James House: Beyond Obamacare: Life, death, and social policy

>> I'm Susan Collins the Joan and Sanford Weill Dean here at the Gerald R. Ford School of Public Policy and we're delighted really to be able to have a special event on a book that you'll be hearing much more about in just a few moments. I do want to say at the beginning that today's event would not have been possible without generous support from the Gilbert S. Omenn and Martha A. Darling Health Policy Fund. And Martha Darling is here with us today and we're delighted to have you with us, thanks for joining us and thank you for the support.

[ Applause ]

Well thanks again for joining us today as we both celebrate and learn from the research of our own Professor Jim House. It's always really exciting to be able to showcase and recognize the work of one of our colleagues and a new publication but it really is a particular pleasure with today's book, Jim's latest "Beyond Obamacare: Life, Death and Social Policy". Jim's research has focused on the role of social and psychological factors in health and illness including the role of psychosocial factors in understanding and alleviating health disparities-- social disparities in health. And this new book "Beyond Obamacare" explores those themes making the case that effective health policy begins with comprehensive social policy reforms more comprehensively. Among many distinction, Jim has been elected to the American Academy of Arts and Sciences, the Institute of Medicine and the National Academy of Sciences. He's been a part of the University of Michigan's research family since he graduated with a PhD in 1972 becoming one of the University's very select distinguished university professors in 2008. At the Ford School, he taught courses in Socio-Economic Policy and Health Policy and in 2013 he delivered the Henry Russel Lecture which is considered the University's highest honor for a senior faculty member. Jim retired in 2014 and although he's added emeritus to his title he remains a very impactful scholar and certainly an engaged member of our extended family here are the Ford School and in the University more generally. Jim, your colleagues and I are so proud of your book and of our continued engagement with you, so thank you very much for being here for this book release. Well before Jim begins, I'd like to briefly introduce our moderator Paula Lantz. Paula is Professor of Public Policy, she joined the Ford School of Faculty this year as our very first Associate Dean for Research and Policy Engagement and we're delighted to have her here back at Michigan and in particular moderating this special panel. After Jim's remarks, Paula will introduce our discussants Palin Leedy and Richard Lichtenstein, we're delighted to have both of them here with us today. So a very big thank you for joining us. So just a quick note before we get started about the format, Jim will provide just and overview of his book and some of it's major points. He will then join Helen and Rich for a moderated conversation and then there'd be time for questions from the audience. So as you came in you should have gotten a card around 4:40 p.m. or so, our staff will be walking up and down the isles to collect cards for questions and they'll continue to do so and we welcome you're questions for that session. If you're watching online, please tweet your questions to us and use the #policytalks. So it is-- and after the program I should mentioned that in our great hall we are delighted to host a reception and there will also be copies of the book "Beyond Obamacare" available for purchase and for signing by Jim House and so we invite you to stay to continue the conversation at that point and to get your own book signed. So with no further ado it is my great pleasure to welcome Jim House to the podium. Jim the floor is yours.

[ Applause ]

Would you please come up here, you're going to talk from up here?

>> Yeah.

>> Yeas OK great.

>> Thank you. Everybody hear me OK? It's not one of my strong points but let me thank Susan for the kind introduction and I guess my goal today is-- at least initially to offer a brief overview of the book as a context for both the discussants' comments and the questions that you, the audience may have and hopefully to entice you to invest and then subscribe copy of the book. Let me also just start briefly with some-- a few thank you's, there are really many that are represented in the book. But I particularly want to thank the people who the book is dedicated to, several of them are here, my wife Wendy, Bob Kahn my long time mentor and colleague and Bob Schoeni who as a colleague has helped to bring me into the realm of Public Policy. Since she is also here, I just want to acknowledge Ria Khish [assumed spelling] who is like Bob, a nonagenarian going on centenarian who gracefully edited the entire first draft of the manuscript and it was a bigger mess then than it is now. So, also thanks to Paula and Helen and Rich for their willingness to join in today. I'd also just briefly like to acknowledge the various educational and research context that have trained and supported me over my career and leading up to this book, especially to thank the Ford School for providing me a late career opportunity to focus more on public policy and implications of my work and for sponsoring today's event with the support, very kindly of the Omenn and Darling Fund and with the arrangements today by Cliff Martin who has been exceptional in that regard. And also I should probably give special acknowledgment to the Russell Sage Foundation which enabled me to begin the book as a visiting scholar in 2010-11 and to actually get it publish 4 years later. Let me just offer to start with a brief disclaimer and emphasize that the goal of the book is to get us to move beyond what has been the core of American health policy but not to undo or leave that policy behind. The book's Table of Contents gives a sense of the territory that it covers and which I'll try to go over briefly. Today you'll generally be able to tell which chapter I'm talking about at a given point as the first number in each table or figure indicates the chapter that it appears in. So, let me begin with just where I started from in thinking about this book. For over a century, I think one could say American health policy has become increasingly what I've called the Supply-Side Policy with three major components, one, enhancing biomedical research and training of health practitioners. Expanding availability of an access to biomedical health care insurance. And thirdly trying to keep both of those processes as cost effective as possible and this concern has become increasingly front and center since the 1970s as you're well aware. For the past century, the major basis for evaluating health policy has been the health of the American population which generally improved enormously in the 20th century with life expectancy increasing from 45 to 50 years around 1900 to over 75 years by the dawn of 21st century. For the first two-thirds or so of the century, American spending on health was among the highest in the world but it was not exceptional compared to other comparable countries and about the same could be said about our health outcomes, thus America's supply-side policy seem to be working well with the major continuing goal of expanding availability of an access to health [inaudible] as other nations were doing even more rapidly than we. However, since the 1970s America has been confronting a growing a paradoxical crisis of health care and health, that compass two components. The spending side of the crisis is well-known and increasingly acutely felt by individuals, families, organizations and governments. Figure 1.1 and in all of the figures you're going to see have this type-- the white line tracks the US performance and compares it to a select but broadly representative group of other developed nations to relatively low spenders on health, the UK and Japan, who spend in the range of 8 to 10% of GDP on health and the next highest spender after the US, Switzerland, and the country that is most similar and nearest to us, Canada. In 1960 as you can see, the US was among the several biggest spenders on health in the world but not highly distinctive. Since 1980, however the US has increasingly diverge form these and all other nations currently spending almost 18% of our GDP on health projected to grow to over 20% in the next decade. To put this figures in another context and perspectives, US spending on National Defense aside from World War II, peaked at 13% of GDP at the height of the cold war in 1950s when President Eisenhower warned against the power of the military industrial complex. Today, spending for health increasingly dwarfs current and past to spend passed defense spending and we have what could be called a medical biotechnology complex that is larger and arguably more powerful than the military industrial complex ever was. These trends have broadened health care reform goals to increasingly make controlling spending equal rival of expanding access. One might expect and many believe that our higher spending level gives the US comparably high returns in terms of population health. Paradoxically and not yet quite as widely recognized, the reality is quite to the contrary especially for America's women and children. Figure 1.6 shows that US infant mortality has gone from one of the lowest among developed nations in 1950 to among the highest in-- since 1970. More strikingly and this is a process that is ongoing, American female life expectancy in the 1950s was the equal of any other nation, since then and especially since 1980 American women increasingly like precipitously behind women and virtually all other developed nations now by 2 years for example compared to women in the United Kingdom and up to 6 years compared to women in Japan. American women have also lost almost 3 years of the nearly 8 year advantage in life expectancy that they held for a relative to American men in 1980 and those men have themselves been increasingly lagging behind their male counterparts in comparably developed nations. For some health indicators and more disadvantage parts of the population, women's mortality experienced is actually worsening absolutely and a relatively unprecedented phenomenon in a highly developed and wealthy country. So, between 1980 and 2008 advances in women's life expectancy actually-- diminished for all less educated women and among the least educated, there was a decline of almost five years as shown in the left side of the figure you're looking at. In 43% of US counties by a recent analysis, female life expectancy is actually declining, a pattern that could characterize almost all American women within several decades unless current trends are reversed. One small contributor to this declining female life expectancy is an absolute increase in maternal mortality. Oops, getting ahead of myself here. In the US as shown in figure 1.7 which is again unprecedented in highly developed countries, thus America's current health policy problems and indeed crisis go far beyond just increasing access to health care and insurance and increasingly or simultaneously trying to reduce spending for healthcare and insurance while at the same time improving population health and those may sound almost contradictory. Reform of the American health care and insurance system has been illusive and partial due the particularly and peculiarly fragmented nature of American government and our social welfare system which assigns to the private sector, major responsibility for programs especially pensions and health insurance that are almost entirely in the public sector in comparable nations. After repeated failures to achieve comprehensive reform of health care since the creation of Medicare and Medicaid in the 1960s, the patient protection and affordable care act of 2010 a.k.a Obamacare was a notable political achievement with at least four major goals as shown in table 2.1. The prognosis for achieving most of these goals however remains quite guarded while substantially expanding insurance coverage and access to care, Obamacare will likely have it best marginal success in either controlling health expenditures or ameliorating the worsening of American's population health. This somewhat dower assessment reflects the range or projections being made for the impact of the law including quasi-experimental and experimental evaluations of the Massachusetts Healthcare Reform of 2006 and an early reform of Medicaid expansion in Oregon in 2008 respectively. In addition, we have seen increasing evidence that the Obamacare potency has been and is being greatly diminished by the political compromises made to achieve its passage and by the opposition and obstacles it has faced since and continues to face. More fundamentally, Obamacare, like all prior healthcare reforms is largely a supply-side policy focused on expanding and managing the supply of health services and the pricing of them rather than on altering the major driver of the demand for health services which is the health of the population itself. If Obamacare and healthcare reform more broadly can not solve our current health policy crisis then what can? My answer is a new demand-side approach to health policy grounded in the science of social determinants and disparities in health. The fundamental source of America's paradoxical crisis of spending more and more on health care and getting less and less in terms of health outcomes is the seemingly intuitive but unfortunately erroneous assumption that healthcare is the primary determent of individual and population health. While healthcare is important to health, is much less so than we customarily think. Logically, this reflects the fact that health care most often comes into play after we are already sick or injured, often seriously slow and health care frequently cannot cure our illness or injury but only help us to manage its further course. Empirically, multiple estimates suggest that health care accounts for probably only 20% or so of the variants and change in population health and certainly less than the assumed 50 to 100% that underlies our current supply-side approach to health research, education, practice, and policy. This estimate reflects but goes beyond the important shift over the last century from infectious diseases to chronic diseases as the major sources of morbidity, disability, and mortality. For example, historical demographers and epidemiologists discovered that modern medical health care had not actually been the major determinant even of the decline of infectious disease is mortality from the mid 18th century to through the mid 20th century as had previously been assumed. Most striking, was the work of the medical demographer Thomas McKeown, we're looking at the decline of tuberculosis mortality in England and Wales between 1838 and 1960 as shown in figure 3.3 and tuberculosis has been referred to by Susan Sontag as the cancer of the 19th century. TB mortality declined from relatively epidemic proportions in the mid 19th century when it accounted for 20% of all deaths to almost nothing by 1960. However, 50% this decline occurred before Robert Koch had even discovered that tubercle bacillus, an 80 to 90 cent-- percent occurred before the development of effective pharmacological treatment and vaccination against TB. Others produce similar analysis of the decline of many other infectious diseases over this period, with vaccination proving the major determinant of such declines only for three diseases, small pox, whooping cough, and polio. Another perspective on individual and societal health has existed since ancient times in the antinomy between the Greek goddesses, Hygeia and Panacea, and later in the 19th century, beginning in the 19th century between the traditions of social medicine and biomedicine. In this alternative view, the health of individuals and populations is primarily a function of their ability to adapt and thrive in relation to the environments and conditions in which they live and work. It is these conditions of life and work that mainly shape health with health care more a response to health problems that are primarily determined of health. To understand chronic diseases, biomedical research have to move outside of the laboratory and clinic, and develop a new conception of the ideology of disease and a new research designed for studying it, the long-term population based prospective study which sought to identify characteristics of people that predicted on set of major morbility or mortality in persons free of disease at entry in to the study. Studies and places like Framingham, Massachusetts to Coloma City, Michigan and other communities identified first physiological variables like blood pressure and cholesterol. It is major predictors of cardio vascular morbility and mortality. These were not however, the necessary and sufficient clauses that bacteriology and virology had discover for infectious diseases but, rather what came to be termed risk factors that increase the likelihood of disease on set, acting multifactorially with the range of other factors. Through these and other methods, the adverse-- a health effects of environment toxins and pollutants became increasingly well recognized beginning in the middle of the 20th century or even little before that. In the 1960s, it became clear that risk factors were not only physical, chemical or biological but also behavior. As can be seen in figure 3.1, the 1965 Surgeon Generals' report on smoking and health showed that the emergence and growth of the production, and consumption of cigarettes in the early 20th century lead with the lag of20 to 30 years to a mid century epidemic of lung and other respiratory cancers while also contributing the increases in cardiovascular disease and not a respiratory cancers. By the 1980s, a major public health effort most importantly increase taxation of cigarettes and major restrictions on when and where they could be smoked has began to achieve a substantial and continuing reduction in smoking. And declines in cancer and cardiovascular disease have followed by the end of the century again with a 20 to 30 year lag. This-- the range of behavioral risk factors expanded beyond cigarette smoking to include lack of physical activity and immoderate levels of alcohol consumption in eating or weight. From the 1960s through the 1980s, I and others, will have to identify through similar prospective epidemiologic research major, social and psychological risk factors for morbility and mortality. By the mid 1980s, stress and work and other aspects of life, a number of psychological traits and perhaps most striking lack of social relationships and supports have been shown to be risk factors for health comfortable to blood pressure, cholesterol, smoking and other behavioral risk factors. In the 1988, article in science, I and my colleague show the congruence, that's in figure 3.2 of our own and other research in the US and Europe, indicating that a low level of social integration or relationships produce the doubling or more in the risk of death for all causes which is exactly the same thing that cigarette smoking does. Unfortunately, both medical care and non-medical risk factors for health are often quite unequally distributed by race ethnicity, socioeconomic position, gender and combinations thereof, perhaps especially, and increasingly so in American society. During the first decades, after World War 2, social inequalities or disparities in health were curiously ignored even as research on social determines of health moved ahead. Things changed markedly in the 1980s the seminal document and event was the report of a commission established by the labor government of the United Kingdom and the late 1970s to investigate how the first quarter century of operation of their national health service had affected socioeconomic disparities in health. The commissions report, known as the Black Report after its chair Sir Douglas Black, who is the UK equivalent or Surgeon General surprisingly showed that socioeconomic health disparities were still a large in the UK in the 1970s and virtually undiminished by a quarter century of universal access to health care through the NHS. The report was delivered to the new conservative government of Margaret Thatcher in the beginning of the 1980s, which proceeded to issue 250 copies of the report on a bank holiday with a preface by the secretary of health essentially saying that, "We're not sure we believe your findings and even if we did, we could do nothing about them." Re-issued by penguin press, the report ultimately became a sensation and social epidemiology in certain areas of public policy and both United Kingdom and internationally. Research in other western European and North American countries including Canada in the US replicated wide socioeconomic disparities in health, little changed by the spread of systems and national health care and insurance. The 1980s saw a similar discovered-- rediscovery of racial ethnic disparities in health. Evidence since then suggest that social disparities in health both socioeconomic and racial ethnic have generally increase further over the past quarter century. In the late 1980s, my own research group had a similar epiphany regarding socioeconomic disparities in health. In 1986, we launch something called the American Changing Life Study or ACL, a long term national prospective study of the role of social psychological and behavioral factors in the maintenance of health and effective functioning over the adult life course. It was conceived and fielded before the wide spread rediscovery of socioeconomic disparities in health, so this was not initially our central concern. However, our first analysis over 1986 survey focused on how the relation of age to health varied as a function of a wide range of social psychological and behavioral risk factors. As it turned out, socioeconomic position is indexed by education and income prove most powerful by far in shaping these relationships. Slide 4.4 or figure 4.4 graphs by age and for different levels of education, the proportion of people who in 1986 reported no functional limitations. That is, they said that they could do heavy work around the house such us shoveling snow. As you can see at the age of twenty five, few people manifest functional limitations. But functional abilities decline linearly with age among people with less than high school education, while the college educated continue to show almost no limitations until somewhere between their mid 50s and mid 60s with the-- and those within intermediate education lie in between. These are large differences, 20 to 30 percentage points in middle age. Sort of use the arrow here for a second if it works, yes, look across here, and were conceived in other way 20 to 30 years in deference in the age of on set, substantial or significant limitations. At the-- and as the end of life-- whatever as, Johnny Maynard Keynes said, "In the long run, we all are dead", socioeconomic differences are getting narrow. One cannot be sure from cross sectional data that these patterns are a product of the way health changes with age as a function of education. However, we know now from our longitudinal data through 2011-12, that this is the case. We have seen similar results by income, and we and others have also shown similar socioeconomic differences in mortality over the life course and have also analyzed racial ethnic disparities in conjunction with socioeconomic lounge. These social disparities in life expectancy ranged up to ten to fifteen years. We know understand that shown in this table, for example that socioeconomic factors can account for 50 to 75% of racial differences in mortality especially for man. So if you see, the over all racial difference is 4.9 years as of this particular population in time and that difference is essentially cut in half when you start looking within particular income groups. Further the income difference that you observed both within the white and then particularly in the black population is even larger than the racial difference that you observe. However, it's also the case as you can see that the remain racial ethnic differences at all socioeconomic levels and factors such us discrimination and segregation we know now have significant adverse effects on health over and above those from socioeconomic position. We now understand that socioeconomic position, which is here, which is itself a function of age, gender, race ethnicity and broader social, political and economic conditions and policies, constitutes what some have termed a fundamental cause that shapes individuals exposure--where did my arrow go-- there we go-- to any in all risk. Factors for health, medical care, psychosocial risk factors, environmental risk factors and, and alike. A racial study has been-- we've also documented and others have sociogenic disparities and medical care and insurance and exposure to environment hazards and in health behaviors from smoking though eating, drinking and exercise to obesity. Our studies been more uniquely able to show similar results for social and psychological risk factors and for virtually, every risk factor that we can measure and that we and others have shown to predict adverse health outcomes. There's a mark gradient by education and also by in government. We've also shown that if education and income did not produce such pervasive differences in exposure to an experience of these risk factors socioeconomic disparities in health would be commensurately reduced. In our original cross sectional data statistically adjusting for income and in a set of eleven behavioral social and psychological risk factors reduced educational disparities by 70 to 80% as shown the as dotted lines here which are supper impose on the figure that you've just looked at. All that we and others have done longitudinally produces result consistent with these data. Thus the socioeconomic factors are particularly important and potent for health science and policy because of their wide range and impact on virtually all health or risk-- risk or protective factors including new ones as the arise and because they show us where in the population are the greatest opportunities for improving health. Given the relatively modest relation of health care and insurance to health and the large impact of social determines and disparities on health. It's not surprising that there is essentially no coralation across countries as shown in figure 3.4 between spending on a medical care and insurance here as a percentage of GDP and life expectancy or there is actually a decidedly negative one if we include the egregiously outline point of the United States. Little wonder that spending more and more on medical care and insurance has not produced amounts of gains in population health. Over the last decade culminating in my in my book , I've increasingly focused on the implications of all these for current debates on health policy in brother or social in physical policy. The several implications from what I've said as far. First, America is paradoxically is paying more and more for health care and insurance but getting less and less in terms of population health outcomes. Second, this paradoxical crisis arises with the understandable but unfortunately, mistaken belief that health care and insurance are the major determines of health and hence the only proper domain of health policy including the Obamacare. Third, there's little reason to believe that Obamacare or any other proposal for supply side health care reform will more than martially either improved population health or restrain the growth of spending for medical care and insurance. What is required is in my view-- could we just skip over a couple of things. And he there we go. OK, is substantially a demand side policy that reduces the expenditures by first improving population health by a broad range of public and problem--private policies outside the domain of current supply side health care and insurance policy that is we need to use what we've learned about the nature and sources of social determines and disparities in heath to promote public and private policies that are enable more, and more people specially disadvantage socioeconomic racial ethnic and gender groups to live in work under conditions that protect and promote their health. Let me just-- in time, skip over a couple of things. All of these, further means that virtually all social policy is in fact health policy. And just as we evaluate the environmental impacts of a wide range of seemingly none environmental policies, we need to evaluate the health impact of seemingly none health policies and to consider the result in our analysis of the cause and benefits of those non health policies. So let me close with two related points, first we know, now know that we can improve health through a very broad range of public and private policies. Second, we also know-- all that we know, I say indicates that a healthier population spends less in less, rather than more on more on health care insurance. Most widely recognized and in discussed at this point in problems, probably also most intuitive are the ways that agricultural, transportation, housing, urban land use policies, have adversely affected patterns of smoking, eating, drinking, and physical activity enhance body weight, and the ways that these policies we now know can be modified to improve patterns of health behaviors in itself. We've similarly recognize the potential adverse self impacts of physical, chemical and biological, environmental conditions and increasingly have found ways to mitigate at least some of these. In addition however, both prospective epidemiologic data of that we already discussed, and field experimental research in the US and other countries has now documented substantial health impacts from a wide range of socioeconomic policies. Let me briefly note newer experimental data in the five major areas are shown here. For example, when states, in the US or nations across the world increase the number of years of compulsory schooling. People affected by those changes live longer, than people who just missed falling into the new compulsory schooling policy. Similarly, children randomly assign to receive enhanced pre-school education. Have better health, well into adulthood, than those who randomly did not receive that enhanced education. And $10,000, this partly comes from the work of, one of our colleagues here Sue Dynarski in financial aide to oppose secondary students, results in 1.6 years of additional education. Which in turn, translates from other-- as knowledge that we have into anywhere between the third and the full year of additional life expectancy. In contrast, economist estimates it, it takes $30,000 to almost $150,000 in health expenditures to yield in additional year of life expectancy, depending on the point in the life course that these expenditures are made. Experimental studies in the US, Latin American countries in South Africa, have shown that increasing the income of individuals and families is beneficial for their health at points from early life through old age. And job lose during major economic down terms, produces a reduction in life expectancy of 1.5 years or more due to largely to attend a $15,000 permit loss in annual income. Laws that broke down de jure and de facto segregation, in schools, housing and access to medical care, have now been clearly shown to have improved the socioeconomic and health levels of African-Americans. And a major experimental study has just shown that moving people out of public housing in the socioeconomically better neighborhoods, reduce levels of obesity, and diabetes, among those randomly assigned to move, compared to those who randomly were left in their originally poor public housing, neighborhoods. All of these socioeconomic policies impact a wide range of risk and protective factors for health, and they also have other non-health benefits. Thus a wide range of social and economic policies affect health perhaps? Most notably education income and employment policies, ranging from support for public education, to student financial aide. To social security, or in the income tax credits, the minimum wage, and employment and unemployment policies. We have yet to plan fully evaluate the health effects of such policies on a large scale. But it's possible that since that 1970, the US has been running a perverse national experiment in moving many of these policies and consequent levels of education in common employment in directions adverse to health. Trends in education and income are perhaps clearest in this regards. As many of you may know, from the 1970s through the end of the 20th century, at least levels of high school and college graduation, essentially plateaued in the US after having ridden steadily between 1900 and 1970. As seen here in figure 1, for high school graduation and figure 2, 9.2 for college. In the current US ranking on educational intergenerational educational mobility that is to, do children do better than their parents? As seen in figure 9.3, eerily mirrors are rankings on population health outcomes. We're 23rd in this list of 20, I think out of 23 in this list of OECD countries. Similarly, growth in earnings has plateaued since the 1970s as seen in figure 9.4, and the real value of the minimum wage is steadily decline. These-- changes have arguably driven declines in health with a consequent rise and health expenditures. Which I must say this is all still a hypothesis but worthy of more research. Finally, do healthier people really spent less on medical care, rather than spending more in order to make themselves happy-- healthy. Maybe happy, maybe happy too. Reserve research indicates the answer as yes. On an annual basis, people in better health including those from more advantage racial ethnic or socioeconomic groups, utilize less health care and spend less on it. And projections that are much more solidly based on solidly based on past empirical evidence than those regarding the hope for economic savings from health care reform, show that healthier people spends substantially less over their lifetimes. Even though, we all make most of our medical expenditures in the final years and even months of our lives. For example, as shown in figure 8.1, simply being obese at age 50, results for 15,000 more and lifetime health expenditures compared to the non obese . This differential would be much larger if conditions often associated with obesity. Such as, hypertension, diabetes, or muscular skeletal problems were also considered. Returning to where we started today, suppose that the population of the United States had levels of population health, comparable to other highly developed nations, instead of a relatively worsening population health parameters. What would be the implications for health care spending? We now have a first estimate from a micro simulation model of the American population age 50 and over, using parameters drawn from the national health and retirement survey done here at the Institute for Social Research. If you as population, age 50 and over came gradually over a period of 25 years to have the same average level of serious diseases and health risk factors that those in major-- as those in major European countries, this would erase the 1.2 year gap in life expectancy between us and those nations at age 50. More importantly, there would come to be savings of $60 billion current dollars annually in public spending for medicare, medicaid, and disability benefits or over a half of trillion current dollars over a decade. And now it goes to the projected savings from Obamacare and other healthcare reform proposals. The impacts of which remained answered at best. The spending trends can be seen in the next figure and here just focus on the blue, which is the spending for health expenditures as essentially, each new age group. 51 year old, 52 year old, as they come on the population have health that matches the European numbers. By the time you go out 2025 years, you're saving 60 billion dollars a year and those savings continue pretty much indefinitely. Equally large savings would occur in private spending on health, which does not necessarily happen. Under health care reform proposals that focus on the public sector. And may merely shift cost from government to private organizations families or individuals. All of these savings would be larger, still, if people below age 50 are also included or if the US' health is allowed to improve beyond the average of major European nations. Or of these changes more rapid, occurred more rapidly than over 25 years, or extend beyond the 25 years used in this projection. The potential total savings would then in being in trillions of current dollars in the range of the expenditure reductions, currently seen as necessary to create more sustainable overall budget for government at various levels. Not to mention organizations and individuals suffering under the burden of rising healthcare costs. Efforts, such as Obamacare to reform healthcare insurance, cannot and should not be abandoned. As we need to do all we can to achieve universal access, and to make the soon to be 20% of the GDP spend on health is close defective as possible. But in addition, we needed a demand side policy that improves levels of population health via broader social policies in determinants of health especially at middle and lower socioeconomic levels, and for disadvantage racial on ethnic groups, where the opportunities for health improvements or greatest. Improved population health, decreases the need to demand and hence the expenditures for health services. Just as deescalating the cold war, did more to shrink our spending on national defense, than efforts to make the military industrial complex more cost effective. So, just the man side approach to help policy is likely to have larger and more certain effects in both improving population health and reducing health spending in health care insurance than Obamacare or any alternative proposals for healthcare reform on the supply side. Thank you.

[ Applause ]

Just-- So I just stay here?

>> Yeah.

>> Good afternoon. It's really an honor to be part of the event of this afternoon for many reasons, but the most important of which is that I came to the University of Michigan in 1994 to do a post doctoral fellowship in Health Policy and Jim was my main mentor. I have been privileged to learn from and work with Jim for over two decades now and I-- I can't begin to express my gratitude to Jim and his wife Wendy for how wonderful they've been to me all this time and again how much I've learned from Jim over the years. He's had a tremendous impact on my own career. And I'm delighted this afternoon. We also have two terrific people who are going to provide some comments and reactions, first of all and now we're going to turn it over to all of you. And I do want to do remind the people who are joining us online. That if you have a question you want to ask, so please tweet that using the #policytalks. So, today, we have with us Helen Levy s an Economist and a Research Associate Professor at the Institute for Social Research, at the Ford School of Public Policy here and also the School of Public Health. Her research interest include the causes and consequences of lacking health insurance, evaluation of public health insurance programs, and also the role of health literacy and explaining disparities and health outcomes. And we also have with us today, Professor Richard Lichtenstein, who is the S.J. Axelred Collegiate Proffesor of Health Management and Policy. Dr. Lichtenstein research interest include, community based participatory research, racial and ethnic disparities in health and barriers to health insurance coverage for low income children. You can read more about their terrific interest and also some of their side projects and activities and addition to their academic ventures. But I'll turn it over to them right now, Helen, will lead us off and then Rich will follow up.

>> So, first, let me let me start by congratulating Jim on his book which represents a remarkable synthesis, have facts and ideas. At Jim, I learned so much from every conversation with you and the book was a very forceful reminder of that. It is-- the book is distilled essence of Jim House and that such it is wonderful. The connections across disciplines, that cross policy domains, that cross areas of human activity, reflect a remarkable depth and breadth of intellect. Now, depth and breadth of intellect are not necessarily the things you think of if you here the words Washington DC. And I want to talk a bit about some of the things that lie in the space between the vision that Jim's Book lays out for a more enlightening socio and health policy. And some of the immediate concerns that are part of the implementation of the Affordable Care Act. So, you can think of my comments as a much less visionary Beyond Obamacare. And I'm going to come back to the issues raised on Jim's book. But I want to start bu talking a little about the Affordable Care Act itself. The Affordable Care Act is often describe as having had two goals, Jim said four but only in five minutes, so, I'm going to say two. And one of those was to cover some of the approximately 50 million people that are uninsured at the time that the law was passed. And the other goal was to try to do something about the controlling the growth rate of health spending. And this are quit different goals from each other and a number of ways. An important one is that for the first one covering the uninsured. This was not a difficult problem from a policy prospective. So, there were lots of policy proposals that have been sitting around for literally decades for how you can do this. You can expend medicare and medicaid, you could have tax credits, you can have an employer med aid. There are lots of ideas for how to do this. And the hard thing about covering the uninsured was getting the political will and the political coalition to make it happen. And conditional on having that, you know, pick anyone of these policies off the shelf and its going to work. And in fact that is what we're seeing because the fraction of the population that's uninsured drop from 13% to 10% as soon as law was the coverage provision of the law went into effect in 2014. So, that part of the policy wasn't hard from a policy prospective and it seems to be working. Now, the second goal of the Affordable Care Act. How to do with slowing the growth of health care spending in getting more value out of the spending that we do. And that's much harder to do because we don't really know how to do it. There's also questions about the political will to do it, but we actually don't have bunch of great ideas, about how to slow spending in a way that preserves the things we spend money on that are valuable and selectively cuts out the spending just on stuff that's wasteful. So what the Affordable Care Acts did on this front and light up this sort of gap in our knowledge about how to solve this problem was try a bunch of different things, so some examples of the-- I'll call them experiments in the Affordable Care Act, of how to get more value about health spending. Some examples of these are instead of paying doctors and medical care for each thing they do, pay them more if they do less but keep their patients healthy, it's so crazy it might just work. Another example is instead of paying hospitals more when their patience acquire infections while in the hospital, to actually penalize hospitals for that. And another example that actually been in the news lately is imposing a tax on a very, very generous health insurance plans, this is sometimes called the Cadillac Health Insurance Tax. It's been in the news for the past couple of weeks, even just this morning was in the New York Times, both because there's a moved in Congress to repeal this element of the Affordable Care Act. And then today because Hilary Clinton and came out and said yesterday that she supports the idea of repealing it. The idea of-- repealing is not a popular idea with the economist probably yes. In any case what these and other things in the Affordable Care Act are essentially doing is, we're bumbling around trying to find different ways to reduce spending in ways that don't harm health. Now coming back to Jim's book, the vision that he lays out in the book, is that if we spent more on basic things, like quality educations and social programs, like food stamps for the EITC or SSI. People would ultimately be healthier and in a long run would need less medical care, and so they'd spend less, so in a nutshell he's arguing the social policies are very cost effective way to deliver better health. And the economist in me says that, you know, even if we did these things-- mumbling around with these other attempts to cut cost in the system for number of reasons the first of which is that the social determinants approach, doesn't do anything to distinguish between the medical care that's useful and the medical care that's wasteful that we pay for even if it improves the profile population health it also takes a long time relatively speaking and my reading of the numbers is slightly different from what Jim said my reading was, that it wasn't actually saving enough money to actually ensure that medicare will still be there for me let alone for my kids. And those are the kinds of numbers I'm looking for when we talk about reducing health spending. Now--I don't mean to suggest that Jim argues in the book that social determinants approach are to replace other approach is quiet confront about that. These two types of policies, this sort of grab bag of cost control efforts that I've talked about. And the more coherent vision that Jim's lays out in his book, they're complements not substitutes, not an either or situations. And so I think that even us folks in Washington continue to experiment with ways to try to turn off the spigot of healthcare--especially federal state healthcare spending a little bit in ways that don't harm health. I think the value of Jim's book will be to add to those debates, a longer term and broader perspective. And I suggest we need to think outside the healthcare for other solutions to this problem. Thank you!

[ Applause ]

>> Good afternoon, appreciate the invitation to speak here, let me just start by saying that a Jim has had a very big affect on my career also, he was on my dissertation committee which was chaired by Bob Kahn long ago, so I appreciate that very much and I've read he has written in the have really incorporated into a lot of teaching that I do in the School of Public Health. So let me start by saying that, I am a total adherent to the idea of the man side that Jim is talking about. I also run into the same problem I think he had writing this book which is I teach kind of aspiring health administrators, hospital administrators, policy people in health, physicians about the health care system and they're very committed to it, and, you know, they have a lot of-- at stake in the health system. And I also try to tell them that the healthcare system is not the only way to create health in fact as Jim described beautifully in his book, it doesn't even make a big difference at the margin anymore. So I'm interested in racial and ethnic and socioeconomic disparities, I'm interested in inner cities. It's very important for me to tell people that, just providing more health care is not going to end those health disparities. The inequalities of health between the poor and the rich, between blacks and whites, Latinos and whites it is not just going to do it. So one of the things I try to do when I teach people especially physicians who work in inner cities, is to tell them that your not going to make a difference in health just working hard all day inside your office treating patient exactly the right way, because think about it somebody comes to an office with diabetes. In Detroit, the things that a physician is going to tell that person is, first of all I want you to start eating fresh fruits and vegetables. Second I want you to get exercise, I want you to go out and jog, I want you to walk a long way. And if you've been in a part of Detroit where I work, you know, that there's no fresh fruits and vegetables available. And, you know, that is not safe to walk and most time people can do it, I can tell you example of how we-- able people to walk. But the point is just going with the medical care side doesn't really solve the problem. You really need to think more broadly, you have to get outside the walls of your office or your hospital and you have to really get involved in Population Health, which is what the Obama administration tried to do in the Affordable Care Act by trying to get to hospitals incentives improve population health. It's very hard to tell hospital administrators, you've got serve the community because your not going to re inverse for that but that something that I think is really important. So let me give you a case study, about how Barbara Israel, who is kind of leader of a big [inaudible] work. She wouldn't use that term, he would say the facilitator but she's colleague and she and all Paul actually who is involve in this sensorial faculty at the School of Public Health care at the nursing school and public policy and social work and medicine. We went into Detroit in 1995, to try a really do something about health in inequalities in Detroit. We got bunch of community based organization to agreed to partner with us, on a equal footing, that's a whole story really changing the way we do research in Detroit but we got eight different organizations to assigned all with us. And we sent in the proposal to David Satcher, who was then the head of the CDC later he became search on general. And a couple months later we found out we've got funded, and we had to go back and talked to this organizations that we had talked to and say, now we're ready to do it. OK, so I just want to tell you first of all the nature of the organizations that we partnered with to improve the health of people in Detroit and then I tell what they reaction was, so I just going to list the couple of sectors and which they we're active. So one was dealing with housing, you know, low income housing neighborhood. Another was a doing job training and economic development work. Another was doing education in the public schools. One was dealing with youth violence on the East side of Detroit. Another was community center that tried to provides activities, healthy activities for kids and on the East side of Detroit. A behavior health organization dealing with substance abuse and mental health problems. And environmental justice organization, which deal with the-- some of the terrible pollution that goes on parts of Detroit,. And then finally a federally qualified community health center. So only that last one is a real health provider, all the others deal with the social determinants of health. The funny thing was when we went back in this organizations that sign on with us find out we got the grant, they said ''Why do you want partner with us? We have nothing to do with health. You know, we provide jobs for people, we do education'' and it was-- that's the whole point. That's how you improve health, you upgrade peoples education, their income, you get them physical active, you know, and all these other things that really don't have much to do with the clinical work is really the way we saw improving health. And we've been quiet active for 20 years now doing projects with community members not on communities but with community members. And let me gives you a sampling of the kind of things that we been dealing with. So first of all, that whole issue of they're not being fresh fruits and vegetables in Detroit, I don't know if you know this but up to until few years ago there were no national grocery stores or supermarkets in the city of Detroit. So you had to go party stores to get fruits and vegetables and you can imagine the quality of those fruits and vegetables there. Very hard to get wholesome food, be nutritious, people ate bad foods you get, you know, obesity is something that's going to rise out of that. So we try to deal with that problem. Lack of places and which to be physically active. We have a project that works, so about heart health and they actually have develop several different walking groups around Detroit, where people get together and they have charted it out safe areas to walk in and they met two or three times a week and they walked quiet a long distance, they had a really great time interacting with each other, they really enjoy doing it and they lost weight and their blood pressure went down. So this are things that can be done with out condition and a stethoscope to try the improve peoples health. We work on youth violence, gang violence, its kind of hard stuff to deal with but that's how you try to improve the youth health in Detroit. And the quality of the public schools we actually tried to work with that, that was very hard to do in Detroit because there closing schools every time you turn around and that was kind a issue. We also try to work with community partners to talk about, how do you approach policy makers and get them to change health policies. Or some of the other policies like, air pollution in Detroit, there's a big health issue how do you deal with as a community resident who doesn't want another bridge span coming through your neighborhood, which is what's going on in Detroit right now? So I can't tell you that we solve the problems of Detroit, I can't tell you that people are-- buy large-- much healthier than they were 20 years ago but I do know that we have made really good in roads into the health of many of the people that we work with. And that despite the fact that I teach about health care and the health care system in my class is, I really believe that the way they go about improving health specially in places like big inner cities is through working on a social determinants, so, thank you!

[ Applause ]

>> So we're going to give Jim a moment to respond some of the comments of our discussants, and then were going to turn to audience question.

>> I try to brief you all been very patience, just in general like thank Helen Rich for relatively kind comments. On the one point that Helen raise, you know, we want-- we all want to be able to preserve medicare and preserve other programs, what's not clear at this point in time is whether healthcare reform can produce enough savings to allow that or whether-- I won't claim that this a guaranteed from a micro simulation model. But actual policies will produce the same thing but I'd say just point in time there's at least kind of equal chance on both sides and she's started it off within as I feel. This is not either or situation but it is a situation where we need to restore kind of balance to thinking about health policy and not treated as entirely a problem of healthcare and insurance. Rich's, you know, comments reflect that and again I-- there's nothing that I'm saying when I focus a little bit more on broad or national policies that contrivance the idea that one should be doing things in the community I would only say that It would be a lot easier in communities if the national policies were flowing in the same direction and rather than communities trying to work against the tide of a national policy that's going in the other directions.

>> OK.

>> Can you hear us, OK. Well first of all thank you all for being here, it's been really interesting to hear your comments today. My name is Janelle Farrow [assumed spelling] I'm a second year of the PPA at the Ford School

>> And I'm Dennis Chee[assumed spelling], I'm a senior studying Political Science.

>> OK, so to start us off on the Q&A one of the first questions that we've got which was the big one. Is single-payer system the way we must go?

>> I think I yield to, you know, to Helen for the most part on that, all I guess I would say again is that what I find when I talked about these things is that, the questions come back to questions about health services and healthcare insurance and what I'm trying to do. And what I'm trying to do is move the conversation beyond that, that's not to say that other conversation is not important. I would say that the evidence indicates that, yes-- yeah, a single-payer system, from my perspective, probably could get better control of healthcare cost. On the other hand, the evidence we have from other countries is they are not absent, the policies that we have. The development of a universal insurance in Canada did not solve all the problems. So, that is not a panacea for everything, but I say, Helen is much more qualified to talk about this.

>> I mean, you know, I think, we do have single-payer for people over 65, and it works well in someway and has problems in some other ways. And, I don't think that is the only way to achieve equitable and efficient outcomes and certainly there are the examples of say Germany, Netherlands and Switzerland. All of which have universal coverage built around employer-based systems, more less like we have for people under 65. And those system seemed to work pretty well too. So, no, I guess I don't think that single-payer is the only way to go, which is good because I don't think we're going to get there.

>> The next question is [inaudible], OK. The next question is, "Does enactment f the affordable care act make progress population health more or less likely going forward? So, to rephrase that, Can the inadequate quality measures in the affordable care act, serve as a foot in the door towards substantial improvement such as, mental health treatment policy?"

>> You know, again, I would say, you know, I--there's nothing-- I think the Affordable Care Act includes a lot f good ideas, about both dealing with health service and trying to expand things to think more clearly about population health. But if you continue to restrict the discussion, to things that are mostly centered within the healthcare and insurance system and those kinds of ideas, I don't you're going to get very far.

>> So, I just want to make a point that Jim makes several times in the book and said it right at the beginning here and then I always try to make this point too. Which is this, that you can talk about inadequacy of the healthcare system improving everyone's health, but that does not mean that the healthcare system and that healthcare itself is not important. You know, there were-- there was a time in the 70s, I remember, when people were saying, you know, "Healthcare doesn't matter, so what difference does it make if people don't get Medicaid", you know, its not going to help them. They were sort of medical analyst and sure that's easy for people with insurance to say, but you know, I think the issue is we need to have everybody insured, so whether its-- you know, I'm not sure, if single-payer system is possible, whether that story would do it. I do think we have to get everybody insured. So that, when all those decades of problems, in terms of social problems that they've lived with cause health problem, people would be able to get treated for. But I definitely think we have to fix-- upstream, you know, that things that people live with, during there whole lives, as a way of trying to improve health. We can't just rely on rescuing people after they've gotten sick by living a lifetime in deprived conditions.

>> OK. The next question is, how do we incentivize the government and investors to budget more money towards social services and other forms of prevention? And also thinking about of a prospect of a potential republican president and republican congress.

>> These are easy one.

>> I'll start. I spend sometime in the book, because I get--you get--I get those response, you know, all the time, I got it in the reviews is-- well this is all sounds all very nice, but you can't-- it will never happen, nobody wants to do this. I mean, we just watched over the last year, a substantial change in both public and private thinking about the minimum wage that I think two years ago, people would have said, "Nope, nothings going to happen, to improve the minimum wage". Now, something's going to happen, that's not just coming out of-- solely out of the democratic or the more progressive side, there are people-- other people in the republican side are doing it. Similarly, earned income tax credits are things that have been done, generally, in a bipartisan way and even people like Paul Ryan continue to support that. So, I don't think, you know, my view on public policy has been shaped a lot by a book, by a guy named John Kingdon, who used to be in the political science department here and is now in the Brookings Institution. And he said, "You get policy changed when you got three things--three streams coming together". One is a problem stream, and as you people got to believe there is a problem that needs attention. Secondly, is a political stream, you have to have the conditions to make things happens. But the third one is, there has to be a policy stream that points you in the direction that is actually really going to make a difference. And so, it seems to me that, you know, our role in policy is not to necessarily say, what is politically palatable at the given moment but to say what we think is actually going to make a difference and hope that at some point, things are going to come in that direction. And we seen that happen in the past, on a wide range of areas, and I think we're going to start to see that happen with respect to some of the kinds of socioeconomic policies that I'm talking about.

>> There's also follow up question to that and I think some people on the back are having trouble hearing so if you could all speak into the mics. So, inconsideration of the multitude of-- and continuing challenges to healthcare reform, could you assume that large scale population health initiatives at the national level will face opposition or-- will continue to face opposition?

>> I mean there are lots of opposition, healthcare reform continues to face huge opposition. It's--there's always, you know, political disputes about things, but there are moments when we have been able to and, you know, I think, will be able to in act both positive changes in terms of healthcare and insurance policies and positive changes in terms of social policies that impact health. And I, you know, as I say, you can't-- I think to go away and I think that's been a tendency in some parts of the health policy community. As I understand it, Robert Wood Johnson Foundation set up a group, that was suppose to produce by the people who initiated the idea, something like the Black Report from Britain. And they essentially start off by talking about social determinants and particularly social disparities in health and then they almost entirely drop the subject. And I'm told in, you know, this is a--may or may not be true, but this was largely a result of not the republicans on the committee, it was the result of the democratic co-chair of the committee who said, "We've been there and done that and tried to do stuff here and we can't do it". And, I, you know, I think, you know, that kind of approach I think in the long run isn't going to get us anywhere. That's not to say that you're not going to make, you can say exactly when to change is going to occur, but changes like this are going to happen. They have happened and they will continue to happen. Even if you listen to Donald Trump, he talks some of these kinds of stuffs [laughs].

>> All right. So we have a very specific question from a person in the audience. In 1968, Dr. Jack Geiger argued a similar demand side approach to improving population health in rural Mississippi. He treated a community health center but also spearheaded many social improvements in the area to improve health. How would you assess his efforts and why do we still-- why are we still proposing this policy in 2015?

>> Rich, probably.

>> Yeah. So, I know a little bit about this. So, Jack Geiger was the-- sort of the grandfather of the community health center movement in the United States, and it turns out that he was trained by two South Africans, Sidney Kark and Emily Klark--Kark, who created this movement called community-oriented primary care. Which is basically that, as I was saying, before you can just treat people in the four wall so your clinic, you really have to go out and deal with the issues that are causing them to have health problems. So, Jack Geiger studied with them, came back to the US, got the Johnson administration to actually create community health center, they were called neighborhood health centers. It started in 1966, and the first ones were in Mound Bayou, Mississippi, which is what you were talking about, and the other one was at Columbia Point in Massachusetts in Boston. And, their whole emphasis was to go beyond just treating people but to actually-- like Jack Geiger, who was dealing with the population in very fertile areas of Mississippi, where people were starving because they would-- used to be share cropper and they couldn't work the land anymore. So he created prescriptions for food that was one of the things that the health center did. In other health centers over the years, they've done things like train people to become health workers. They've done things on housing. I was-- I worked at a health center in 1968, where they had a legal staff that sued landlords, to try to improve conditions in housings. So I think, getting outside the walls and doing that, is great idea. There are now 15 hundreds community health centers, so that movement has gone bigger. It's the one thing in the Obamacare legislation and after that, just recently, that got funded with billions of dollars more, because that's the groups that's going to take care of the new Medicaid patients. So I think there's-- that was a very positive movement. I don't think it's blossomed into changing everything, but I think that was a very positive thing and there are lots of communities where there's healthcare now, where there wouldn't have been before. And, some of the other, you know, issues that are address and social factors too.

>> Can I-- going to--

>> Yeah.

>> -- I want to chime in on that. I actually met Jack Geiger, he's an amazing person and his legacy is just tremendous as his legacy of community health centers. However, I just spent the last four years on the board of a federally qualified community health center in Washington, DC. And on the board, you know, we have to be worried about what are the finances of the health center, and the money comes in and to cover medical care. And I think, one of the big problems we have right now is insurers and including Medicaid, a lot of people who go to health centers now, do have coverage to Medicaid, which is great. Medicaid per law and regulation doesn't cover non medical care, it's very hard to get Medicaid--

>> Yup.

>> -- to cover non medical care things, like housing, supportive housing and employment investments and even food. So, I think, until we really kind of change policy at the federal level, in terms of what Medicaid and other programs can cover, its going to be really hard to move off and have health centers move off of the-- their primary business, which is to provide healthcare.

>> Yup, that's great.

>> I think we have time for two or three more questions. So, the next question is, "A startling finding in your presentation, is how strongly social relationships affect health. Is this finding true among disadvantaged groups? How would demand side policies address this issue?

>> I should probably be better prepared to answer this then [laughter] than I have. I, you know, as far as I know, there is no major difference socioeconomically in the impact of these kinds of relationships, they're beneficial at all levels. You know, how you-- that it is a complicated issue, a very complicated issue and people have tried various small kinds of things to effect relationships. I think a part of it again is you have to look at that in a broader context. That I think we need to think about, you know, how do socioeconomic policies, employment policies, work family policies, how do they affect social relations, the ability of people to have them and not--personally, I'm interested-- I'm not going to do it myself, but I'd love to see people doing more on what's the impact of digital--the digital age on social relationships. There are many ways in which that could be helpful, and there are other ways in which it could be very adverse. At the time that I wrote and did most of the research on this, the evidence was that things were a little bit deteriorating in some aspects of social relationships in terms of people's organizational involvement, certainly, you are seeing marital and family break up and all of those things, you know, those are fundamental things that social policy has to think about and address. And they're broad, there's not-- its not affix to go in and have the support of marriage act or something, it's not alone going to make it possible for people to establish and maintain good marital or partner relationships, which are one of the fundamental types of social relationships that matter for health.

>> So, I know, we have many more questions that you've all put forward then I'm so sorry, we don't have a time to get to all of them. I think we do have time for one more question.

>> So the last question is, "What can healthcare centers do to move into social health? For example, social workers in the ER, and providing a breastfeeding classes."

>> Jim, you should--you get the last word.

>> Well, you know, again, I think the, you know, I mean, clearly, health centers and the healthcare system can play a role in doing things to promote larger things. They cannot in and of themselves make the kinds of policy changes, the full range of policy changes that are necessary. So, there is a need for, you know, coordination and collaboration there. I do worry at times when I was on a panel that was looking at the issue of how to include social determinants of health and electronic health records. And it was composed of a large number of what I-- who I'd-- people who are pretty enlightened, physicians and health care administrators. But, to some degree they had a hard time getting passed, things like smoking, drinking, physical activity and so forth, to see that the kinds of factors that affect the health of people coming in, is different. I must say, I-- you know, I have some hope that there maybe, you know, that there's sort of gradual generational change occurring. We get a fair number of younger physicians, who come to our training programs on psychosocial factors in health. And sometimes, I asked them, you know, why the Robert Wood Johnson Program used to have several programs among the ones that Paula mention, but also one that they've had for a very long time called the Clinical Scholars Program, which was specifically targeted on physicians. And, I would ask these people, "So Why are you coming to our program on social factors and health or social policy in health, rather than the clinical scholars program", and they would say basically, "When we see people in our practice, in our office, in our clinics, we can do something, to help those people but we increasingly recognize that we could-- so much more could be done if we could reach people earlier and prevent or at least ameliorate the onset of disease and the kinds of problems that they have. And therefore, we recognize, we got to start thinking more broadly about these kinds of thing."

>> We'll thank you to Helen and Rich for their comments and provocative reactions. Thank you to all of you for your comments and questions. Thanks to the students, for their role today. But most importantly, thank you so much Professor Jim House for your amazing scholarship and this wonderful book that really I think represents a pinnacle of what's been an amazing career. So thanks for sharing this with us today.

[ Applause ]

>> And I just wanted to say that this has been a very important, informative conversation, I hope you will stay and join us to continue it out in the Great Hall and also have your book signed by Jim House. Again, thank you very much for joining us and again thank you to our panel and especially Jim House.

[ Applause ]