later today at 7:30 p.m. eastern. part of american history tv. this weekend on c-span3. >> elizabeth bradley and lauren taylor are next on booktv. the two authors question why compare to all other industrialized nations americans spend more and receive less from our health care system. this is about one hour and 10 minutes. >> hi, everybody, and welcome. so, welcome to the special event hosted by the institution for social and policy studies new health care center. we are here to have a conversation about elizabeth bradley and volunteers asked what her new book, "the american health care paradox." there's no shortage of health care in the news right now. we've got democrats furiously defending the affordable care act. we would all argue they're

missing what might be the key point. which is that the health care system is broken. we spend more and we get less than virtually every other country. and that neither party are really talking about what we do about it. i would argue that our ability as a country to rant and health care spending is going to determine our fiscal future. this is the largest single factor that's driving our debt. quite literally, health spending is bankrupting this country. different able to get this under control will not have a whole lot of money to spend on anything else. this is the sort of underlying rationale. we firmly believe that evidence should be what's driving out their policy. and public policy in general. we've got three goals. the first is to link these extraordinary resources at yale together and get scholars from the medical school together with

economists, political science, sociologist, the divinity school, and come together to produce this scholarship. the second is to get our students involved. the students here, the future health care leaders, and talk about these issues. talk about what's happening, why do we care about this, why it is so challenging. and 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. betsy bradley is a -- the master of this beautiful college, davenport. just kidding. i lived in davenport. she i think than anybody else personifies these three games. extraordinary scholar who has done leaving work looking at why

we see variations in hospital performance. you are one of the most popular teaches at the university which is pretty amazing thing in and of it it's all right. and a scholar who is not only produced the research but translated it into practice, improving the way hospitals are managed across the globe. lauren is a presidential scholar at the harvard divinity school, and they have come up with this book, "the american health care paradox." we've got a lot of explanations for why spend more and get less. economists say the reason why the health care system is so expensive because of technology, the fancy kits in our hospitals. doctors often say it's because of malpractice. you to have come up with a different explanation, something where you've argued the causes of why the health care system is so 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 then open it up for discussion with the audience about this new

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

amount on a medical site and we don't spend as much as of the countries on services that would really support these more fundamental determinants of health. that results in an expensive system that doesn't really confer a health we deserve. >> why? why have we evolved in this way? why hasn't scandinavia look so different? >> i think one of the reasons that we found was there's a very strong historical precedent in the united states for letting this system kind of grow organically. so health care in the u.s. as it did in many places began as a real cottage industry. doctor for entrepreneur. they put a plaque outside the house and they say i'm open for business. we have continued down the path of an entrepreneurial free market health care system because we feel that's the american way to approach the system. scandinavia really moved, and much of europe moved, in the beginning of the 20th century

for the most part to a more kind of centralized and budgeted system where they said health care wasn't something to be allocated to the market was a social good they wanted to ensure for people. i think those are very different approaches and tell us a lot about how we have arrived where we have. >> how do you articulate the paradox? how would you framework this paradox really is? >> i think it's straightforward. we are spending more and getting less. you usually expect when you buy more, you buy a cadillac, you spent a lot more money on it, you are going to get a better car. you don't -- it's paradoxical to dissipate your spent $8000 per capita in the united states, where as the next most expensive country would be two-thirds of that. you would expect you should have better health outcomes, longer life expectancy, lower infant mentality, less heart disease, less disability. we don't have any of those things.

>> the research community missing the point? why haven't we come to an answer, 10 years ago? why is it taking this long? >> a good point that this is a historic of problem. what's amazing about the paradox, it's not the paradox itself that that we have had for decades. of the authors have written about it, but why haven't we addressed it? that you have to step back, as lauren begin to step back, and look at what is the history of the way americans relate to the health care and other health. and who is benefiting from a very large medical care 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's -- just cannot be conferring health we want but it makes a lot of profit for our country and it's really set up that way. >> do you think probably is the reason we have this paradox? >> i do think that's part of the reason. i think that's undeniable.

i think a 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 distributed way. i think that's really at the heart of that. high health spending and poor outcome. the outcomes that we look at and outcomes that many people point to when you talk about this paradox are things like life expectancy, maternal r. kelly can infant mortality. these outcomes that are driven by the social and behavior and environmental factors. there are other health outcomes where we do quite well and we don't want to not acknowledge those. those with the things that respond well to heavily medicalized intervention. so we have more people living with a kne knee replacement in e united states than anywhere else in the world. or are on keeping the ouster it's not that we don't dwell anything. is that we don't do well on these broad population health

outcomes on which we are so often compared with her pure investor let's countries. >> to get at the heart of what of the most interesting, you look at the differences in health care spending across the country. we spend more, the new doctor spending on social care. when you look at the collective tide, we spend less than a lot of other countries. how do you divide health care? wants a health care system, how do we think about it? shouldn't just be for heart attacks? should be for the population measures? how do we think about this? >> i would like to address the. it's an interesting question and giving many people run hospitals and many physicians in the united states probably do see their job as fundamentally medicine, medical care, i have medical treatment. but we also to look at who is paying for our medical care system. 50% of the revenue of the hospital typically, even more

than that is paid for by medicare and medicaid. that's the public dollar. the question has to be then what is that public dollar by? should be buying health are should only be? the two are very different i think. when we visited of the country, there's a different conception of health in other countries. were held i think it's broadly understood as medicine is one input to it but so are many, many other things. it's not so clear in the united states we have that view. i think with a much more separated you as this is the medical system. it as a whole different revenue stream from all different government structure and here's education and housing and nutrition completeness of it. we don't always see that in every country spend so health isn't the key input to our health. do you -- >> i agree. it is not the key. >> once an example? what's an example concretely?

the fellow who did not sneakers, talk more about that spent do you want me to read? >> sure. they didn't give me a copy of the book. i will steal one after. >> it's a passage that we've gotten a lot of feedback on and it is 100% true story. so i will read it, and it's meant to illustrate, as you suggested, this kind of, the power of social determinants of health and the way they can really help drive health care expense. joe is a 20 a euro man with type i diabetes living in the united states. he lost permanent housing and has been staying in a friends condemned boarded up house to avoid being seen, joe enters for the marshlands behind the house. his shoes are full of holes but he cannot afford to replace them. his diet has similar suffered from his lack of income. he sometimes goes several days without fresh food which negatively affects his diabetes.

also, after a lifetime of poor insulin control you starting to lose circulation in his seat. last year joe had to does removed on his right foot to save his life at hospital cost of $7132. still, if he continues -- an increased risk of trauma to his feet. the doctor he last saw emphasized the importance of keeping his feet dry, taking his insulin as prescribed. all of which joe is eager to do. since the deployment joe has been diligent in taking his insulin but dry feet and proper nutrition remain difficult to achieve. is doctor has already raised the issue of having to more toes removed on his foot at a cost of over $14,000, and without immediate changes joe wanted to have a below the knee application in the years ahead at a cost of over $17,000. he will also likely need a wheelchair. the extra cost of his medical expenses will easily top $30,000 paid by state medical assistance

programs that are funded by taxpayers. a metasystem 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. so i think as you said, this really illustrates how we place the burden on the medical system to respond to people's illnesses and diseases that really have roots well outside the health care system. and tiller medical system and help your system kind of a i think address the fact that these determinants lie outside their scope and are willing to coordinate and collaborate with social services and other civic society who can address really chose challenges, they are going to keep paying a lot of money to fix joe up and send it back out to house in and of him actually unhealthy. >> to think about -- the problem with her health care system or the problem with the welfare state. the one argument is we should

change health care system and focused more on prevention. another is a health care system is great but we just don't have adequate support structures around it. isn't health care system or something else that is missing? >> i don't think it has to be one or the other. probably both need tweeting. one of the teachings of the book is a broader view, a more integrated view of how to make somebody healthy. it's not going to be the problem that is only at the feet of our health care system or a problem at the feet of the welfare system. let's think a list of about what other services we can give the people. sometimes it's subsidies for shoes for somebody who's diabetic. sometimes it's going to have to be amputation and it's going to be a medical treatment. but to be able to play and services and also tailor services so that you're spending the most -- intervening in the most cost effective way to the root causes of the disease is ultimate going to make our system a lot better spent you said the word we. who is the we and who is --

where is the doer ship? who should be doing at? >> it's an enormous question and its accountability. who is accountable for health in our society? we believe in individuals take care of themselves and we are very much formed on the idea of individualism first. of course we have government programs that support as well for people who can't take care of themselves, et cetera. but it's not a widely shared accountability. what we find particularly when we look across the globe is we are one of the only countries that is quite so individualistic about health, not seeing any part of it as related to our social context and not seeing it as lauren had said, in any planned way. a question would be asked to our we dumping too much into the individual's responsibility without thinking more broadly about both how the private sector, corporations at the center and the public sector and public programs can work

together. when we say who is we, unfortunately i think it's all of us. >> so then the aca. he talks a lot about changing the health care system, the incentives for what doctors provide, expanding coverage. have we just spent three years spinning our wheels in the sand is what we should have been doing is providing sneakers? >> i don't think so. i think the aca has a lot of good stuff in it, you know, and it was born of a political process. that's very american. i think expand health care insurance and access to the system is critical. you need those people to be in the system to start getting insurance, budget for them over the long-term. hopefully give them some prevention care that can start to bend the cost curve. but i don't think it's quite as bold a reform as maybe we do need to create really meaningful sustainable reforms over the long-term. i think that would require a larger reconceptualization of

the ability and terms of what health is a is and what the rolf the health care sector is and how we're investing in health versus social. of course in her 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 they think it's a cheat. so i think the aca was the right reform for maybe where we are right now, but we would hope with the book we can start a larger conversation that can maybe when they get us to a broader reform. >> would you agree that we needed the aca? >> i would definitely agree. i think the aca has set a platform i which i think a great health care system can be built. and i think that has a couple of inputs to it. one is getting everybody insured and making them more explicit. this is what we're spending to ensure this population, and if you make that explicit with the american public we're going to be more discerning about what are the inputs to what are we

paying for and getting everybody in the system i think is a huge step forward. >> the scared thing for me about the book, we talk about joe, how does this affect me and my mom and all of us? it's terrible that he is being so marginalized, and we know it's not cost effective but this this shift adversely -- what's best for the individual and what's best for society? >> there may become yes, if we can talk about that, but i think in the near term you referenced the deficit and the debt. that is primary concern for all americans because those are our taxes and those are our kids -- maybe not my kid, but some of your kids are going to confront that. and so i think that creates a sense of urgency in this discussion about health care where we need to do something. maybe politics, people's individual politics don't support helping joe because joe

is disenfranchised or he is vulnerable, but i think certainly their pocketbooks will benefit over the long term, and the nation's pocketbook will benefit over the long term from us responding to this crisis, which is people using medical care for social issues. >> just to push back, the argument is spend more now on joe will save me in the future. more money will solve the problem. >> i don't think that's the story of joe at all because i don't think it's spending more money. it's spending less money now will make you better in the future. you asked the question of how does it affect you, and i think as a taxpayer id is a great one. let's say you come down with abdominal pain and you think, i don't feel well, i need to go -- you get emergency room. were not established what it is, you get a full worker. you have a full worker and to go home and you start feeling again.

to go back and get another full worker. would you like to have an awareness that is a drive my abdominal pain? what have i been eating? what's my job doing to me? to sort of raise the awareness in the american public that the first step does not always have to be i must insurgent or i have cancer. it might be what else is going on in my life anyway that i could manage or even worked in consult with the medical care system? we would have want to tell people, never go to the hospital if you're ill, but we was a think about it. think about the other things that might be starting to make your help not as strong and work collectively, integrated fully with the medical care system. >> do we see this happening now? isn't happening in the u.s.? is this only france where this is occurring? >> where this sort of heavy dependence on medical care? >> no. where people are doing the right thing. where we are seeing holistic

models. >> doubtfully. we spent a fair amount of time traveling high-income countries to understand what would be sort of the ones that we might be most eager to learn from. we have to do everything in an american way, but what can we learn from the others? >> what did you find? >> so, there's a lot of reason for optimism here, because when we went to the front lines and we spoke to people who are confronted with its challenge every day, we found some really innovative models where people are doing a great job working upstream against perverse and since the great collaborative models of care. we saw in santa monica, california, there's a committee since it has a long history of providing care, substance abuse, rehabilitation, shelter for homeless people, like really serving the most in need. they have partnered with a local hospital and the local hospital gave him a block grant of money in order to try and push back on what they call frequent flyers, people who came into the

hospital, you treat them, you give them their medication, they go back out and they come back soon after. so the hospital knew this was a problem and the committee sent me this was a problem, so the hospital gave them a block grant and said please come would go to take the people who come in and treat them and then we would like to partner with you, get these people to the kennedy center and for going to set up a respite care with a nurse who can look after them facilities so that they're not being bounced right up to the street. and wind up right back. so this partnership has been working out for some beers and it saves the hospital a ton of money but in the version i think 2009, they saved over $300,000 in inpatient cost. a pretty small cohort of folks. is only i think 15 or so people who they were doing this with, but that kind of partnership i think is really the reason to be helpful. this is something that they did on their own.

the system is not set up to support this really, but it's working and it's showing us that these things are important. >> save costs or cut revenue? >> so if you want to know the nitty-gritty is i believe this is part of a community benefit spending program which hospitals are obligated to do. this is money they have to spend our to maintain and nonprofit status. this is a nonprofit catholic local hospital. so this is part of the hospital's mandate and with how much revenues hospitals are taking for medicare and medicaid in government, one could argue that all hospitals have this mandate to take care of population health and the most needy. so i think they are saving costs. >> do you agree? other examples in the u.s. we should be looking at? >> we profile for cases in u.s. something that's important about it is is the only, this is a great example but it's not only in areas where taking care of the poorest who have the biggest

health risk, et cetera. we found a fair number of cases in which, that are serving middle-class even high income clientele, but looking at the whole patient. looking at the whole polite and figure out what would be the most cost-effective in -- intervention to occur. i feel optimistic. we need more research. we need more experience, more research on how to create services where you align the incentives to really pick the most cost effective intervention you can pick. we don't have a lot in the nested but i think with the aca we are gaining some traction on this and will ultimately save costs. >> we've got some folks from the connecticut state government. what should -- if the governor called gets it what should i do in connecticut to make these ideas reality, what would you tell him? >> on the very first things i would do is in been a group who are charged with not only the health services, a key health

services in the state, but also education, employment support, housing. convened a group that's almost like an interdisciplinary group to say we have a collective problem here we are spending this much money in health, this much money in education, as much in housing, et cetera. and these are our common health metrics that we can agree on, that goals relative to them, and start to think what are the barriers. what are the barriers between housing and hospital? how can we have these work closer together to more effective using the public dollars more efficiently? it's going to take some effort to look carefully at how the agenda is integrate a look carefully at where there can be some synergy. i think we can align objectives differently than we do now. some of the indicators and metrics by which hospitals get paid and by which housing agencies get paid and our education departments get their budgets, it could be aligned

better. >> this is a discussion you and i had before. the rt issues when it comes to health care spending. one is the fact america spends more than everybody else. we spend what 700 billion more than we expected. that is the rate of growth. if we look over time is speeding up a larger and larger share of our budget. this affects, this is a question of differences between countries, not something about levels of growth. is that fair? the real issue i would argue is rate of growth between countri countries. >> the differences between countries, however the exhilaration across countries is a pretty common phenomenon. when we look at the percent increases over time in the uk budget or in the swiss budget, or in sweden, every country is worried about this. countries are expanding their health services spending without question, and i don't think the u.s. is very different. in some ways i think the most important question is really the

question of how is your current spending different from others and what are the patterns. >> and speaking about spending and who are the high spenders, we know 20% of the population is spending somewhere in the neighborhood of 80% over health care dollars. does this get at that 20% or is that really a medical issue? are those the same people? >> i think this does get at that 20% the a lot of the 20% i think is driven by the elderly and people who are in medicare who have complex conditions, often accomplished of both medical problems, some psychosocial issues. these are people who really are well served by social services. there's a great example in the book of a woman who is burning out a ton of medical expenses which are paid for by the state because she lives alone. she i think recently lost her husband, and she was really lovely. so she calls an ambulance because she knows that when she

calls 911, someone will come, paper, talk to her, take her to the hospital. she will interact with more people. this was written about reason in the atlantic, a big piece of loneliness as a real powerful determinant of health. i think the 20% actually, many of their expenses kind of strike right to the core of what we're talking about. >> so why is this book and why now? when making your you are this giant global health. you are in ethiopia the first week that i got to yale. why write a book on u.s. health policy lacks how did this come about? >> i think it is a global issue. i think that, in fact, every country struggles with this exact same question, how do we invest in the most effective way to get the healthiest population we can. and so it was in large part my engagement globally that i think also triggered ideas about how other countries really map this

difference of where they going to put it all and how they're going to organize their medical care. in fact, the book is quite international because we get a large spectrum on scandinavia which is the part of the world that we really found that does look at this in a more integrated way. of course, we can't be scandinavia by the army things to learn from scandinavia nonetheless. a lot of the inspiration came from the global work and i think also the decades in which we been trying to do health reform, but we keep having the same problem. we've tried everything in health reform. we've tried to change the way networks are put together. we change the reimbursement system six times since i went into health care. we've changed how the training programs were. we've tried to help through education to fully. we started hmos. we stopped hmos. we constantly have this same problem that the costs remain much higher than any other country and we get more out of the there's got to be something else going on.

and look at other countries they dutifully. >> what do they do differently? >> the address them. >> can look at scandinavia and take their lessons back here, or is that a function of culture? .. >> and the u.s. and scandinavia are really far apart on a number of crucial ones which told us,

okay, in this isn't going to work, to just import them. but be i think for us traveling there in ways held up a mirror to our own system and helped us get a closer read on what exactly are the issues. for instance, before we went, we had not been thinking the conception of health here in the u.s. was different. it wasn't until we went there and heard scandinavians talk about health as a means to an end, not an end itself, that we started to think that's different. so i think we put forward some lessons from scandinavia. certainly, there are models there, poor budgets at the local area, and if we could do them on a local level and certain states or regions want to take them up, bless them. but i also think that some of the larger lessons just about health care culture in this country, trust of government, trust of one another were things that really emerged from that investigation that were crucial. be. >> before we go to the next question, we're going to open up to questions from the audience.

there are two mics in the back. if you have questions, line up there, and we'll call on you in just a second. i would encourage you to keep the questions fairly brief and to say who you are. >> [inaudible] >> the mics are going to come to you. so the mics are actually going to get passed to you. so if you raise your hand, we'll pass the mic to you and give you a question. key takeaways from the book. what would you like, what would be success for this book? so you've written the book, you're out talking about it quite a bit. what would success look like, what do you hope to achieve with it? >> one of the key successes we're looking for is as lauren had said that the discourse changes a bit. that more and more people really see the difference between health and health care and you understand that health care is just one input into our health and a small input actually. if we could change the discourse, if we could change the way people talk about this, i think it really is the first step to making a large

difference. additionally, it would be nice to see over time these experiments that are really being spawned by the aca would start to be collected, and we'd really start to learn something about integrating health and social services, about landing things together at a local level, about aligning incentives so that the health care system is trying to accomplish some of those social goals and trying to accomplish some of the health goals. and together we use that health investment in the smartest possible way. align some of those incentives. and over time you would hope you'd see infrastructure be changes, that you would see there were new models emerging sort of like the model we saw in santa monica where actually the people are thinking together what tool do i have? some of it's medicine, some of it is housing, system of it is education that can make this population as healthy as possible. if we could change awareness, change incentive systems over time and watch some new

infrastructures emerge, we would be very successful. >> does that sound about right? >> yeah. let's go to questions. she nailed it. >> perfect. so questions from the audience. >> hi -- [inaudible] >> how are you? >> you're among friends. >> yeah. >> current political debate is not particularly favorable to the argument you're making either here or in europe where the sustainability of the welfare state is in question. so so if you were in front of congress or in front of a european parliament, how do you make the case that more social spending is the thing to do when the politics of austerity are what reigns right now across the globe? >> >> yeah, it's a great question. i don't think we start with more social spending, and i am sorry if the interpretation of the bookends up being that, because that's really not what we're saying. we can spend exactly what we're spending now, not a penny more be, but we can do it better. we can do it much better. we are doing redundant services. people who are getting cared for with these high, heavy care

medical bills and sent out to live on a park 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 i think we have to go at this from almost an economic security effort to say if you want to create a secure future for our globe, we have to be using every resource we have in the most effective way. and right now we're wasting a lot of it. >> let's see if we can bring a mic up to the front. >> [inaudible] in many our policy class a quote i usually hear is a quote i think about often, every dollar spent in health care spending is a dollar of income in health care. and, you know, i think you guys touched on before, about 18% of our gdp is spent, and, you know, if i'm taking the flip side,

what is my incentive to, a, keep my income the same which is, i guess, e nor or mouse compared to everything else and not have it increase in the future? >> yeah. so i think, um, we worried about this, of course, because this is a real, i think, barrier to change. and, of course, every retomorrow effort the aca is -- reform effort the aca comes up against these powerful health care lobbies and a huge infrastructure. so it's an issue, you know? no matter what kind of change you do, there are going to be winners and losers, and if someone in the health care system perceives them as a loser, you're going to meet some serious resistance. but what we did find that was quite encouraging was when we went to the front lines and we spoke to over 65 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 ask so exasperated because these people want to practice medicine. that's what they were trained to

do. and the administrators want to manage hospitals that deliver medicine. and right now they're just having to, you know, a physician is having to play nutritionist and social worker and case manager. and they said to us, please, help us come up with a new system, new models of providing care so that i can get back to doing what i was trained to do and really want to do. so, you know, i hear that concern, but we were encouraged by the front line perspectives that said, please, we immediate to make a change -- we need to make a change because we are getting inundated by things we're not trained to address, and we want to get back to practicing medicine. >> to follow up on that, is the we've got hyperspecialization? any doctors out in the audience? do we need a couple less doctors coming through the medical system? >> that's a good question, do we need fewer doctors coming through the medical care system. hard to know. i think what we really don't need, though, is the kind of mix of physicians we have.

we have a very specialized group of physicians and we have, actually, very limited numbers of primary care physicians. and what we mean is primary care physicians, the first you would see who might be most likely to look at the whole person, would understand your housing situation, would understand -- would know you, would understand where you're working, etc. we have compared to other countries we're quite limited in this, and we have super specialists. so over time i think our country would do well to think about shifting towards more primary care physicians and fewer specialists. and in the long run, everybody would benefit from this. >> would the folks with cancer benefit? so, you know, i, you know, my mother gets diagnosed with cancer, she goes in, and i want her to have the latest kit. does she benefit? this is the tension between the individual -- >> right. >> -- 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 system -- than the service might be needed. and, in fact, potentially sort of moving the care path towards a very highly intensive medical approach to something when other alternatives may either be complimentary to it or actually replace it. and i think right now we don't really have a system of full choice at that, because the specialist is there. it's the old adage, you have the hammer, everything needs pounding. but the fact is, that's not true. we need more than a hammer in our medical care system. >> i would add to that that i think your mom who hypothetically has cancer would benefit from increased primary care also because when she gets to that special bist, you want a full, robust medical history and maybe a little bit more coming from a primary physician to make that call to a specialist 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

you with, so let's make sure we accommodate it. she recently went through a divorce, let's take extra precautions to make sure she has the support system needed. and so when you circumvent the gp and go directly to the specialist, i think sometimes you can lose that added texture to the medical history that really can enhance care. >> so i think a lot about incentives. one of the things we've seen, the true statistics we've seen is health insurance has become exceedingly more generous over the last 50 years. it covers a whole lot more than it did in 1960. is that the problem? if insurance were really under financial pressure, we might have seen the health system become less medicalized and these interventions come through. is that what we need, to roll back insurance? >> it's a bit of a chicken and egg, i think. you know, we have a very generous insurance system because we have a very expensive and wise-ranging medical --

wide-ranging medical care system. so which comes first and which drives which, i think, it's not possible to disentangle them. there are things in the aca if cadillac tax ever does pass which will sort of roll back the incentives in terms of a more generous system. but the degree to which that's going to make a major change in what is, i think, a much broader problem, i'm a little bit skeptical. >> individuals paying more? should i be forced to pay more out of pocket, would that lead me to think more about what's worthwhile, making the certain investments that you say i need to do? >> 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. so, you know, the research has all shown if there's some amount of consumer engagement through financial incentives from co-payments, etc., that does change the way consumers consume

things. probably don't want -- there are many bad things, so we don't want to go overboard, but it clearly, i think, wakes up a consumer think more strategically about how they'll use their health care dollars. >> all right. sir? >> yeah -- [inaudible] political science. i'd like to follow up on one of the themes that has come through in what both of you have been saying. 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 infant births, we've pushed back further and further when an infant can survive. new organ transplants, cancer cures, all sorts of things. this kind of stuff we're the best in the world. a part of that is, i think, what is the -- think about the incentive system within the medical profession. it's not just making more money

at being a specialist, it's the fame, the glory, the recognition, making new breakthroughs. it's much more glamorous than being a primary care physician. so one of the problems then is somehow to reincentivize what is it that people in medical school would really like to go into? i imagine you've got some thoughts about that in the book and yourselves, and i wonder if you could tell us a little bit about that. >> yeah. i would add to your comment by saying that gps and physicians who we spoke to in scandinavia joked, you know, we spoke to the highest ranking physician in all of denmark, the one who runs the whole show, and she said, yeah, i think i make less than gps do in the u.s., you know? so they're very aware of this and the fact that the incentives are skewed to higher specialization, high intensity, in some ways, you know, a fame or fortune.

i think the aca tries to address this in some ways, they're trying to increase payments to primary care providers in order to make it so that they feel like they can make a more fulsome living. but i don't have the answer. certainly betty can weigh -- betsy can weigh in after me, but the incentive structure and kind of the way the proto negatives is structured now finish profession is structured now is very reflective of american values, and i think that's important to take into consideration. there are upsides and downsides, and the upside is you can be a physician, you can make a ton of money, but the downside is that you call things in such a way that not everyone has access to them. so this is the tension that i think we really need to be talking about here. it's not that there's no upside to our value profile or to the way that we've addressed medicine in this country. there are. we need to look at those side by side with the costs, both financial and human, and say,

okay, weighing these both what do we need to do? because we don't want to lose all of the good things that we have going. but there also does seem to be a sense of urgency for a change. >> i would just add to that, i think it's a really insightful question, and i would just add to that that our innovations in the united states are very biomedical, they're very -- we have just the tippy-top best drugs coming out, the best new lasers, the best new imaging, etc., but there's also real excitement in thinking about a population and how do you get very creative at keeping them healthy. so in some ways we are our own worst enemy because we see innovation in one small piece of the medical care system as opposed to how innovative it could be to have a city that was all about health from the way the buildings are made to the way the streets are put together, the way people's cohesiveness happens, the way the hospital works. so sort of, i think, looking at

innovation in this ore places. but as lauren said and you identified, this is definitely a stress on the system. and for the globe. because we feed a lot of the globe, our medical testimonying. so -- >> another question there, me that? >> hi, yes, i'm nina russell, an undergraduate. i was just wondering given your analysis what would you say -- would you say that the next steps in reforms to take place at the federal or the state level given political feasibility? >> so i guess i wouldn't say one or the other. i think the states have 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've looked over the states, they already are different in terms of what they're spending in medical care and social services. so we have natural experiments going on. we need to do the research that then ties those spending

patterns to actually health outcomes. but i'm excited about the state level experimentation. i think that's going to prove very fruitful for us. >> any state in particular that we think is doing a good job? connecticut perhaps? [laughter] >> connecticut is right on the precipice of doing a great thing. [laughter] >> i worked for a politician for a stretch, and we would have these academic discussions. at some point he would interject and say stop admiring the problem. fix it. when it comes to this, what would we say a month be, a year and ten years from now are the interventions that we need to do to make this a reality? so more than just having a conversation, what are the structural changes? are there structural changes that we really need to put in place? what would those look like from a government perspective or from a private market perspective? >> sure. i can take a swing. i -- it's hard to know what we can do structurally and through government in a month, you know?

i don't have a lot of optimism about that. so for the month month, i think this course is a good goal, and i think as i've alluded to before, talking about the value base, looking at what we do well and in the well and putting those things side by side for some real critical and nonpartisan evaluation is where we should be focused. down the line i think betsy and i discuss in the book, um, the aca really is a platform where i think we could do some needed experimentation and start to make some incremental change in the responsibility and accountability that hospitals have to population health. so one of the things that the aca does is it incentivizes or puts forth a set of indicators that hospitals will be reimbursed by the government on, and right now they're very medical. so they're your traditional how many patients had a hospital-based infection, how many patients, you know, how many of your staff wash their hands every day? they're very inside the hospital. but if we could scoot those out and be innovative in the ways we

conceptualize those to include health metrics, you could say, you know what? hospital, you are now responsible for how many eighth graders are to bees, and if you're below the threshold and you've really engaged with the community to make the metric change over time, we're going to give you more money. so i think that's an instance where you could take the aca which is a behemoth infrastructure and policy that we're not i don't feel totally optimist inabout overhauling, but you say i think we can create a bit of change so so that these social determinants of health are being addressed within the health care system that we have now. >> the exciting 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. it's a regulatory change which is a lot easier to push through. and you could really imagine a shift. imagine if the hospital were held accountable to some degree, had some incentive for how many eighth graders are obese. you would be sure your board of

directors, somebody was on the board of ed, someone was engaged with really the exercise program in the city, etc. there are clever ways in which our health care system can be used to accomplish pop tolation health without -- population health without, i think, revolution but, rather, some incremental shifts in the regulation. >> hi. i'm -- [inaudible] from gails, department of biomedical engineering, and so i have a question coming back to medical technology. >> yeah. >> and i'm curious what you learned about how costs for new technologies are handled in different countries. and i've also been thinking particularly with the last remarks about if there's some ways that technology could actually contribute to this connection between health care and the individual in social care. >> yep. i'm so glad you raised that. the first thing we found is in scandinavia, although we think the united states is the one that spends all this medical technology and puts a huge amount of our gdp in this, we're not that different from scandinavia.

denmark, norway and sweden are very, very invested in technology and medical technology. so we aren't as different as we might think that way, and i think they are nervous about the costs of that as well but also see it as potentially cost savings as the technology are constructed with that in mind. in terms of the issue of can medical -- or can 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 being creative in one industry, how can we be creative to span a couple of industries, a couple of sectors that together could create a healthier population. that could be everything from information technology to all kinds of things i bet your lab could think about that would, in fact, bring these two in closer communication and just more efficient with each other. so i think it's a great spot to develop things. >> there's a question over here.

>> hi. i'm evelyn chen from the school of medicine. thank you so much. i'm curious, there's been a lot of conversation about the organic evolution of our medical system, health care system, and i have been influenced by consumer as well as industry. so in your conversations during the development or after the publishing of the book, what has been the conversation with consumers of the health care system been like? is this, is this message one that seems to resonate with people, or 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 that, you know, part of the story about the organic evolution of the medical system is a story of medicalization, right?

and so often physicians and the health care industry are really, we shake our fingers at them, and we say you've medicalized us, you know? you've done this. and i think certainly some of the blame, quote-unquote, does rest with the health care system who places a ton of money in marketing and really trying to get people in the door. they tell us your health is everything, come in, we'll make you better, etc. but i think in the book we are really careful to tread this line and say consumers have a responsibility too. and some know it more than others, but they're definitely there. so we tell the story of one family from a pediatrician who just will not take no for an answer. child has headaches, comes into the physician. the physician does all the standard tests, no finding. the child has headaches. they're probably stress headaches. family will not accept it. they want certainty, they want to extract certainty from the system maybe because we've told them that the medical system can provide them all of these

answers, but maybe because that, too, is an american thing, to strive for perfection and want to get it right. so we tell the story in such a way as to say there's a lot of moving pieces here, and consumers definitely, you know, have grown into the system to expect certain things from the system and want certain things from the system. so i would say, you know, consumers will have to change too. if we're going to change the health care system, of course, we need consumers to change their dialogue to prompt some policies. but also we need to watch out for the fact that there's going to be a renewed sense of discipline that probably needs to accompany any sort of reining in of health care costs over the long term. >> i guess 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. how do we reconcile the sort of political timeline and political tension with what you're arguing

needs to occur? >> yeah. i think something that really we need to get in our heads is it's not a book that asks to spend less in health care and more in social services. it does not do that. keep the spending the way it is, but hold the health care dollar more accountable to the population's health. so you don't have to lay off anybody in the hospital. people need to do different jobs. there may be better connections with some of the social services, other ways to conceptualize how do i use this health care dollar to instead of just give medical care actually confer health. and that is, i think, sort of a shift in the way we think about what the obligation of our health care dollar is. i do think shifting and asking there to be a change in our allocation pattern and or taking away and giving more over here, i just don't think the politics in the united states would tolerate that. but i think there are ways in which exactly what the patterns we have but you think about how do we 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. >> [inaudible] bailey, 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. >> could be, yep. >> so in the short term, what would that look like in talking with policymakers, but also having a chi log with -- dialogue with hospitals, these community health centers and the consumers. >> uh-huh, yep. what would it look like? that's a great question. i think it could take a lot of different shapes, but maybe something concrete can which lauren alluded to earlier. imagine that you got a city together and all the services that were given to a population in that the city, the leaders came together to say what are the core accomplishments we're trying to address?

what are the indicators of new haven being healthy? and what can each of us provide this that area, align the incentives so all of those public dollars and some of those private dollars are focused and rewarding and are being rewarded for accomplishing those goals? so instead of the hospital's quality indicator being how many of my patients with heart diseases -- [inaudible] maybe it has something more population based. similarly, the education system, the housing system, etc., job training, service providers having some incentive themselves for being sure they have coordinated with the health care system. that's what it would look like. you could finally 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 system as working on the medical care side, you could point to education as trying to educate people, you could point to housing as trying to keep 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 then? if we came together and said we need to draw up a list of indicators, which should we be looking at? [laughter] >> do you want to -- >> i think obesity would be a great target. it's something that there's a lot of political priority being placed on right now. the costs 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 on chronic disease would really be wise because those are the things that are going to really balloon, maybe something on mental illness, you know, days -- there's an indicator days lost due to mental illness are days lost due to mental -- what's the term? >> disability. >> disability, thank you. and i think that's one that has proven really costly because if you stay home from school, that

child needs extra attention from the administration and teachers, they're not going to test as well, you know, school districts get reimbursed from the state in some ways on test scores, same thing with employment. if someone's not going to work, obviously, that's cutting into business revenue. so those would be examples, i would say. >> yeah. and i think you could really broad been it to say what's the percent of people who are employed? what's the percent of people who are housed? we know these are fundamental to creating health. and if you had a joint group that was worried about these core indicator, some of those obesity related, smoking, mental health and some more related to the social determine in a minutes of health. >> exciting. >> connie -- [inaudible] from the yale school of management. as you're talking, i could imagine some cadre of consultant organizational change experts going out, identifying sites that would be ripe and fertile for change and that would be

motivated almost ready for a makeover. what not to wear, kind of thing. going to these places, helping the people get together, advising them, help see them through, pull together the results, who is that going to be and how are they going to get themselves organized? >> that's a good question. maybe i can start. but, um, because you're hitting on something so fundamental, and i just want to underscore it that these kind of collaborations, what we would call intersectoral collaborations, are hard to do. there's a reason that they haven't just sprung up organically, and part of it is incentives, but part of it is very structural. i mean, we heard from folks who had done it. they said, look, it's a long road, you're working upstream, there are different professional cultures, we work different hours. certainly, we don't share an i.t. system or common medical records and, you know, it's hard. and people aren't really -- even if they think in theory, yes, collaboration is what we need,

it would be best for patients, it's a good idea. when the rubber hits the road and you say, okay, we're going to start a project, you're going to run into some resistance. so i'm not sure who the person is. i would be hopeful some of the people who we profile in this book and i know they're eager to do so could go out and be consultants, and i think maybe that was part of our motivation of holding up some real stars in this community in the hopes that by publishing some of the record of what they've done, it can be replicated. and i'm sure that they would be willing to go in and talk about their journey as well. but do you have other thoughts? >> and depending on how the reimbursement system goes, you could imagine it's in groups' self-interest eventually with this kind of awareness to get together because they can, in fact, save some dollars out of the system. of course, you've got to set, okay, who benefits from those dollars that are saved. i can hear the economists asking me that next. but i think there are incentives to get together. it will take a trigger or

something sort of probably larger than just organically to say this is something that will incentivize you to get together and start to meet on. nonetheless, we have come across teams that are already starting to work on this in different cities in the u.s., and i'm optimistic that something will emerge in this way,yeah. >> hi, betsy, lauren, i'm dave mccord, a local business owner. and my question centers around individualism. we're talking a lot about public policy and governments and what we should or shouldn't do, but how much emphasis would you put on the individual taking responsibility for education, exercise be, eating properly? >> yeah. >> isn't that really the core of so many of these diseases today? you know, that it's what people have done to themselves. so how much emphasis and how do we keep -- should we or how cowe keep putting that emphasis so it's just not big government is going to solve your health issue.

>> yep. yeah, it's a great question. you know, 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. so in ways i think we have to use that as a strength. the issue tied to the question zack had asked earlier, what would you do about co-payments, etc. how do you have the individual feel the penalty of not taking care of themselves, etc. that's actually a strength i think the u.s. has it's sort of tolerance in being able to say this can be in part an individual cross to bear. on the other hand, it's important to understand the science. and the science really is that your social environment, the network you're in does influence your health behavior. if you are living in a community where smoking is normal and it's fine and there's no stigma to it, you are just more likely to smoke period. and same for eating and exercise and all of these things.

so we like to think it's an individual decision, and it is. but that individual choice so influenced by our social network. now, that doesn't mean a government program, however. a social network can emerge from a community, or it can emerge from your employer. it can emerge from the corporate life of great corporate life of the u.s. economy. so i don't think we would want to put the accountability in sort of -- and sort of throw it into the government's arms necessarily, but i think that understanding it's more than just an individual because our behavior is very determined. we are social animals no matter how we think about it. >> to build on that, are we seeing businesses starting to take up this idea? >> absolutely. there are some very, very exciting programs. i mean, i think there has to be two steps forward, one back, three forward because there have been programs that have backfired as well. but it's in the interests of a corporation to really think about the employment work force

and think how can they be as healthy as possible since the employer's paying the bills. so we've seen ebb and flow over time, wellness programs, etc. today i think we're starting to see all kinds of things from united health care and aetna and others that have really started to work with their employer, employee base to understand how can we incentivize exercise, good nutrition, reduce stress, etc. so that's another place in addition to the states where we'll see great innovation ahead, i think. >> if i could just go back to the individualism point, because i think it's so fundamental, and i'm so glad you raised it, and it's something that i think we need to talk about more. the only thing i would add is that sometimes because we're so interested in individualism, when we purchase health insurance, we think that we are paying for our own health care. and this is where i think sometimes we get into trouble because we miss that when we pay for our insurance, we're buying into, essentially, a risk pool, a community. and we're accepting that, you know, i'm paying this much so that if something really bad,

more money will come to me, and that more money is pooled by other people paying their premiums. so sometimes people ask us, you know, as zack did before, what's in it for me? why should i care if so and so is fat and racking up a ton of health care bills? and i would suggest that you should care because you are paying for that. you're paying that, certainly, through your taxes if that person is on a medicaid roll, and i think you're paying it in your own health care premiums and expenses as well. >> time for a last question. >> my name is anna -- [inaudible] of yale college, and i was wondering what do you think the impact of our expensive and competitive medical school system is on our health care system. [laughter] >> an easy question to end on. [laughter] >> our expensive medical care -- our expensive medical school system. certainly, having -- i guess if we are thinking about your

question, you must be asking people spend be all in this money in medical school, and so they have to get out and take the most high-paying job. i can't see you anymore, anna, but that's what you're thinking, yes? yeah. and so that probably is one of a whole myriad of incentives to take the high paying and specialist job. and so we might look at that broadly and say that's one, but there's several other ones. in terms of being able to say is that one of the most important or medium important or less important, i don't really have the data to be able to answer that question, but certainly, it falls in that same concept where there are many incentives why we get to a highly specialized medical work force. and it's really not helping us over the long haul have a system that is cost effective and produces the healthiest population. >> so any, any final, concluding thoughts about the book that we ought to -- >> read the book. [laughter]

>> that was a pretty good plug. >> and then let's work together. try to make it a healthier place. >> of course, read the book and then talk about it with people. i am a big proponent. i know that some people feel like, oh, all they're prescribing is discourse, but that's where this change begins. because if we don't talk about it and we don't discuss, well, what does health really mean and who is accountable? should it be me? should it be my doctor? my insurer? then this is what happens, policies unravel because a policy sets forth a certain set of values, and we don't know if we really abide by those values. so i think those discussions about what is great about the u.s. health care system and not so great are really critical and to do in an open way that is not overly partisan where we listen to each other and really learn from each other. that makes me deeply optimistic. >> i think that's a good point to say thank you. thank you for coming, thank you for writing the book, thank you

for finish. [applause] >> you know, this is, this is precisely the type of discourse that icf health wants to promote. there's so much noise about what's going on in health care policy, and to have academics willing to put out controversial ideas, have discussions about them and use them to provoke a thoughtful conversation, we can't think of anything better. so thank you. thanks for coming, and we look forward to having a discussion afterwards. [inaudible conversations] >> we'd like to hear from you. tweet us your feedback, twitter.com/booktv. >> a few weeks left in 2013,

many publications are putting out their year-end lists of notable books. these nonfiction titles were included in the economist's books of the year. in coolidge, amity. >> laze recounts the tenure of america's andth president. ian buruma presents a global history of the end of world war ii in "year zero." in "margaret thatcher: the authorized biography volume one," charles moore, a reporter for the telegraph, recounts the late british prime minister's personal life and early career. in "my promised land: the triumph and tragedy of israel," ari -- [inaudible] presents a history of israel. margaret mcmillan, professor of international history at the university of oxford, recalls the events that led to world war were in europe in "the war that ended peace."