensive death. a decent pair of shoes costs $50. i think as he said this really illustrates how we place a word in on the medical system to respond to people's illnesses and diseases but really have roots while outside the health care system. and until our medical system in our health care system kind of addressed the fact that these determinants lie outside of their scope and are willing to coordinator and collaborate with social services and other parts of civic society who can address joe's challenges they are going to keep paying a lot of money to fix joe up and send him back out to an environment that's really unhealthy. >> to think about differently is

their health but -- problem with our health care health care system or the welfare state? another is that the health care system is great but we don't have adequate support structures around it. is that the health care system or to something else that is missing? >> i don't think it has to be one of the other. probably both need tweaking. it's not going to be a problem that is only at the feet of our health care system or problem that's only at the feet of the welfare system. let's think a listed way about what of the services we can get to people. sometimes subsidies for shoes for someone who is diabetic. sometimes it's going to have to be amputation. it's going to have to be medical treatment but to be able to plan services and also tailors services so that you are spending -- you are intervening in the most cost-effecost-effe ctive way to the root causes of the disease is ultimately going

to make her system better. >> you said the word we. who is do we in this space -- placed? >> and it's an enormous question and who is accountable for help in our society? we believe in individuals taking care of themselves and we are very much formed on the idea of individualism. of course we have government programs and supported for people who can't take care of themselves as starter but it's not a widely shared accountability and what we find particularly when we look across the globe is we are one of the only countries that is so individualistic about health not seeing any part of it as related to our social context and not seeing them as lauren said earlier in any planned way. a question would be asked are we delving too much and individuals responsibility without really thinking more broadly about the

private sector and corporations etc. in the public sector and public for grams can work together. let me say who is we unfortunately i think it's all of us. >> than the aca. you talk a lot about changing the health care system and the incentives are what doctors provide, expanded coverage. have we just spent three years spinning our wheels in the sand but we should've been doing is providing sneakers clacks. >> i don't think so. i think the aca has a lot of good stuff in it you now and it was born out of a political process. i think expanding health care insurance and access to the system is critical. we need those to be in the system to start to get them insurance and budget them over the long term, hopefully get them some preventive care that can bend the cost curve but i don't think it's quite as old reform as we need to create a system of reform over the long

term. i think that would require a larger reconceptualization as betsy alluded to in terms of what health is in what the role of the health care sector is and how we are investing in health versus social. of course in order to achieve that kind of reform we need a different kind of discourse and we need a more inclusive one where people talk about what health means to them and how that is achieved. i think the ac it was the right reform for were we are right now but that scene i would hope that with the book we can inspire larger conversation that will one day get us to broader reform. >> do you think we needed the aca? >> i would definitely agree. the aca has set a platform on which i think a great health care system can be built and i think that as a couple of inputs to it. one is getting everybody insured and making it more explicit. this is what we are spending to ensure this population and if you make that explicit with the

american public we are going to be a little bit more discerning about what are the inputs to this and what are we paying for and getting everybody in that is a huge step forward. >> this -- in the book is all politics are local only talked about joe. how does this affect my mom and all of us? it's terrible that he is being so marginalized and we know it's not cost-effective but does this ship the effectiveness of their attention to what's best for the society invest for the individual? >> there maybe we can talk about that but in the near term you reference the deficit and the debt. that is the primary concern for all americans because those are taxes and those are our kids, maybe not my kids but some of our kids are going to confront that. that creates a sense of urgency in this discussion around health care where we need to do something and maybe people's

individual politics don't support helping joe because joe is disenfranchised or he is vulnerable but i think certainly their pocket this -- pocketbooks will benefit over the long term from us responding to this crisis which is people using medical care for social issues. speeches to push back the government just keeps spending. more money will solve the problem. >> i don't think that's a story of joe because i don't think it's more money. spending more in the future and it's a pretty good deal. you asked the question of how does it affect you and the taxpayer i.d. is a great win but also i would say let's say you come down with abdominal pain and you think i don't feel well. you go to the emergency room. we are not exactly sure sure what it is and you get a full

workup. you have a full workup and you go home and you start to feel again. you go back and get another full workup. people like to have an awareness thing what else is going on the straining my abdominal pain? what i've been eating and what is my job tuning to meet? the first step is not always have to be i must be in surgery or i have cancer. it might be what else is going on in my life in a way that i could manage for even work in consult with the medicare system. we would say think about the other things that might actually be starting to make your health not as strong and collectively work integrated that the medicare system creates. >> we see this happening now? is it happening in the u.s. or is this only france where this is occurring? >> this heavy dependence on

medical? >> work people are doing the right thing to? >> absolutely. we actually spent a fair amount of time traveling to high income countries to understand what would be the ones we might he most eager to learn from. we have to do everything in an american way but what can we learn from the other's? >> what did you find? >> so there is a lot of reason for optimism here because when betsy and i went to the outlines and spoke to people who are confronted with this challenge every day we found some really innovative models where people are doing a great job working up strain to create collaborative models of care. the software and since in santa monica california a community center that has a long history of providing care for substance abuse ,-com,-com ma rehabilitation, shelter for homeless people, serving the most in need and they have partnered with a local hospital and the local hospital did them

a block grant of money in order to try and push back on what they call frequent flyers, people came into the hospital is that too was explaininexplainin g. you treat them and give them their medication and they go back out and they come back soon after. this was a problem and the community center knew this was a problem. the hospital gave the community center of block grant. we are going to take people who come into the eddie and were going to treat them and then we would like to partner with you, get these people to the community center and set up a respite care. the nurse can see them for several days of there not being bounced out to the street like joe is that have ones that are infected. this partnership has been working out for several years and it save the hospital atomic money. the first year i think in 2009 if i'm remembering correctly they saved over $200,000 inpatient costs for small cohort of folks. it was only 15 or so people who they were doing this with but

that heart worship i think is reason to be hopeful and this is something they did on their own. the system is not set up to support this really but it's working. it shows is that these things are important but there are ways to fix them. >> save costs are cut revenue? >> so if you want to know the nitty-gritty i believe this was part of the community benefit spending program which hospitals are obligated to do. this is money they have to spend this is a nonprofit catholic local hospital so this is part of the hospital's mandate and his betsy said before with how much hospitals -- revenue hospitals are taking one could argue that all hospitals have this mandate to take care of population health and the most needy. i think you know they are saving costs. >> do you agree? other examples in the u.s. we should be looking at? >> we profile cases in the u.s. and something that's as

important about it, is a great example puts not only areas were taking care of the poorest of the it is health risks etc.. we found a fair number of cases in which -- serving middle-class high income clientele that looking at the whole patient, looking at the whole client in figuring out what would be the most cost-effective intervention to occur. i feel very optimistic. when need more research obviously. we need more experiments, more research on how to create services where you align incentives to really pick the most cost-effective intervention you can pick. we don't have a lot of them in the united states but with the aca we are gaining traction on this and we will ultimately save costs. >> but that we have some folks from state government. if the governor called you and said what should i do in connecticut to make these ideas a reality what would you tell them? >> one of the very first things i would do is convene a group

who are charged with not only the health services, the key health services in the state but also education employment support, housing. convene a group that is almost like it interdiscinterdisc iplinary group to say we have a collective problem. we are spending this much money on health care in this much money on education in this much money on housing. these are common health metrics that we can agree on and set goals relative to them and start to think what are the barriers? what are the barriers between housing in the hospital? how can we have these two were closely together to be more effective using the public dollars more efficiently and it's really going to take some effort to look carefully and have the agenda is integrated and look carefully at where they can be some synergies. i think we can align objectives differently than we do now. some of the indicators and the metrics by which hospitals get

paid and by which housing agencies get paid and educational departments get their budgets. >> this is a discussion you and i have had before but there are two issues when it comes to health care spending. one is the fact that america spends more than everybody else and we spend $700 billion more than we would expect and if you look over time it's eating up a larger share of the budget. as i read this is a question of differences between countries not something about levels of growth. is that fair? i would argue rate of growth looking at differences between countries. >> at differences between countries however the acceleration is countries is a common phenomenon. when we look at the% of the increases over time in the u.k. budget or the swiss budget or in sweden, every country is worried about this. countries are expanding their health services spending without question i don't think the u.s.

is in a different. in some ways the most important question is really the question of how is your current spending different from others? >> speaking of spending and who are the high spenders we know 20% of the population is spending somewhere in the neighborhood of 80% of our health care dollars. does this get out that 20% a medical issue? are those the same people? >> i think this does get up at 20%. a lot of the 20% i think is driven by the elderly and people who are on medicare who have complex conditions often a confluence of both medical problems and some psychosocial issues. these are people who really are well served by central services. there's a great example in the book of a woman who is burning up a ton of medical expenses which are paid for by the state because she lives alone. shea think recently lost her

husband and she was really lonely, so she calls an ambulance because she knows that when she called 911 someone will come and pick her up and talk to her, take her to the hospital and she will interact with more people. this was written about recently in the atlantic. a big case about loneliness is a powerful determinant of health. i think 20% actually many of their expenses strike to the core of what we are talking about here. >> so why this book and why now? when i came here you are this giant global health. you were in in ethiopia the first week that i got to yale. why write a book on u.s. health policy lacks how did this book come about? >> i

a not an end in itself. that is different so i think we put forward lessons from scandinavian certainly there are models at the local level and planning health and social side-by-side which are wonderful and if we could do them on a local level they want to take them up, bless them but i also think some of the larger lessons just about health care culture in this country, chest of government, chest of one another worth things come from the

investigation are crucial. >> before we hear the next question we are going to open up missions to the audience. there are two mics in the back so if you have questions lined up there and we will call on you in just a second. i would encourage you to keep the questions fairly brief and to say who you are. the mics are going to come come to use of the mics are going to get past you. you raise your hand we will pass the mics to you and give you a question. key takeaways from the book. what would the success for this book? you have written a book. you are out talking about quite a bit. what would success look like and what do you hope achieve with its? >> one of the key successes we are looking for is as lord had said the discourse changes of it that more and more people really see the difference between health and health care and understand that health care is just one input into our health and the small input actually.

if we could change the discourse, they could change the way people talk about this i think it really is the first step to making a large difference. additionaadditiona lly it would be nice to see over time this experiment that is really being spawned by the aca would start to be collective and we would really start to learn something about integrating health and social services about planning things together at a local level, about aligning incentives so that the healthcarhealthcar e system is trying to accomplish some of those social goals and the health care system is trying to accomplish some of the health goals and together we use that in the smartest possible way. align some of those incentives and over time you would hope you would see infrastructure changes, that you would see new models emerging sort of like a model we saw in santa monica where actually the people are thinking together, what tool do i have? some of it is medicine, some of it is housing in some of his education that can make this

population is help the as possible. if we could change incentive systems over time and watch new infrastructures emerge we will be very successful. >> does that sound about right? >> it's a good question. she had it. >> a question from the audience? >> you are among friends. the current political debate is not particularly favorable -- favorable to the argument you are making. if you were in front of congress or in front of parliament how do he make case that more social spending is the thing to do when -- rains across the globe? >> is a great question. i don't think we start with more social spending and i'm sorry if the look and if the interpretation of the book ends up in that because that's not really what we are saying. we can expend exactly what we are spending now and not a penny more but we can do it better. we can do a much better and we

are doing redundant services. people who are getting care for with these high heavy medical care bills and then sent out to live on a part bench and we haven't even thought boy if we got that person overnight housing they would not be back in the emergency room the next day. that would save money, not cost money so we have to go at this from almost an economic security effort to say if you want to create a secure future for loeb we have to use every resource we have in the most effective way and right now we are wasting a lot of it. >> if you could bring the mic up to the front. >> in our policy class a quote occasionally hear is a quote they hear and think about often is every dollar spent in health care is a dollar of income in health care and you know i think

you guys touched on this before. about 18% of gdp and if i'm taking the flipside and i'm someone in health care what is my incentive to a keep my -- which is enormous compared to anything else and not have interest? >> yeah so i think we are worried about this of course because this is a real i think very her to change and of course every reform effort the aca is certainly a party to this comes up against these powerful health care lobbies and the huge health care infrastructure so it's an issue. you know no matter what kind of change you do there will be winners and losers and if someone in the help system perceives himself they are going to be looser they are going to me serious resistance. what we did find that was quite encouraging was when he went to the front lines in we spoke to over 65 health care health care and social service providers so more health care than social to

be honest but when we spoke to them they are so frustrated and so exasperated because these people want to practice medicine. that is what they were trained to do and the administrators want to manage hospitals that deliver medicine and right now they are just having to, a physician is having to play nutritionists and social worker in case manager and they said to us please help us, the new system, new models of providing care so i can get back to doing what i was trained to do and really want to do. so i hear that concern but we were encouraged by the frontline perspective that said please, we should make a change because we are getting inundated by things that we are not trained to address and we want to get back to practicing medicine. >> to follow up on that do we need fewer doctors? is it the problem that we have hyperspecialization and? any in the audience? do we need a couple less doctors coming to the medical system? >> it's a good question. do we need fewer them doctors

coming to the medicare system? hard to know. what we really don't need though is the mix of physicians we have. we have a very specialized group of decisions and we have actually very limited numbers of primary care physicians. what we mean by this is primary care physicians who might be most like to look at the whole person would understand or her housing situation, would know you, would understand where you are working etc.. compared to other countries were quite limited in this and we have super specialists so over time i think our country would do well to think about ship ding towards more primary care physicians and fewer specialists. in the long run everybody would benefit from it. >> with the folks with cancer benefit? if my mother gets diagnosed with cancer and i want her to have the latest, does she benefit? this is the tension between individuals and society. >> i think she does benefit

because in fact you want the specialist to intervene at the time the specialist is needed. what we have in our system is sometimes a specialist intervening earlier than the service might be needed and that's potentially sort of moving the care path towards a very highly intensive medical crutch to something when other alternatives may they be complementary to it for actually replace it. i think right now we don't really have a system of full choice because the specialist is there. the old adage it have to hammer, everything expounding but the fact is that's not true. we need more than a hammer in our system. >> i think your mom who hypothetically has cancer would benefit from increased primary care also because when she gets to that specialist you want a full robust medical history and maybe a little bit more coming from a primary care physician to make that call to specialists

and say mrs. so-and-so is coming. this is what her employment status looks like. she can't take a ton of time in the middle of the day to come to the premise of let's make sure we accommodate her in that way. she recently went through a divorce. take this into consideration. she may not have someone at home to care for her during chemo and let's take extra precautions to make sure that she has the support system needed. when you circumvent what you pay and go directly to the specialist i think sometimes you can lose that added texture to the medical history that really can enhance care. >> in congress we think a lot about incentives. the true statistics we have seen is health insurance becoming exceedingly more generous and it covers a whole lot more than it did in 1960. is that the problem? if insurance really want is pervasive and under financial pressure we might have seen the health system become less allies and these interventions come through. is that what we need, to roll back?

>> it's the chicken and ag i think. we have a generous insurance system because we have a very expensive and wide range of medical care systems so which comes first in which drives which i think it's not possible to disentangle them. there are things in the aca if the active or does does pass that will does pass that will sort of roll back the incentives to have the more generous system but the degree to which that is going to make a major change in what is i think a more broader problem than i'm a little bit skeptical. >> are individuals paying more and should i be forced to pay more out-of-pocket thinking more about what's worthwhile in making the investments that you say i need to do lacks. >> i think it is hard if people are fully insulated against any expense. it's hard for them to really step back and say do i need this? is this the very best? to do the research one needs to pick the very best service.

the research has all shown that there are some amount of consumer engagement through financial incentives and co-payments etc. that does change the way consumers consume things. you probably -- there are many bad things to maximize don't want to go overboard with that but it clearly wakes up a consumer to think a little bit more strategically about how they will use their health care dollars. >> i would like to follow up on one of the themes that has come through that in many ways a serious problem with the u.s. health delivery system is not that it's so bad. it's that it's so good at the top end. we do all sorts of things. premature and anthem verse and we have pushed back further and further when in an thing can survive. new organ transplants and cancer cures and also to things. this kind of stuff is the best in the world. part of that is i think, think

about the incentive system within the profession. it's not just making more money in being a specialist. it's the fame and the glory and the recognition, making new breakthroughs. it's much more lammerts than being a primary care physician. one of the problems is somehow to re-incentivize what is it that people in medical school would like to go into? i imagine there are some thoughts about that in the book and i wonder if he could tell us a little bit about that? >> yeah. i think it's absolutely concerned and i would add to your comment by saying that gp's and physicians who we spoke to in scandinavia, we spoke to the highest-ranking position the one that runs the whole show and she said i think i make less than gp 's din united states.

higher specialization, high-intensity and in some ways fame and fortune. i think the aca choice to address this in some ways. they are trying to increase payments to primate care providers in order to make it so they feel they can make a more fulsome living but i don't have the answer certainly. i would just add that the incentive structure and the way the profession is structured now is very reflective of american values and i think that's important to take into consideration when we are having these discussions about values. their upsides and their downsides and they upside is you can be a physician and you can make a ton of money and you can be famous and do something that is social service granted. this is the tension that i think we need to really be talking about here. it's not that there is no upside to our value profile at the way

we address medicine in this country. there are. we need to look at those side-by-side with the cost, both financial and human and say okay what do we need to do because we don't want to lose all the good things that we have going. there also does seem to be a sense of urgency for a change. >> at which is set to that i think it's a really insightful question now would just add to that that our innovations in the united states are very -- we have just the tippy top best new drugs coming out, the best new laser and the best new imaging etc. but there is also real excitement in thinking about our population how do you get very creative about keeping them healthy? in some ways we are our own worst enemy because we see innovation in one small piece of the medical care care system as opposed to how innovative it could be to have a city that is all about health from the way the buildings are made to the

way the streets or put together in the way people's cohesiveness happens in the way the hospital works works. sort of i think looking at innovation in other places but as lawrence said dennis you identify this is definitely a stress on the system. the feed a lot of the globe without medical technology. >> another question there? >> i was just wondering given your analysis what would you say say -- would you say the next steps and reform should take place at the federal or at the state level given political feasibility? >> so i guess i would say one of the other but i think the states have a tremendous opportunity right now. they are enabled to experiment. there are 50 of them so we can look at 50 different experiments and they each have a different sort of culture and actually as we have with over the states they already are different in

terms of what they are spending in medical care and what they are spending and social services. we have natural experiments going on. we need to do the research that ties the spending patterns to actual health outcomes. i'm excited about the state level experimentation. think that's going to prove very fruitful for us. >> anyone in particular that's doing a good job? >> connecticut is right on the precipice. they are doing great rings. >> i worked for a politician for a stretch and we had these academic discussions. at some point they say stop admiring the problem and fix fi. when it comes to this what would we say a month, a year and 10 years from now in the interventions we need to do to make this a reality? somewhat in making the changes are their structural changes that we really need to put in place and what were those the light from a government perspective where private market perspective?

>> i can take a swing. it's hard to know what we can do structurally and through government in a month. i don't have a lot of optimism about that sofadin next round talking about the value base, looking at what we do well and not doing well and putting those side-by-side. evaluation is where we should be focused. down the line i think betsy and i discuss in the book the aca really is a plaque or my think we could do some experimentation and start to make incremental change in the responsibility and accountability that hospitals have two patients. one of the things the aca does the is puts forth a set of indicators that hospitals will be reimbursed by the government in right now they are very medical so they are your traditional how many patients had a hospital infections? how many patients, how many of your step wash their hands every

day and their variants at the hospital but if we could spread the subtle little bit and be innovative to include some of these population. you could say you know but community hospital you are now responsible for how many eighth-graders are obese and we are going to set a threshold and if you are below it and you have worked with partners and really engaged with the community to make this metric changeover time we are going to give you more money. i think that's an instance where you could take the aca which is that behemoth infrastructure and policy that you work within the system and you say i think we can create a little bit of change the population of health and social determinants of health are being addressed within the health care system that we have now. >> the second thing about exactly what lauren has said is this is not a major overhaul. this is a regulatory change. it's not a legislative change which is a lot easier to push through. you could really imagine a shift. imagine of a hospital were held

accountable to some degree and have some incentive for how many eighth-graders are a obese. you can be sure someone is on the board of adding a gauge with the exercise program zero -- clever ways in which the health care system can be used to accomplish population health without i think revolution but rather incremental shifts. >> i mark salzman. i have a question coming back to medical technology. i'm curious what you learned about how cost for technologies are handled in different countries and i'm also thinking with the last remarks about if there are some ways that technology could actually contribute to this connection between health care and the individual and social care. >> i'm so led the race that. the first thing we found is in scandinavia although we think united states is the one that

spends all the medical technology and puts a huge amount of our gdp in this we are not that different from scandinavia. denmark norway and sweden are very and invested in medical technology. we aren't as different as we might think that way and i think they are nervous about the cost of that as well but also see it as potentially cost savings if the technology are constructive with that in mind. in terms of the issue of canned technology generally bring together and create avenues of communication, absolutely. this is exactly what we need. i think it's where the real creativity can be. instead of in creative than one industry hath only be creative to span a couple of industries, couple of sectors that together could create a healthier population? that could be everything from information technology to all kinds of things that you are allowed to think about that would in fact bring these two and closer communication and

just more efficient which -- with each other so i think it's it rates spot. >> there is a question over here. >> i met evelyn from the school of medicine. thank you so much. i'm curious, there has been a lot of conversation about the organic evolution of our medical system, health care system and i as my husband am influenced influenced by consumer as well as industry. in your conversations during the development or after the publishing of the book what has been a conversation with consumers of the health care system and is this message one that seems to resonate with people over do you think that there will be some wariness or do you think that if these changes are in place that the transition will be a very natural one? thank you. >> yeah, so i would say you know

part of the story about the organic evolution in the medical system is the story of medicalization. so often physicians in the health care industry are really really -- we shake our fingers at them and we say you have medicalized us. you have done this and certainly some of the blame does rest with the health care system that places a ton of money on marketing and trying to get people in the door who tell us your health is everything. come in and we will make you better etc.. i think in the book we are careful to try to say consumers have a responsibility to. some know it more than others but they are definitely there so we tell the story of one family who will not take no for an answer. the child has headaches, comes to the physician and the physician does all the standard tests and there's no finding. they are probably stress

headaches and the family will not accept it. they want certainty and they want to extract certain from the system. maybe because we are told in the medical system can provide all these answers or maybe that's an american thing to strive for perfection and get it right. we tell the story in such a way as to say there are a lot of moving pieces here and consumers definitely have grown into the system to expect certain things from the system and want certain things from the system. so i would say consumers will have to change. if we are going to change the health care system we need consumers to change their dialogue to prompt policies but we need to wise up to the fact that there's going to be a renewed sense of discipline that probably needs to accompany any reigning in of health care in the long term. to follow up on that if i were a member of congress, my biggest job creator in most of my districts is going to be my

hospital and any cut on that is going to be a cut on jobs. had a wit -- we reconcile the political timeline of political tensions with what you are arguing needs to occur? >> something we need to get in our heads is it's not a book that asks to spend less on health care and more in and social services. it does not do that. keep the spending the way it is but hold the health care dollar more accountable to a population's health. you don't have to laugh anybody in the hospital. there may be better connections with some of the social services there may be other ways to conceptualize how delays this health care dollar instead of just to give medical care actually confer health. that i think it's sort of a shift in the way we think about the obligation of our health care dollar. i do think shift thing and asking there to be a change in our allocation pattern are taking away in giving more over here i just don't think the

politics of united states would tolerate that that i think there are ways in which exactly the patterns we have and you think about how to use this health care dollar to achieve some of the social and behavioral goals? i think that's an avenue of exploration that could potentially hold promise. speech. >> theresa daly, yale college. just to pursue that point a little bit more, you mentioned that these discussions, these reforms aren't a matter of taking money from one department and moving it to another but simply redefining how we use our health care dollar. in the short term, what would that look like in talking with policymakers but also having a dialogue with hospitals, these community health centers in the consumer's? see what would it look like? is a great question. i think it could take a lot of different shapes with something concrete which llorente alluded to earlier, imagine that you got a city together and all the

services given to a population that city, the leaders came together to say what are the core of accomplishments we are trying to address? what are the indicators of new haven being healthy? what can each of us providing that area, align the incentives all those public dollars and some of those private dollars are focused and rewarding and are being rewarded for accomplishing those goals. instead of the hospitals quality indicator being how many of my patients with heart disease got beta blockers maybe it's something that's more population-based and similarly the education and housing system and job training service providers having some incentives themselves for being sure they have coordinated with the health care system. that is what it would look like. you can point to a group that together was working on improving the population's health. today you couldn't really do that. you could point to the health care and point to education is

trying to educate people. you could point to housing is keeping homeless people off the streets but you couldn't point to one group that felt its obligation was to make new haven healthy. >> what indicators would those be? it became together and we need to drop a list of indicators what shall we be looking at? >> i think the dash would be a good target. the cost of it over the long term have been projected as just astronomical so i think everyone in the community so to speak would have some skin in the game if you will. i think several others like chronic disease would be wise because those are the things that are going to really balloon. maybe something on mental illness. there is an indicators -- lost due to mental what's the term?

disability, thank you. i think that is one that has proven really costly because if you stay home from school that child needs extra attention from the administration and teachers. they are not going to tests as well. the school districts get reimbursed on test scores in the same thing with employment. if someone is not going to work that is cutting into business revenue so those are great examples i would say. >> it think you could broaden it also to say what is the% of people who are employed? what is the person of people who are housed? these are in the metzl to health. if you had a joint group that was worried about this some of them would be obesity related or smoking or mental health and some of them might be more related to the social determinants of health. >> connie from the school of management. as you were talking i can imagine some cadre of consultant

organizational change experts going out in identifying sites that would be ripe and fertile for a change and almost ready for a makeover. go into these places and helping people get together advising them see them through and pull together the results. who is that going to be and how are they going to get themselves organized? >> that's a good question. you are hitting on something so fundamental and i just want to underscore it. these kinds of collaborations what we would call intersect tool collaborations are hard to do. there is a reason they haven't sprung up organically and part of his is the set -- incentives. it's a long road in their different professional cultures. we were different hours. certainly we don't hear an i.t. system were common medical

records and it's hard. people, even if they think in theory collaboration is what we need when the rubber hits the road and you say okay we are going to start a project you are going to need assistance. i'm not sure who the person is. i would be hopeful that some of the people we profile in this book i know they are eager to do so could go out in the consultants because they have done anymore through them and that is part of her motivation of holding up some real stars in this community in the hopes that through some of the wreck or they can be replicated and they would like to go in and talk about their journey as well. >> depending on how the reimbursement system goes you could imagine it's in the group self-interest eventually with this kind of boring us to get together because they can in fact save some dollars out of the system. of course you have to decide who benefits from those dollars that are saved.

i think that there are incentives to get together and it will take a trigger or something probably larger than just organically to say this is something that will incentivize you to get together. nonetheless we have come across teams that are starting to work on this in different cities in the u.s.. i'm optimistic that something will emerge. >> hi. i'm a local business owner and my question centers around individualism. we talk a lot about public policy and governments and what we should or shouldn't do but how much emphasis would be put on the individual taking responsibility for education, exercise, being mad properly? these are not -- are at the core of so many diseases today. what people have done to themselves so how much emphasis on how to be --

should we are how do we keep putting that emphasis so it's not just the government. >> it's a great question. we have to do this in an american way and america is about individuals and has been built on that and is strong on that. in many ways i think we have to use that as a strength. the issue that ties to the question zach asked earlier, how do you have the individual feel the penalty of not taking care of themselves etc. lex that is actually a strength the u.s. has and the tolerance of being able to say this can be in part an individual cross to bear. on the other hand, it's important to understand the signs and the science really is that your social environment, the network you are in, does influence to help a fear. if you are living in a community