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Elizabeth Bradley, PhDProfessor of Public Health

Yale School of Public HealthElizabeth.Bradley@yale.edu

Follow @EHBYale

Getting to Better Health: CONNECTing Care and Community

UNIVERSAL HEALTH CAREFoundation of Connecticut

Spending More and Getting Less

Acknowledgements

Robert Wood Johnson FoundationBlue Cross Blue Shield of Massachusetts Foundation

Co-author: Lauren TaylorPresidential Scholar, Harvard Divinity School

Collaborators: Erika Rogan, Maureen Canavan, Kristina Talbert-Slagle, Chima Ndumele, Leslie Curry

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Acknowledgements

Robert Wood Johnson Foundation

Blue Cross Blue Shield of Massachusetts Foundation

Co-author Lauren TaylorPresidential Scholar,

Harvard Divinity School

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Health Care Spending as a % of GDP, 2009

*Turkey is missing health expenditures data for 2009

Knee Replacements

Kidney Transplants

MRIs

Some Very Real Benefits

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Some Very Enduring Challenges

Out of 34 OECD Countries

25th in maternal mortality

26th in life expectancy

28th in low birth weight

What determines health? SOCIAL,

ENVIRONMENTAL, and BEHAVIORAL

FACTORS(60%)

GENETICS(20%)

HEALTH CARE (20%)

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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France

Swed

en

Denmark

Austria

Finlan

d

German

y

Belgium

Italy

Portuga

l

Netherl

ands

United St

ates

Spain

Norway

Greece

Hungary

United Kingd

omIre

land

OECD

Luxe

mbourg

Slove

niaJap

an

Poland

New Ze

aland

Icelan

d

Canad

a

Czech Rep

ublic

Estonia

Slova

k Rep

ublic

Australi

aIsr

ael

ChileKorea

Mexico

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00Total Investment in Health as a % GDP

Social Service Spending, %GDP

Health Care Spending, %GDP

*Switzerland and Turkey are missing data for 2009

Italy

Hungary

Luxe

mbourg

Poland

Finlan

d

Estonia

Belgium

Austria

Denmark

Spain

Norway

France

Czech Rep

ublic

Swed

en

United Kingd

om

German

y

Greece

Portuga

lJap

an

Irelan

d

Slove

niaOEC

DIsr

ael

Icelan

d

Slova

k Rep

ublic

Australi

a

New Ze

aland

Netherl

ands

Chile

Canad

aKorea

Mexico

United St

ates

0.00

0.50

1.00

1.50

2.00

2.50 Ratio of Social-to-Health Spending, 2009

*Switzerland and Turkey are missing data for 2009

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.

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Determinants

SOCIAL, ENVIRONMENTAL, and BEHAVIORAL

FACTORS(60%)

GENETICS(20%)

HEALTH CARE(20%)

HEALTH CARE SPENDING

(65%)

SOCIAL SERVICE SPENDING

(35%)

InvestmentMismatch

Does it matter?

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Countries with higher ratios of social-to-health spending have statistically better health outcomes.

Lower infant mortality Fewer low birth weight babies

Less premature deathLonger life expectancy

Bradley , Elkins, Herrin, Elbel et al., BMJ Open, 2011

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What about inside the United States?

All Social _x000d_Services

Education Income _x000d_Support

Transportation Public Safety Environment Housing0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

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Social Services Spending by Type of Service (as % of GDP, 2009)

Health ca

re

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Ratio of social-to-health care spending*

*Medicare and Medicaid spending

LOWEST QUIINTILE

MEDIAN QUINTILE

HIGHEST QUINTILE

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Ratio social-to-health spending

Percent of population that is obese

LOWEST QUIINTILE

MEDIAN QUINTILE

HIGHEST QUINTILE

HIGHEST QUIINTILE

MEDIAN QUINTILE

LOWEST QUINTILE

States with higher ratios of social-to-health spending have statistically better health outcomes.

Lower mortality among those with lung cancerLower rates of asthma and obesity

Lower rates of limitation in daily activities per monthLower rates of mentally unhealthy days per month

Lower post-neonatal mortality

2000-2009 data, adjusted for region, GDP, and socioeconomic factors Bradley et al., under review 2015

What to do?

Spend more! 28% GDP 35% GDP?

Transfer $$ from health care to social services

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Taxes? NON-STARTER

Unlikely

Incentivize collaboration on health

Evidence Supports Integrative Models

Health Care SectorCommunity Outreach

Mobile Clinics

Case Management, Patient Navigators, Care

Coordination

Nutrition support

Housing First

Mobilizing collaboration for health nationally

Mitigate financial incentives to medicalize health

Establish common metrics for health and social services- % obese, % depressed…- % on target to finish high school- % employed- % housed

Talk differently about health and health care

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Health = Health Care

Thank you

Follow @EHBYale@laurentaylorMPH

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Extra slides for reference

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Public Health Services DefinedDescription: Provision of services for the conservation and improvement of public health, other than hospital care, and financial support of other governments’ health programs.Included examples: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), protective inspection services, health related inspections, community health care programs, regulation of air and water quality, rabies and animal control, ambulance and emergency medical services (unless operated by local fire department), and hazardous waste cleanup. Also includes medical appliances, supplies, or services as part of public assistance programs as well as construction and maintenance of nursing homes, homes for the elderly, orphanages, and veterans' homes.

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Social Services Spending CategoriesEducation (primary, secondary, and higher education)TransportationEnvironmentPublic SafetyHousingCorrectionsIncome Support, including:

– Social Security (Old-Age, Survivors, and Disability Insurance)– Supplemental Security Income (SSI)– Temporary Assistance for Needy Families (TANF)– Supplemental Nutrition Assistance Program (SNAP)

Public Health Programming, including:– Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) – Protective inspection services– Health related inspections– Community health care programs– Regulation of air and water quality– Rabies and animal control– Hazardous waste cleanup

% State GDP

State Variation in Health Care Spending (Medicaid and Medicare) (as % of GDP, 2009)

WV ME KY MI SC FL AL

NM LA OKMA IN NC NH IA IL MD OR TX NE ND HI

VA AK UT DC0

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4

6

8

10

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Spending on Social Services

EducationIncome Support, TANF, SSI, Social Security, SNAP

Transportation, Public Safety and EnvironmentCorrections and Housing

Other social services excluding health care

* And public health spending

% State GDPState Variation in Social Services Spending

(as % of GDP, 2009)

WV MS ME VT KY AR MI RI SC NY FL PA AL OH

NM MO LA TN OK AZMA W

I IN MT NC ID NH CT IA MN IL NJMD KS OR CA TX SD NE GA ND

WA HI DE VA NV AK CO UT

WY DC

0

5

10

15

20

25

30

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Social Services-to-Medicaid & Medicare Spending Ratio, 2009

AK UT CO DC VA ND GA ID MN IA NJMD SD IL MI

OH AZ PA NC CT FL NYMO KY ME MS

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6

C-TRAIN (Portland, OR)

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• Academic medical center• 570-bed facility• 33% of patients are un- or

under-insured

• 501c3 serving Portland• Serving individuals and

families facing homelessness, poverty and addiction

• Affordable housing is primary service, plus health care, recovery services and employment assistance

RCT has found C-TRAIN patients have lower mortality and better quality of care;

hospital is funding expansionEnglander, J Hosp Med, 2012

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Academic Medical Center2,600 beds

Community Center with childhood asthma rates 3 times national average

Bilingual Community Health Workers provide asthma education and referrals for housing, immigration, and mental health services.

50% decline in emergency visits and hospitalizations; 30% decline in school absenteeism

WIN for Asthma

http://nyp.org/services/acn_outreach_win.html

The 10th Decile Project

Works with hospitals to identify the 10% of homeless people with the highest hospital costs and to find permanent housing with strong medical and mental health support.

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Healthcare costs decreased by 72%, from $58,962 to $16,474 per person.

http://www.economicrt.org/pub/Getting_Home_2013/Getting_Home_2013.pdf

Opportunity costs

1 Emergency department visit = 1 month’s rent

2 hospitalization = 1 year of child care

20 MRIs = 1 social worker for a year

60 echocardiograms = 1 public school teacher for a year

35SGIM Presidential Speech, Dr. Moran, 2015