we will talk about salt, sugar and fat and investigate the world of processed foods. and carla kaplan will profile black women in the renaissance. and david finkel talks about the war on iraq and thanks people for their service. and the life of foster care. chris bean examines what life is like for children in the foster care system. and the science between the human digestive system in gulp.

a ... there's certainly no shortage of professional health care in the

news right now. we've got democrat seriously defending the affordable care act, republicans. the attacking it. i think we would all argue that they are missing at the health care care system is broken. spend more and get less than virtually every other country and neither party are really talking about what we would do about it. i would argue that our ability as a country to rein in health care spending is going to determine this is the largest single factor driving our debt. it is bankrupting this country. if were not able to get this under control, we will have money to spend on anything. this is the underlying rationale. we firmly believe evidence should he what is driving health care policy. public policy in general.

we've got three goals. the first is to link the extraordinary resources and produce to give scholars a medical school together with economists, political science is, sociologist and come together to produce disciplinary scholarship. the second is to get our students involved. the students here come in the future leaders and talk about these issues. talk about what's happening, why we care about this, why it is so challenging. the third is to connect what we do here at yellow to the outside world. there's no better better example of this data to review of you and what you're doing. betsy bradley is a professor of public health here at the university. director of the global health leadership institute and the beautiful college. i live in davenport.

she, more than anybody else personifies the extraordinary scholar and performance. you're one of the most popular teachers at the university, which is pretty amazing in its own right. scholars not only produce the research and translated it into improving the way hospitals are managed across globe. the presidential scholar came up with this. the american health care paradox. so economists say the reason the health care system is so it is because of technology. the fancy kits in our hospitals. doctors say because of malpractice. you come up with a different explanation. you argued the cause why the health care system care system is so expensive i'd be outside

of the health care system. it's an extraordinary book. we are going to talk about 20, 30 minutes and then open up about this new book, what it means and what we should do. i guess we'll start with the first question. why is the u.s. health health ce system so expensive? why do we spend more and get less? >> thank you so much comments that. wonderful introduction. i think it's weird we are depending on a medical care system to adjust social, behavioral and environmental challenges that are deterring us from being a healthy population. when you look at the most common causes of illness, colon cancer, heart disease, adult onset diabetes. 70, 80, 90% of the cases are related to economic determinants exercise, sleep, nutrition, and

yet we are expecting a medical model and they are looking to fix this. we spent an enormous amount on the medical side and we don't spend as much as other countries to really support these more fundamental determinants of health. that results in an expensive business that doesn't confer a health we deserve. >> why? viably evolved in evolved in this way? you talk about scandinavia look so different. >> i think one of the reasons we found was there's a series drawn historical precedent in the united states for letting the system kind of grow organically. so health care in the u.s., as it did in many places monday canister real cottage industry. doctors are entrepreneurs. they put a plaque outside the house and said i'm open for business. we have continued down that path as an archer gregorio free-market system because we

feel that the very american way to approach the system. a more centralized unbudgeted system where they decided health care wasn't something to be allocated to the market, both a social that they wanted to ensure for people. those are very different approaches and tell us a lot about how we've arrived where we have. >> i would you articulate the paradox? how would you frame at this paradox really is? >> i think the paradox is straightforward. first turning more and getting less. you usually buy a cadillac companies spend a lot more money on it. but you don't expect this paradoxical to anticipate a spent $8000 per cap will in the united states come over the next most expensive country would be two thirds of that. you would expect you should have better health outcomes.

lower infant mortality, less heart disease, disability. >> is a missing the point? i haven't we come to an answer 10 years ago? why has it taken this long? >> convicted point this is restore problem. it's not the paradox itself, but we've had it for decades. other authors have written about it. why haven't we really just this? one of the things you have to look at is really what is the history of the way americans relate to their health care in health? and who's 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 benefiting many, many people. it may not be the house we want. it is really set up that way.

>> keeping profits the reason we have this paradox? >> i do think that's certainly part of the reason. i think that's undeniable. i think the system permanents such an unplanned ways a big part of it also and the lack of attention to kind of equity and making sure everyone is getting resource is in a fairly evenly distributed way. i think that's at the heart of the high health spending and poor outcome. i mean, and the outcomes we look at many outcomes many people point to when you talk about the paradox or things like life me, infant mortality. these are population health outcomes that are children by the social and behavioral and environmental fact yours. there's other health outcomes were we actually do quite well and we don't want to not acknowledge those. those are the things that respond well to have a medical waste intervention. we have more people living with

a replacement in the united states than anywhere else in the world and on kidney dialysis. it's not that we don't do well in anything. it's that we don't do well in these broad population health outcomes on which are so often compared with industrialized countries. >> you look at the differences in health care spending. of course we spend more. manufactured in spending on social care. when you look at the collective pie, we end up spending less than a lot of other countries. how do you define health care? how do we think about it? what should the help care system due? should it really be for these population measures? how do we think about it quite >> yeah, i would like to address that actually. it's an interesting question. i think many people run hospitals and many probably do see their job as fundamentally i get medicine, medical care, i

operate, i've medical treatment. we also have to look at who is paying for medical care system. 50% of the revenue of the hospital, typically more than not is that she paid for by medicare and medicaid. that's a public dollar. the question has to be than what is that public dollar buying? should be buying health or the medicine? the two are very different i think. went to visit other countries, there's a different perception warehouse i think it's broadly to as medicine is one input to it, but so are many, many others. it's also clear the united d.c. at the integrative view. we have a much more separated view. it has a whole different revenue stream. a different governance structure. here's education and housing and nutrition completely separate. >> health isn't the key input to our health. >> i agree.

>> what's an example of concretely the idea of sneakers. can you talk more about that? i found that as one of them are powerful examples in the book. >> sure. do you want me to read it? >> sure. they didn't give me a copy of the book. they make me by. >> is a passage or got a lot of feedback on and it is 100% a true story. so i will read it. it's meant to illustrate as you suggested, the power of social determinants of health and the way they can address health care expense. joe is a 28-year-old man with type one diabetes living in the united states. he? permanent housing and has been staying in a boarded up house to avoid being seen by her camacho understood the the marshlands behind the house. issues are full of holes, but he

cannot afford to replace them. joe's diet has loyally suffered from a sauce of income. he sometimes goes several days about fresh food come which negatively affects the diabetes. also after a lifetime of orenthal and control user into the circulation is the period last year joe had two toes removed on his right foot to save his life at a hot little cost to $7132. till now it continues to causing decreased sensitivity and increase risk of trauma to exceed. the dr. eli thought emphasized proper patrician and taking insulin prescribed, which i was eager to do. since the appointment, joe's telogen and taking insulin, but it is -- does dr. astarte raise the issue of having to mark those are the dumbest foot at a cost of over $14,000 without immediate changes in the joe on me to have a blown up in the amputation in the years ahead at a cost of over $17,000.

they'll also likely need a wheelchair. the estimated cost of his medical expenses will easily top $3000 paid by state medical assistance programs that are funded by taxpayers. admitted with a of the most advanced medical system in the world your joe's site is slow,, painful and expensive death. a decent pair of shoes cost $50. as you said, this really illustrates how we placed the burden on the medical system to respond to people's illnesses and diseases, but really avarice while outside the health care system. until our medical system and health care system kind of a think address the fact that these determining lay outside their scope and are willing to coordinate and collaborate with social services and other parts of senate society who can address joe's challenges, they will keep paying a lot of money to fix joe up and send them out to an environment that is really

unhealthy. >> to think about it differently, the problem with our health care system or the welfare state? one argument is we should change the health care system and focus more on prevention. another is the health care system is great, but we don't have adequate report structures around it. is it the help or system or something else missing? >> you know, i don't think it has to be one or the other. both needs tweaking. in the book is a broader view and more integrated view. it's not only at the feet of our health care system, but it's really think holistically about the services we can get you people sometimes for shoes for somebody you include diabetics. sometimes it has to be amputation and medical treatment. to be able to plan services and also tailor services so you're spending the most -- really

intervene in the most cost effective way to the root cause of the disease is ultimately going to make our system a lot better. >> you said the word we. who is the we in this case? where's the stewardship? >> it's accountability. who's accountable for help in our society? we believed individuals take care of themselves and where formed on the idea of individualism first. we have government programs that support as well for people who can't take care of themselves, better. it's not a widely shared accountability. what we find particularly when we look across the globe is one of the only countries that is so individualistic about health, not seeing any part of it is really related to her social context and not seen it as lauren had earlier said, in any planned way. the question would be asked, are we putting too much and

individual responsibility without thinking where bradley about the private sector corporations, et cetera in the public sector and public rocher and can work together. so when we say who is we, unfortunately it's all of us. >> said the aca. we talked about the incentives for doctors provide come expanding coverage. have we spent three years spinning wheels in the sand? >> adult think so. i think the aca has a lot of good stuff in it. it was born of a political process. expanding health care and access to the system is critical. you need those people to be an assist and get the insurance, hopefully get them some prevention and care they can start bend the cost curve. it was quite to create really

meaningful sustainable reform. that would require a larger reconceptualization as bad he alluded to about the role of the health care sector is and how were investing in hospers is social. in order to achieve that reform, we need a different discourse in a more inclusive on where people talk about what hope is to then and how it's achieved. the aca was the right reform. as he and i would hope that the book we can spark a larger conversation that can maybe one day get us to a broader reform. >> would you agree we needed the aca? >> i would definitely agree. the aca has a platform on which a great health care system can be built. i think that is a couple of inputs to it. one is getting everybody in sheraton make a network with it.

this is overspending to ensure this population. if you make it explicit with the american public, will be more discerning about the input, what are we paying for and getting everybody in the system is a huge step forward. >> the scary part for me about the book. all politics are local. how does this affect me and all of us? has been so marginalized and we know it's not cost effective. does this shift adversely affect the tension between the individual and society? >> or maybe, yes. we can talk about that appeared in the near-term, you reference the deficit and the data. but his primary concern for all americans because those are attacked us and our kids who are going to -- maybe not my kids, but those are some of your kids who are going to confront that. and so, that creates a sense of

urgency in this discussion around health care where we need to do some name and maybe politics, people's individual politics to support helping joe, but i think certainly their pocketbooks will benefit over the long term in the nation's pocketbook will benefit over the long-term from us responding to the crisis, which is using medical care. >> spending more now the government should just keep spending. more money will solve the problem. >> i don't think it's more money. it's a good deal to the more money now. and not being better in the future. you asked the question of how does it affect you. also i would say it's down abominable pain. you go to the emergency room.

were not exactly sure. you get a full workout. you start to feel it again. you go back and get another full workout. we have an awareness. but have i been eating? with my job doing to me? to serve every see awareness in the american public about the first step of not always having to be any surgery or have cancer. what else is going on in a way that i could manage or even work in consort with the medical care system. we would never want to tell people never go to the hospital if you're ill. bootsy think about it. think about the other things that might actually be starting to make your health not as strong and work collectively and integrated fully with the medical care system. >> do we see this happening now?

people are doing the right thing. where we are seeing holistic models. >> we actually spent a fair amount of time traveling to high-income countries to understand what was the one that we might be most eager to learn from at least. we have to do everything in american way. what can we learn from the others? >> what did you find? >> there's a lot of reason for the optimism here. when betsy and i went to the frontlines, we spoke to people confronted with the challenge. we can stimulate innovative models where people are doing a great job working upstream to create the collaborative models of care. we signed santa monica, california, a community center as a long history of providing care. substance abuse, rehabilitation and serving the most in need.

the local hospital gave him a buck or enough money in order to try and push back on the stem of what they called frequent flyers. people who came into the hot those betsy was explaining. you give them their medication. go back out and come back. the hospital knew this was a problem in the community senator this is a problem. they said please, we are going to take the people who comment and treat them and then we would like to partner with you, get these people to the community center and we are going to set up respite care what the nurse took a look after them for several days of it not been bounced out to the street the way joe is too unhealthy circumstances. this partnership has been working for several years. it saved the hospital time of money. the first year, 2009 saved

$200,000. it's only 15 or so people, but that kind of partnership is reason to be hopeful. this is something they did on their own. it's not set up to support this. but it's working any day showing us these things are important, but there are ways to fix them. >> save costs or cover-up and no? >> if you want to know the nitty-gritty, this is part of the community benefit spending programs which hospitals are to do. money they have to spend in order to maintain a nonprofit status, local hospital. so this is part of the hospital's mandate. as betsy said before, revenues are taking medicare and medicaid government. all hospitals have been mandate to take care of population health and the most needy. i think they're saving cost. >> you agree? other examples in the u.s. we should be looking at?

>> we profile cases in the u.s. here's something important is this is a great example, but it's not only in areas where you take care of the poor who have the biggest health risk, et cetera. we also found a fair number of cases in which our serving middle-class, even high income client. looking at the whole patient. looking at the whole client in figuring out what would be the most cost effective intervention to occur. we need more research obviously. more experience, more research on how to create services where you align the incentives to really take the scott affect the intervention. 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 stay calm. >> if we look outcome without votes in the connecticut state government. if the governor culture and said what should i do in connecticut to make these ideas reality,

what would you tell them? >> so one of the very first things i would do this convene a group who are charged with not only the health services, nikki health services in the day, but also education employment support housing. convene a group that's almost like an interdisciplinary or to say we have a collective problem. for spending this much money and health care, this much money money in education. these are our common health metrics that we can agree on that boat relative to them. researchers think, what are the barriers between housing and a half ago? how can we actually have these two were closer together to be more effective using the public dollars more efficiently. it's really going to take some effort to look carefully at how the agenda is integrated and where there can be synergies. we can align differently than we

do now. some of the indicators and metrics by which hospitals get paid and housing agencies get paid and educational department could be aligned better. >> this is a question you and i have had before. there are two issues that comes to help her spending. one is the fact health care is more than everybody else. we spend 700 billion more than we'd expect. second is the rate of growth. overlook over time, it's eating up a larger and larger share for budget. this is the question of differences between countries, not something about levels of growth. is that fair? the real issue is rate of growth. this is looking at different as between countries. >> the acceleration across countries is a pretty common phenomenon. you know, when they look at the percent increases over time in the u.k. budget of the swiss

budget for this reason, every country is worried about this. countries are expanding health service spending without question and i don't think the u.s. is very different. in some ways but the most important question is really the question of how is your current spending different from others and what are the patterns? how are they different? >> thinking about spending in the high spenders, we know 20% of the population is spending somewhere in the neighborhood he% of health care dollars. does this get a 20% or is that 20% really medical issue? it does the scene peep hole. >> i think it does get a 20%. a lot of the 20% is driven by the elderly and people who are in medicare who have complex conditions, often a confluence of medical problems in psychosocial issues. these are people who are well served by social services. there's a great example in the book of a woman who is burning off a ton of medical expenses,

which are paid for by the state as she lives alone. she recently lost her and she was was really lonely. so she called an ambulance because she noticed when she called 9-1-1, someone with a corrupt, talk to her, take her to the hospital, shall interact with more people. this was written about in the atlantic. a powerful determinant. i think that 20% actually, many of their expenses kindest drake right to the corriveau were talking talking about here. >> so why this book and why now? when i came here, you're a giant global health. you are thinking in ethiopia, the first week i got to yield. why write a book on u.s. help policy? how did this come about? >> i think it is a global issue. 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? it was in large part my engagement locally but also triggered ideas about how other countries really map this difference of where they're going to put their dollar and how they're going to organize medical care. in fact, the book is quite international because we do a large section on scandinavia, which is part of the world we really found it does look at this in a more integrated way. we can't be scandinavia, but there's many things to learn nonetheless. i believe a lot of the inspiration came from the global work and i think also for decades in which we've been trying to do health reform, but we keep having the same problem. we've tried everything in health reform. we try to change the way networks are put together. we change the reimbursement system six times. we change to the training programs work. we've tried to have education differently. we started hmos, stats.

we can't only have the same problem that the costs remain much higher than any other country in the get worse outcomes. there's got to be something else going on here. we look at other countries, they do it. >> they look outside the health care system are the causes of high health spending. >> and address them. >> and we genuinely look at scandinavia, take their lessons back here? was that a function of culture? we certainly can take the british national health service. we tried that. tom burke is going to a test i go well. can we take the lessons and apply them here? >> betsy and i talked about this because it's a point to get pushback on whenever we go out and share the book. i don't think we necessarily want to scandinavia for the purposes of saying, look, here's what we need to do. now it's important to the american system. that would not work. we have a chapter where we talk about the world values survey, a really neat data source for the

empirically measure cultural and political values across countries. the u.s. and scandinavia are really far apart on a number of crucial months and was told it's okay, this isn't going to work to just import them. i think for us, traveling in many ways held up a mirror to our own system and help us get a closer read on what exactly are the issues? for instance, we have not been thinking the conception of help you in the u.s. is different. it wasn't until he went there in her scandinavians talk about this very broad construct of hope and the means to an end, not an end in hope that we started to think that's different. i think we put forward the lessons from scandinavia. certainly there's models. planning health and social sybase diet, which are wonderful. if we could do them on a local level certain states or regions want to take a month, bless them. i also think the larger lessons, just about help your culture in

this country, trust of government, trust one another were things that emerged from the investigation that were crucial. >> before you go to the next question, we'll open up questions to the audience. there it to maximum back. if you have questions, line up there and we will call on you in a second. i would encourage you to keep the questions fairly brief and say who you are. imacs will come to you. we'll pass the mic from you and get the question. >> key takeaways from the book. what would be success? you've written a book. what would success look like? which you hope to achieve with? >> one of the key successes we are looking for is warren has said the discourse changes 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 house and a small input actually. if we could change the discourse, if we could change people talking about this, it really is the first to make in a large difference. additionally, it would be nice to see over time the six bierman that are really being honored by the aca, with dirt to be collected and would really start to learn something about integrating health of social services, planning things at a local level, combining and his so the health care system is trying to accomplish some social goals and trying to accomplish some of the health goals and together we use that investment in the smartest possible way. online some of those incentives. over time the rpc infrastructure changes. new models emerge where actually the people are thinking together, what tool do i have?

on this medicine, some housing, some education can make this as healthy as possible. that could change awareness, and then to systems over time. >> let's go to questions. >> there's questions from the audience. >> so you're among friends. the current political debate is not particularly favorable. the sustainability is in question. if you're in front of congress or the european parliament cannot he make the case more social spending is thing to do with the politics reigns right now across the globe. >> it's a great question. >> i'm sorry if the interpretation of the book incipient now. we can spend exactly what we

spend more. 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 medical care bills and then sent out to them on a park bench. if we got that person overnight housing, they would not be back in the emergency room the next day. i was it money, not cost money. we have to go at this from an economic security effort. if they want to create a secure future. we have to be using every resource in the most effect way. >> if you could ring the mic up to the front. >> in our policy classic, a court i usually hear off in a think about often as every dollars rent and help care

spending is a dollar in common health care. you guys touched on this before. about 18% if i take a flipside in health care, what is my incentive the same, which is enormous compared to everything else and not have increase in the future? >> yeah. so i think we worried about this of course because this is a real, i think, barrier to change. of course every format or that the aca comes up against these powerful health care lobbies and a huge health care infrastructure. it's an issue. i matter what kind of change, there's winners and losers. if someone perceives himself as a loser camile be some serious resistance. but we did find though is quite encouraging was when i went to the front line and we spoke to

over 65 health care and social service providers. more health care than hamas. when we spoke to them, they are so frustrated no excess rated because the people want to practice medicine. that's what they were trained to do. right now, they are just having -- the position of having to play nutritionists and social worker in case manager. he said to us, please help us come up with a new system, new models for providing care so i can get back to doing what is trained to do and really want to do. so you know, i hear that concern. we were encouraged by the frontline if it says please, we need to make a change because we are getting inundated at things we are not trained to address and we want to get back to practicing medicine. >> to follow-up on that, do we need fewer dock is quickly the papers initialization. any doctors out the audience? to winning a couple less doctors

coming through the medical system? >> good question. do we need fewer doctors coming to the medical care system? hard to know. what we really don't need is the kind of mix of sufficiency has. we have a specialized group of physicians and actually very limited numbers of primary care physicians. what we mean by this as primary care physicians who might be most likely to look at the whole person would understand or housing situation, with no year, when i understand where you're working. compared to other countries, we are quite limited number has for special. we think about shifting towards more primary care physicians into a specialist. in the long run, everyone to benefit. >> my mother gets diagnosed with cancer. i want to the latest kit.

does she benefit? this is the tension between individual. >> i think she does in a fit. in fact, you want to specialist and intervene at the time to specialist is needed. what we have in our system is sometimes a specialist intervening earlier than the service may be needed. in fact, potentially sort of moving the care path towards a very highly intensive medical approach to some name when other alternatives may either be complementary to it are actually replaced it. i think right now we don't have a system because the specials as they are. the old adage you have a hammer, everything is pounding. the fact is that is not true. we need more than a hammer. >> i would add that i think her mom who hypothetically has cancer with benefit from increased primary care also because when she gets to the specialist, you want a full robust radical history and maybe

a little bit more coming from a primary care physician to make that call to specialist and say mr. so-and-so was coming. this is what her employment that just looks like. she can't take a ton of time in the middle of the day to come to your appointment. let's make sure we accommodate her in that way. she recently went through a divorce or take this into consideration. she may not have someone to care for her during chemo. let's take extra precautions to make sure she has the support care needed. when you circumvent and go directly to the specialist, sometimes you can lose that added texture to the medical hiss every bit early can enhance care. >> i think a lot about an end to this. one of the things we've seen is health insurance become exceedingly more generalized over the last 50 years. it covers a whole lot more than it did in 1960. is that the problem? really we are under financial pressure. we might've seen the health system come through.

is that what we need to rollback insurance? >> is word of a chicken and egg. we have a very generous insurance system because we have a very extensive and wide-ranging medical care system. which comes first in which stress which is not possible to disentangle them. there are things in the aca that will sort of rollback the incentive to have a more generous insurance system. 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. >> or individuals paying more? should they be forced to pay more out-of-pocket? would that leave me more to think about was worthwhile and what i need to do? >> i think it is hard to keep it are fully insulated against an expense. it's hard for them to step back and say do i need thiexpense. it's hard for them to step back and say do i need this?

to do the research, one needs to pick the very best service. the research shows consumer engagement to change the way consumers see things. we don't want to go overboard. it clearly wakes up or consumer to think a little bit more strategically about how these health care dollars. [inaudible] -- i'd like to follow up on one of the things that come from a book to you have been saying is that in many ways i'm a serious problem with the u.s. health delivery system is not so bad as that is so good at the top end. we do all sorts of things. the premature infant herbs. we pushed back further and further when the infant can survive. a new organ transplant cancer

cures, all source of things. this kind of stuff for the best in the world. a part of that, think about the incentive system within the medical profession. not just making more money for being a specialist. it's the fan, the glory, the recognition, mickey new breakthroughs. it's much more lambright and being a primary care physician. his how-to incentivize what is it people in medical school really like to go into. i imagine you got some thought about that in your book and yourself and wondering if you could tell us about that. >> i think it's absolutely a good turn. i would add to your comment by saying positions we spoke to in scandinavia joked we spoke to the highest-ranking position, the one who runs a little show. she said yeah, i think i make

less in the u.s. they are very aware of this in the fact the incentives are skewed to higher specialization, higher intensity. i think the aca tries to address this. in some ways to increase payments to primary care providers in order to make it so they can have a more wholesome living. but i don't have the other. i would just add that the incentive structure and the way the profession is structured now is verified as of american values. i think that's important to take into consideration that we have these discussions about values. there's upside and downside. you cross things out such a way that not everyone has access. this is the tension we need to talk about here.

it's not that there's no upside to our value profile or to way we've addressed medicine in this country. we need to look at the side a side, both financial and human and say okay, what do we need to do? we don't want to lose all of the good as we have going. but there also does seem to be a sense of urgency for change. >> i think it's a really insightful question and i would just add to that that our innovation and the united states are very ached at the top of standard drugs coming out, the best imaging, better. but there's somehow excitement again about a population and now you get creative about keeping them healthy. in some ways, we are our own worst enemy because we see innovation in one maltese of the medical care system as opposed to how innovative it could be to

have a city that was all about help from the way the buildings remain to where they are put together. if you identified, this is definitely assist them. in the globe because we see a lot of the globe are medical to elegy. >> another questionnaire. is that enough? >> i was just wondering, given your knowledge, what would you say -- would you say the next step and reform should take place at the federal or state level given political feasibility? >> so i guess i wouldn't say one or the other. but i think the states have tremendous opportunity right now. they are enabled to experiment. we can look at 50 different experiments. they each have a different word of culture.

actually as we look over the state, they already are different in terms of what they are spending in medical care and what they spend and social services. we have natural experiments going on. we need to do the research to actual health outcomes. i'm excited about the state public's ear mentation. i think that's going to prove fruitful for us. tonight is there anything in particular doing a good job? >> connecticut is right on the precipice. doing great games. >> i worked for a politician would have these academic discussion. at some point he would interject and say fix it. it's more than a conversation. other structural changes that we really need to put in place?

but what those look like from a government to her private market is. >> you now, i don't have a lot of optimism. for the next month this course is a good goal. the value base, looking at what we do well and not wanted in the sybase had for several critical evaluation is very should be focused. down the line, betsy and i discuss in the book the aca really is a platform where i think we could use some experimentation and search and make incremental change in responsibility and accountability that hospitals have to population health. one of the things the aca does his incentivizes or puts forth a set of indicators that have those will be reimbursed. right now they are very medical. how many patients have a

hospital-based infection? how many of your staff wash their hands every day? if we could push that thought a little bit and be innovative in a way we could include some of these population health benefits. you are not responsible for how many eighth-graders are of the spirit will a threshold. you really engage to make this much or change over time. were going to give you more money. that's an instance where you can take these ea, and that i don't feel up domestic about totally overhauling. you work within the system and a.i. can create a little bit of change so these determine if their address within the healthh care system we have now. >> 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. you can really imagine a shift. you can imagine at the house overhauled accountable to some degree, has an incentive for how many eighth-graders a an incentw many eighth-graders arby's. we'd be impressed if someone was engaged with the exercise program in the city, better. there are ways in which the health health care system can be used to accomplish population health without revolution, but rather incremental shifts in regulation. >> i have a question coming back to medical technology. i'm curious what you learned about how the cost for new technologies are handled in different countries. i've also been thinking the last remarks about if there's in ways technology can contribute to this connection between health care and the individual social care. >> i'm so glad you raise that.

the first thing we found in scandinavia, although we think the united states is one that spends all the medical medical technology and has a huge amount of gdp and that's. denmark and norway and sweden are very, very investing in technology. they also see it as potentially cost saving technology with that in mind. in terms of the issues that can technology generally bring together avenues of communication. absolutely. this is exactly what we need. is where the real creativity can be. considered being created created in one of his tree, how can we be creative to span a couple industries come a couple factors that together create a healthier population. that could be everything from information technology to all kinds of things you can think

about that would in fact to bring these two closer communication and just more efficient. so it's a great spot to develop. >> there's a question over here. >> hi. i'm avalon from the school of medicine. thank you so much. there's been a lot of conversation about the organic evolution of our medical system, health care system. i have been influenced by chris number as well as in this tree. in your conversations, during the development are after the publishing of the book, what's a conversation with consumers of the health care system than my? is this message one that seems to resonate with people? or do you think that there will be some weariness? or do you think that if these changes are in place that the transition will be a very

natural one? thank you. >> gal, 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 physician in the health care and tree really shake her fingers at them and they use medicalized us. you've done this. i think certainly some of the blame does rest of the health care system and trying to get people in the doors. come in, will make you better, better. i think in the book we are really careful to try this line of vacant dimmers have a response ability, too. some now up more than others. do we tell the story of one family pediatrician who just will not take no for an answer. the child has headaches, comes into the position.

the child has headaches, so probably stress headaches are the female not accept it. they want to extract certainty from the system. maybe because we told them to medical system can provide these answers, but maybe that she was just an american theme to strive for perfection and want to get it right. so we tell the story in such a way as to his day there's a lot of moving pieces here and consumers definitely, you know, have grown into the end to expect certain things can want certain things from the system. so i would say, you know, consumers will have to change, too. if we change the health care system,, we need to pursue change the dialogue to pump some policies, but also many to wise up to the fact there's a renewed sense of discipline that probably needs to accompany any reigning in of health care cost over the long term. >> i guess to follow up on that, if i were a member of congress,

my biggest job creator is going to be my hot little. and they cut him out is going to be a cut on jobs. how do we make an idol is sort of political timeline and vertical tension with what you're arguing? >> i think something we need to get in our head is it is not a book that asks to spend life and health care more social services. it does not do that. expanding the way it does, but hold the health care dollar more accountable to a population of health. so you don't have to lay off anybody in the house at all. people may do different jobs. or maybe better connections connections with social services. there may be other ways to get actualize, how do i use the help care dollar to instead of just giving medical care, actually confer health. that i think is sort of a ship in the way we think about what the obligation of our health care dollar is. i do think shifty and asking her to be a change in our allocation

pattern for taking away more over here. i just don't do politics in the united states to tolerate that. there are ways in which exactly the patterns we have when you think about how to use the thought your dollar to achieve the behavior of goals is an avenue of exploration that could potentially hold promise. >> teresa daly, your college. just to pursue that point a little bit more, you mention these discussions, these reforms are another is taking money from one apartment and moving it to another, but simply redefining how to use their health care dollars. so in the short term, what would that look like in also having a dialogue with house for those. these community health centers and consumers. >> bobadilla clay? that's a great question. if you take a lot of different shapes, but something concrete,

which laurent alluded to earlier. imagine you got a city together and all the services given to a population in that city, the leaders came together to say what are the core accomplishments were trying to address? what are the indicators of new haven being healthy? what can a service providing that area aligning incentives so a public dollars and some private dollars or focus in reporting -- are being rewarded for accomplishing those goals? instead of the hospital quality indicator being how many patients with heart disease got beta blockers, they be if something were population base. similarly, the education system, housing system, better, job training, service providers, having some incentives themselves were being sure they have coordinated with the huskers are sent. that's what it would look like. you could 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 is working on the medical care site. went to education is trying to help people and hostage keep homeless people off the street. they thought this obligation was to make new haven. >> when indicators of the speed? if we came together and need to drop a list of indicators, what should we be looking out? >> it is something that there's a lot of political priority being placed on right now. the cosseted over the long term has been project is astronomical. i think everyone in the community, said his peak, 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 will pull in. maybe some mental illness. it is an indicator days lost due to mental illness or days lost

due to -- what's the term? disability. thank you. i think that's one that is proven really cost you because if you stay home from school, that child needs extra attention from the administration and teachers are not grant us as well. school districts get reimbursed. same thing with employment if someone's not going to work, obviously that's cutting into business revenue. >> i think you could really broaden and also to say what is the percent of people who are employed? with the percent of people house? we know these are fundamental to creating health. if you had a joint group that was worried about the score indicators, some of them would be obesity related for smoking or mental health and might be more related to social determinants of health. >> connie from school of >> connie from school of

management. as you're talking, i can imagine them cadre about consultant experts, going out and identify type for change and motivated almost ready for a makeover. going to these bases are not helping people get together, help see them through pull together his old spirit who is that going to be? and how are they going to get themselves organized? >> that's a good question. maybe i can start. because you're hitting on something so fundamental and i just want to underscore it, the these kind of collaborations, what would call intersect your collaborations, health care and social are hard to do. there's a reason they haven't gone up. part of it is very structural. we heard from folks who had done it. it's a look, it's a long road. there's different professional cultures. we were different hours.

certainly we don't share an i.t. system, or a common medical record. you know, it's hard. even if they tank in theory it would be best for patients is a good atf. when they're up red you were going to start a product, but ran into some resistance. i'm not sure who the person is. i know they're eager to these could go out and be consultant. in the hope that by publishing to talk about their journey as well. >> depending how the reimbursement system does, you can imagine it's in the group self-interest of ashley with this kind of awareness to get together because they cannot act save some dollars out of the

system. who benefits from those dollars saved. there are incentives that's larger than just organically that is something that will incentivize you to get together. nonetheless, we come across teams that are in different cities in the u.s. i am not mistake the unthinkable emerged. >> high, they see lauren, i am a local business owner. my question centers around individualism. we talk a lot about public policy and government and what we should or shouldn't do. how much of this what you put on the individual taking responsibility for education, exercise, eating properly? is not the core of so many of these diseases today?

what people have done to themselves. so how much and this is then how do we -- should we or how do we keep putting nonempty set was just a big government is going to solve your health issues. >> yeah, it's a great question. you know, we have to do this in an american way. america is about individuals and has been built on that and is strong on that. in many ways, we have to use that as a strength. the issue ties to the questions earlier, what would you do about copayments, if that are? how does the individuals of the penalty of not taking care of themselves, better? that such a strength the u.s. has been sort of tolerance have been able to say this can be imparted an individual cross to bear. on the other hand, it is important to understand the science. the science really is a your social environment, the network you are in does influence your

health behavior. if you are living in a community where smoking is normal and fine and there's a stigma to it, you are more likely to smoke. same for eating and exercise and all of these things. we like to think it's an individual to vision and it is. that individual choices will influence our social network. at defending a government program, however. a social network can emerge from a community or emerge from your employer. it can emerge from the corporate life of great corporate life and the u.s. economy. i don't think we want to put the accountability into the governments aren't necessarily. but i think understanding he governments aren't necessarily. but i think understanding more than just an individual because our behavior is very determined. we are social animals our we think about it. >> to them i'm not, our business is taking up the idea? >> absolutely. there's some very, very exciting

programs. to set sort, one setba-to set se there have been programs that have backfired as well. it's in the interest of the corporation to really about the employment and how we can pay the bills. the scene of airflow overtime. there's others that it started to work with their employee base to exercise good nutrition, et cetera. that's another place in addition to the state where we see great innovation ahead. >> itself fundamental. because were so interested in individualism, we think we are paying for our own health care.

this is where we get into trouble. we're buying into essentially a wrist pool, a community and were it not more money will come to me and not my money is pooled and other people paying premiums. sometimes people ask us, was enough for me? you know, why should i care if someone's go is racking up a ton of health care bills? i would suggest your pay is not through taxes if the person is on the medicaid rule and you are paying it in your own health care premiums and expenses of folk. [inaudible] -- if your college. i was wondering, what do you think the impact of our expenses and competitive carrier system. [laughter]

>> an easy question to end on. >> are expensive medical system. i guess it were thinking about your question, you must be asking, people spend this money in medical school, so they have to get out and take the most high paying job. i can't see you anymore, and. so, that is one of a whole myriad of incentives to take the high-paying specialist job. we might look at that broadly and say that's one, but there's several other ones in terms of being able to say one of the most important for media and important are less important. i don't have the data to answer that question. it falls in the same concept. there are many incentives why we get to a highly specialized medical workforce and it's really not helping cut over the long haul have a system that is cost effective and produces the healthiest population.

>> and a concluding thoughts about the book? >> read the book. >> it's a pretty good book. >> and must work together. china make it a healthier place. >> of course read the book and talk about it with people. i am a big proponent. i know some people feel like all they are prescribing his discourse, but that's where this change begins. if we don't talk about it and we don't discuss, what does help really mean and who's accountable? should've been me, my doctor, insurer? policies unraveled bec@ insurer? policies unraveled because policies set forth a certain set of values and we don't know if we really abide by those values. i think those discussions about what is great about the u.s. health care system and not so great i really critical and to

do in an open way that is not overly medicine. or we listen to each other and really learn from each other. that makes me deeply optimistic. >> i think that is a good point state thank you thank you for coming. thank you for writing the book. [applause] this is precisely the type of discourse then i want to help promote. there's so much noise out there about what's going on in health care pose to you. to have academics who want to put ideas on the hot discussions about them and use them to provoke a conversation. we can't think of anything better. thank you. as for coming. we look forward to having a discussion afterwards. [inaudible conversations]