1. The American Health Care Paradox: Spending More and Getting Less November 2015 1 Elizabeth Bradley, PhD Professor of Public Health Elizabeth.Bradley@yale.edu Follow @EHBYale

2. Acknowledgements Additional Collaborators: Erika Rogan, Maureen Canavan, Kristina Talbert- Slagle, Chima Ndumele, Leslie Curry 2 Co-author Lauren Taylor Funders Robert Wood Johnson Foundation Blue Cross Blue Shield of Massachusetts Foundation

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4. Knee Replacements Kidney Transplants MRIs Some Very Real Benefits 4

5. Enduring Challenges Out of 34 OECD Countries 25 th in maternal mortality 26 th in life expectancy 28 th in low birth weight

6. What determines health? SOCIAL, ENVIRONMENTAL, and BEHAVIORAL FACTORS (60%) GENETICS (20%) HEALTH CARE (20%)

7. job training and employment programs supportive housing & rent subsidies nutritional support & family assistance other social services that exclude health benefits Social Services

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10. In OECD, for $1 spent on health care, about $2 is spent on social services. In the US, for $1 spent on health care, about $0.90 is spent on social services.

11. Does it matter? 11

12. Globally, it seems to matter 12 Maternal Mortality Ratio per 100K Ratio Social-to-Health Care Spending U.S. 

13. Countries with higher ratios of social-to-health spending have statistically better health outcomes. Lower infant mortality Fewer low birth weight babies Less premature death Longer life expectancy Bradley, Elkins, Herrin, Elbel et al., BMJ Open, 2011

14. Is the same pattern found inside the U.S. across the states? 14

15. 15 Social Services Spending by Type of Service (as % of GDP, 2009) Health care

16. Opportunity Costs 1 emergency department visit = 1 month’s rent 2 hospitalizations = 1 year of child care 20 MRIs = 1 social worker for a year 60 echocardiograms = 1 public school teacher for a year SGIM Presidential Speech, Dr. Moran, 2015 16

17. Ratio of social-to-health care spending* *Medicare and Medicaid spending 17 LOWEST QUINTILE MEDIAN QUINTILE HIGHEST QUINTILE

18. 18 Ratio social-to-health spending Percent of population that is obese LOWEST QUINTILE MEDIAN QUINTILE HIGHEST QUINTILE MEDIAN QUINTILE LOWEST QUINTILE

19. 19 Post neonatal mortality rate per 100,000 live births Red: highest mortality 5 th Yellow: median mortality 5 th Green: lowest 5 th Ratio social-to-health spending Red: lowest 5 th Yellow: median 5 th Green: highest 5 th

20. States with higher ratios of social-to-health spending have statistically better health outcomes. Less adult obesity, less adult asthma Fewer adults reporting 14+ mental unhealthy days Fewer adults reporting 14+ days of activity limitations in last 30 Lower lung cancer and type II diabetes mortality rates Lower post-neonatal mortality rates Greater physical activity and consumption of fruits and vegetables Less smoking tobacco Bradley et al., Health Affairs, under review

21. 21 Medicalization

22. Two Perspectives Give a small boy a hammer and he will find that everything he encounters needs pounding. - Abraham Kaplan

23. Experience in Other High-income Countries 23

24. Values (Scandinavia versus U.S.) 24 Differences (P<0.05) Scope of social contract Views of income, equality and social mobility Degrees of trust in “the other” Similarities (P>0.05) Personal freedom Views about competition Technology as source of progress

25. What to do? Spend more! 28% GDP  35% GDP? Transfer $$ from health care to social services 25 Taxes? NON-STARTER Unlikely Incentivize collaboration on health

26. What does the evidence tell us about which types of social services produce the best health-related outcomes? 26

27. Literature review 27 Total Number of Papers n=74 Positive Findings n=60 Health Improvement n=22 Both n=10 Null Findings n=14 Health Care Cost Savings n=38 CONCLUSION: The literature is mixed.

28. Supportive housing, and Integrated health care and housing Bud Clark Commons Minnesota Supportive Housing 28

29. Nutritional assistance for high-risk women, infants, and children as well as older adults with disabilities 29

30. Case management and community outreach 30

31. DOES IT MATTER? The Work Ahead 31 Changing Our Mental Models: Health and social services are distinct levers to achieve common goals. Changing Financial Incentives: To promote collaboration between health care and social services. Exposing Latent Networks: Connections already exist between health care and social services but are not always leveraged.

32. Health = Health Care

33. Thank you @EHBYale 33