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 thats 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 whats driving out their policy. And Public Policy in general. Weve 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 whats 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. Theres no better example of this than the two of you and what youre 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 its 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 president ial scholar at the harvard divinity school, and they have come up with this book, the American Health care paradox. Weve 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 its because of malpractice. You to have come up with a different explanation, something where youve argued the causes of why the Health Care System is so expensive might be outside of the Health Care System. Its an extraordinary book. Were 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. Well 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, 7090 of the cases are really related to social, environmental, economic determinants. Exercise, sleep, nutrition, stress at work, what are housing is like. And yet were 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 dont 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 doesnt really confer a health we deserve. Why . Why have we evolved in this way . Why hasnt scandinavia look so different . I think one of the reasons that we found was theres 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 im open for business. We have continued down the path of an entrepreneurial free market Health Care System because we feel thats 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 wasnt 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 its 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 dont its paradoxical to dissipate your spent 8000 per capita in the United States, where as the next most expensive country would be twothirds of that. You would expect you should have Better Health outcomes, longer life expectancy, lower infant mentality, less heart disease, less disability. We dont have any of those things. The Research Community missing the point . Why havent we come to an answer, 10 years ago . Why is it taking this long . A good point that this is a historic of problem. Whats amazing about the paradox, its not the paradox itself that that we have had for decades. Of the authors have written about it, but why havent 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 thats benefiting many, many people. Its just cannot be conferring health we want but it makes a lot of profit for our country and its really set up that way. Do you think probably is the reason we have this paradox . I do think thats part of the reason. I think thats 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 thats 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 dont 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 its not that we dont dwell anything. Is that we dont do well on these broad population Health Outcomes on which we are so often compared with her pure investor lets 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 . Shouldnt just be for heart attacks . Should be for the population measures . How do we think about this . I would like to address the. Its 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. Thats 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, theres a different conception of health in other countries. Were held i think its broadly understood as medicine is one input to it but so are many, many other things. Its 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 heres education and housing and nutrition completeness of it. We dont always see that in every country spend so health isnt the key input to our health. Do you i agree. It is not the key. Once an example . Whats an example concretely . The fellow who did not sneakers, talk more about that spent do you want me to read . Sure. They didnt give me a copy of the book. I will steal one after. Its a passage that weve gotten a lot of feedback on and it is 100 true story. So i will read it, and its 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 peoples 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 dont have adequate support structures around it. Isnt Health Care System or Something Else that is missing . I dont 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. Its 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. Lets think a list of about what other services we can give the people. Sometimes its subsidies for shoes for somebody whos diabetic. Sometimes its going to have to be amputation and its going to be a medical treatment. But to be able to play and services and also Tailor Services so that youre 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 . Its 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 cant take care of themselves, et cetera. But its 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 individuals 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 its 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 dont think so. I think the aca has a lot of good stuff in it, you know, and it was born of a political process. Thats 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 longterm. Hopefully give them some prevention care that can start to bend the cost curve. But i dont think its quite as bold a reform as maybe we do need to create really meaningful sustainable reforms over the longterm. 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 were 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 its 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 were spending to ensure this population, and if you make that explicit with the American Public were 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 . Its terrible that he is being so marginalized, and we know its not Cost Effective but this this shift adversely whats best for the individual and whats 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, peoples individual politics dont 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 nations 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 dont think thats the story of joe at all because i dont think its spending more money. Its 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. Lets say you come down with abdominal pain and you think, i dont 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 . Whats my job doing to me . To sort of raise the awareness in the American Public t