Transcripts For CSPAN Computer History Museum - Health Equality 20171127

To be called, is the Senior Vice President for Healthy Communities at the california endowment. The endowments building Healthy Communities initiative is a 1 billion Program Designed to change policy and encourage Civic Engagement in 14 california communities that are affected by health care inequality. Prior to that he served as director for Alameda Countys Public Health department and, if you look up his resume, you will see a string of academic degrees that very impressive to say the least. If you look up his resume, you will see a string of academic degrees that very impressive to say the least. Hes going to be interviewed by vanessa mason. The nasa is the cofounder of pt2, Public Health Tech Venture Fund and also ceo of riveted partners, the Digital Health consultancy. She knows what she is talking about. Please join me in welcoming both tony and vanessa to the stage. [applause] vanessa this promises to be a lovely evening. He has wonderful video to show just why building Healthy Communities initiatives got started and the impact they had already. So, were going to watch the first. [video clip] what determines how long well live . Is it what we do . Is it who we are . Actually, when it comes to predicting how long you will your zip code is more important than your genetic code. Heres how this works. Meet deb and maria. They both have jobs, around the same age, both married with two kids. Deb lives in atown while maria lives less than one mile away. They are similar in so many ways but heres the thing on average, residents of bville will die more than 15 years sooner than the residence of atown. Why . Because where you live is about more than just your address. Its about your opportunities. Access toe, their Healthy Options is really different. There are farmers markets, Specialty Shops and Grocery Stores. The air is cleaner and fresher and there are lots of safe, clean parks where deb can exercise. Public schools and easy access to emergency and Preventive Health care. On the other hand, bville has broken, badly lit sidewalks and the parts are unsafe. With exhaustlled from the nearby highway. Marias only choices are the many liquor stores, fast food places or convenient stores. The schools in bville are overcrowded and under supported and even if maria can get her kids into better schools far away, she need to figure out how to get them there without access to a car. So maria, having to juggle much to find Healthy Options, can be an overwhelming source of chronic stress, which is a Serious Health risk factor. For all the residents of bville chronic stress drives Health Problems like obesity, diabetes, asthma and heart disease. How did atown and bville get so different . In many cases in cities and towns across california, the root cause is racial economic discrimination. Over the generations, for white people and people of color were pushed to less desirable parts of town where banks refuse to lend money, and businesses left and jobs, too, and the neighborhood crumbled. Everyone who could move away did. Whats more, when communities like atown and bville, bville is not the only one that suffers because it turns out that not only is your zip code a predictor of how long you will live, so is what country you live in. Countries with the greatest income inequality have the lowest Life Expectancy. So, even americans like deb who are white, insured and college dieated and upper income younger than their perrers in other countries. Our Life Expectancy is 43rd in the world, and that number is slipping. Our Biggest Health risk may actually be inequality and extreme inequality hurts us all. So, what do we do . Well, if were all going to be healthier, you do not just need to help the person in bville beat the odds, we need to change the odds for everyone. And thats what were doing. There is a movement happening. Were californians. We dont follow, we lead. We are building the power to make health happen in communities across the state. Were coming together to build one california, a smarter, more inclusive and equitable state that creates health and opportunities for all of us. Join us. To learn more, visit building Healthy Communities. Org. [applause] vanessa thank you so much for bringing this video to us. A really wonderful way of illustrating a foundational Public Health concept. Hardeople outside, h ave a time understanding. We are both in the space of Public Health innovation, you are pursuing a through policy and myself through technology and financing but i want to hear more from you. How did you get started with this research and started telling the story . As we move along this evening, you guys will be able to see how technology is playing a role in the discovery and moving this forward, as well. Its actuallyh, interesting because it is kind of a technological story. Im going to tell a quick version of it, but i went to medical schools at Johns Hopkins. Johns Hopkins Medical School is located in east baltimore, which probably one of the worst slums in america and it was a real shock to me because i had grown up in canada and kind of canada had a deep level of investment in its people, universal health care, universal childcare, paid sick leave, vacations, heavy investments in public art and infrastructure. East baltimoreto and i saw the conditions, i was really quite shocked. It triggered this sort of thinking in my head that in the livedoes where you ultimately shape your help more than any of your genetic factors . So, i kind of got interested, when i graduated medical school, then i went through a whole bunch of studies in policy, i got interested in how do you illustrate these differences between neighborhoods and the and packs, the ultimate, to militant impacts on Peoples Health . Using technology. At the time, this was in the early 1990s. Geographic Information Systems were coming online. I kind of got h ooked on gis. If we can bring up the slides. I want to show a couple of slides of how we approach this work. Do i do that . There we go. You probably do not recognize this but you will all have one of these at one point in your life. This is a death certificate. When youre the county health officer, you are the registrar of all births and deaths. In Alameda County, there are about 10,000 deaths a year. So, i got really excited with the technological possibilities using these death certificates to start painting a picture of the distribution of death across Alameda County. And so, each death certificate, needs my signature on a before my body the body can be buried. So it is a real opportunity to get good data. You can refuse to sign a death certificate in till the certificate is completely filled out and you have all the data you need. The data thats most critical for doing this is the age at which somebody died, their race ethnicity, what they died off and where they live. All of that information is on the death certificate. You can take a death certificate and plot a map. This is Alameda County, shaped like a boot, and each of those boundaries are senses census tracks. You can calculate the average age which so we can expect to live. And, when you do that, green areas are neighborhoods and Alameda County where people can expect to live greater than eight or years 80 years. The red areas are areas where people can expect to live 74 years and the yellow as between 74 and 80 years. There are clusters of red areas, neighborhoods and Alameda County were people die earlier than others. His ia phenomenon is a phenomenon, you contract is over decades these neighborhoods have been essentially concentrated neighborhoods of premature deaths for decades. Was veryhis interesting. This ended up on the front page of the San Francisco chronicle. And people would say to me after this happened, it caused a stir. They would say what is the story with Alameda County . Why is it so in a little . My answer is, it is not just Alameda County. You have to start looking around the country for other places where we can replicate this gi s analysis, and it was something that was not done at the time to look at relatively small geographic areas and calculating Life Expectancy per neighborhood and comparing those neighborhoods to other neighborhoods in the same city or the same county. So, we took our map of alameda tonty, and i had to go back baltimore where ive have gone to medical school and i had, this triggered my whole interest in this issue. In baltimore, there are neighborhoods were people on average live into the late 50s. And so, there were dramatic disparities across the city of baltimore. We went to cuyahoga county, cleveland, that showed neighborhoods with 25 years of Life Expectancy difference between neighborhoods that were within a mile and a half of each other. New york city, dramatic disparity. Seattle, los angeles, minneapolis, boston, philadelphia, san antonio, everywhere we looked, we havent found a city in the United States yet that does not have a significant Life Expectancy difference from neighborhood to neighborhood. This is the american pattern. And, before you really had the technological ability to sort of bore down into neighborhoods and use large data sets to sort of discern these patterns, we didnt really understand this. We now understand this that you can have two contiguous neighborhoods with a Life Expectancy difference of 15 years. Fixed difference, not something that fluctuates. And trying to understand that is what ive bspent my career basically doing. So, thats how i got into this. Thats yes, and certainly the problem at hand and i see this in my work as well. We are a fund focused on preventing on prevention and Health Care Disparity and trying to find technology that addresses those. The question of disparity is one that is universal and persistent. Were going to get into maybe how we can address that today. So, moving more into the policy perspective, we know that zip codes and Health Relationship is here. The aca is on everyones mind, is it or isnt it going to be gone at any point in time . From your perspective, how has decouple thed to relationship between zip codes and health and how could repeal effect that relationship . Dr. Iton this is a little complex. It is not really that complex but you might think it is complex the way i explained it. Health care is important for you because, obviously, when you get sick you need access to health care. Health care helps you avoid adverse consequences from being sick. But that is not the most important reason that the aca improves health. To of the things we try explore in these neighborhoods where you have chronically low Life Expectancy, try to understand whether the drivers, what is happening to people in these communities . Come away with most obviously is that people in those communities, most low income communities, are facing indexable stress. Inexorable stress. Tory system they are trying engage is failing them transportation, housing, employment, criminal justice. Even water in some instances. So, people are navigating an environment where they are constantly facing stress, and stress is basically a balance between resources and risk. And in those communities, they are facing an enormous crisp, with limited resources. They are constantly on the balance, and it creates the fancy word, a la static load. But it is really karmic stress. It changes your genetic expression and over time, it actually, it mimics premature aging in these populations. So, the issue of the aca is that the reason the aca is particularly beneficial for your health and all of the western democracies around the world that have universal health care his, is recognizes t that it reduces stress. It allows you not to have to worry about what will happen if you get sick or your children get sick, or you get hit by a bus or what have you. So advanced reducing the d health profoun impacts. That is the fundamental approach we take in our work. Vanessa wonderful. Thats something that we have been keeping close track of, too. Announce they are starting to scale that bundled payments, value based care they got wrought in a lot more with the aca and paying for outcomes. Starting to introduce questions about whether or not itll still be around. Getting more into the work, how are your local partners using technology to improve health for the communities that you work with . Dr. Iton yeah, so, i love technology. To workt, it;s fun with and health care in we have now wes data sets have never seen before, we have the ability to manipulate massive tones of information and get at small questions. The thing that has most important about technology, potential lies, because of this recognition that health and not just talking about low income people were people of color, we are talking about all americans all of us in this room are experiencing load. It varies in terms of its resources risk v. Resources. A lot of the resources side societal created risks, manmade risks. The way other societies attend to them is really through policy. Universal health care is one obvious example but also subsidized education and housing policies that reduces the risk that people have to face. So, this notion that people are experiencing this heavy risk, this burden of risk in their lives is the fundamental issue we are trying to address in tackling these problems. How does Technology Work for that . We recognize that when people can participate cynically in civicially in their environments, people who feel they lack control, a lack of control is very bad for your health. And i can go into the physiology of that. But the bottom line is, feeling that you loss control or agency is bad for your health. So, if you want to help people develop agency or a sense of control, one of the ways you do that is to organize them, bring them together was similarly situated people to have them start tackling things that are presenting essentially risks in their lives. Now, one of those things is government, unfortunately, or the lack of policies where people are looking for policies to benefit them or their families. So, technology that allows people to participate cynically to expressy, to vote their opinions locally, whether it be city council, school board, for the services they are getting, to rate those services and this accountability to some service providers, that is health protective. So, part of our strategy is to essentially facilitate voice in communities, so people have more control over the resources that serveesigned to their needs. And they also have the ability to hold systems accountable for more equitable use of resources. Vanessa great. I know for a lot of you are technologists, hearing us talk about health care is kind of a hard thing to wrap your mind around that health care is not the same thing as health. When we look at media, those two things often get conflated but they are in fact two completely Different Things. A lot of what dr. Itons work and my work thinking about the fund and the start up we are interestedn, we are in alleviating those sources of stress . Where can technology transportation, address other sources of stress and the social determinants of health that are driving a lot of stress and problems. So, you know, getting more, your a physician but a researcher at heart. Where can technology play a role in helping doctors and other resources be able to advance this practice and really accelerate potential interventions or things canthatn help address this problem . Challenges. E of the im interest and the paradigm of medical care are these 15 minute interventions in a cubicle where the doctor disgorge his this information and the supplicant patient sort of takes that in and applies it in their daily lives. Thats a failed paradigm. Sort ofnotion that experts hold the answers i think is flawed. Many of the communities in which we are working are trying to redesign their Health Care Systems. Trying to think of health care more from their perspective of how do we bring people together in a way where they can help each other, as opposed and many of the challenges, the 21st century challenges are challenges of chronic disease, not challenges of Infectious Disease or acute problems as much as they were in the 19th century. Our Health Care System design, where you go into an expert in expert gives you a drug and that drug solves your problem. Century problems are hard disease, cancer, stroke, disease,espiratory chronic diseases related to the environments and the lifestyles in which people are living. And those lifestyles are shaped oftentimes by policies or, in some cases, it is the absence of policy in the face of abject need. So, bringing people together to essentially create the political will to solve problems is a health intervention. And the Health Care System can participate in that, and many sort of Health Systems on the vanguard are doing exactly that. Vanessa yeah, so what are some of the successes you have seen with calling on more political will in bringing people together . Dr. Iton the simplest thing to think about is were in Silicon Valley right now, a no, housing is a big issue, right . Housing is an enormous stressor. I dont about people in this room before my kids friends, that you know, are either in school here or other school looking for places to live, theyre struggling dramatically to find those kind of solutions, and some of thems are working in Health Care Institutions and an academic centers. And those institutions have a policy helping create that facilitates the ability of andle who want to live work your being able to do so in an affordable way. And what is new about them participating in that policy effort is that we now know that the absence of meaningful way actuallyhis creates Adverse Health outcomes in the lives that people that live in these communities. Thee know more now, and question is how do we use that information to apply it. Are Health Institutions around the country that are in gauged housing policy, engage in education policy, not just because they feel like they can, but because they feel like that is actually critical to the Health Improvement of both their workforce and the patients. And definite have seen a growth of this, a Major Health System was just saying if only there was a start up that addressed this issue up they know when to discharge patients and they have housing unstable patients and they might be patients that are homeless and living in a situation, its violent or dirty or something transient, staying with family, it is not permanent that because their patients are housing unstable they will not follow the orders necessary in terms of medication. As a Health System they wanted to start up that was going to be people who had housing benefits with inventory on the market that took those particular benefits. When you look at Silicon Valley and the startups, thats not a problem that pops up on peoples radar because there are a lot of preneursger entre that do not have enough experience to understand how to tackle that problem. Theres plenty of opportunity for lack of a better word, to canlly look at how we leverage institutions to really address some of these sources of stress. You know, that said, we are talking at the institutional level but is there anything from a consumer generated data action that can be driven through technology to do the same thing, to get a bottom up solution to . Dr. Iton i am not an expert in that. Ill disclose that. Been an there has effort more recently and let me explain maybe for folks who do not know what the social determinants of health are but things like housing, transportation, employment, you know, access to healthy food that are essentially the drivers of Health Conditions iat a population level. And those social determinants are fundamentally now being recognized as critical even down to the individual level. And so, Health Care Institutions now are starting to collect information about peoples socials conditions social conditions in the kind of resources they are able to access. Cutting edge work happening at Johns Hopkins and harvard and other places with groups, one of them is called health leads, which is a technologicallybased organization that is focused on essentially taking that information, incorporating into the medical record, and matching patients with resources in the community that they need to be able to address their housing issues or their issues around access to healthy food. The next step beyond that is to start to aggregate sum of the data and use it in the policy space to push for policies that will essentially their access at a Community Level to these kinds of resources. A recognition that we have exhausted the medical model in terms of trying to push essentially that model into improving health of populations. From the traditional medical technology. There are probably some breakthroughs that will come along that will help at the margins, but for the most part if we want to improve the health of our populations, we are not going to be able to do it in the Doctors Office. Wer going to have to doe it in the community, changing the way people interact with their environments and facilitating essentially stressreducing lifestyle for People Living in communities, particularly in low income communities. Vanessa yes, of course. For those of you who are not familiar, part of the reason we are trying to tease apart health and health care is because when you look at the statistics in terms of what actually contributes to our Life Expectancy, of course, is the Public Health interventions like behavior, social and environmental factors up to the point of the last 30 years and the increase of Life Expectancy, 25 of those years are at your people to Public Health interventions, not to access to medical care. But when you look at the what we spend in terms of health care in this country, in this country, only 3 of that goes to Public Health intervention. Is that we areitonso it really getting what we pay for because we are not paying for things that actually work. ,t is a lot of the reason why of course, looking at policies, the things that live in the shadows of policies are about financing and talking about money. What kind of policy changes are necessary to support innovation that will address social inequalities . Dr. Iton i showed you the maps of places where people arent living as long. A death tax for living in a neighborhood that is ereft of the resources needed to pursue healthy lives. These two researchers at harvard and yale that they were looking at a traditional analysis that the United States on a per capita basis spends more on health care than anyone in the world. We spend twice of the oecd average. Economicallyer secure countries. Why are we spending as much so much and other countries that are similar are spending less and their health is better than ours . Not only do we spend more, we actually get worse outcomes for what we spend another countries, so they were looking at this data as well. And they decided to do Something Different. They wanted to look at per Capita Health spending, but add per capita social services spending. When that they did that, typically the u. S. Is out at the end, the big spender, and everyone is at the other side. When they added social benefit spending, the u. S. Was in the middle of the pack. Bigere no longer the spender when you add health care and social spending, we are not the big spender. What they pointed out, and this was an oped in the New York Times and eventually became a book, what they pointed out was we had the accident on the wrong syllable. We spent more money on health care and got worst results, and those country thats been social two times on services and social benefits compared to what they spend on health have that her health outcomes. Health have better outcomes. You should be spending more on social benefits than on health care if you want to improve health. This is the American Health care paradox. Role of technology and that this, they can do this analysis and show it so easily. It is relatively wellknown. The role of technology is how do you get the help benefit of that social services and spending . That is what they are trying to do now, which is take the clinical encounter, where we have invested all this money and effort and start trying to pou r in social benefits and social population that is consuming a lot of healthcare services, because ultimately what is driving the consumption of services is the lack of social supports and social spending. How do we bring that into the health care setting, to drive down the medical care costs and actually improve the health of the people who are essentially showing up in the emergency room or social services . Vanessa and it is definitely going to be a long, long effort. Inre was a piece written Health Affairs written by jeff levy. As another person who was in the department of health and Human Services and was the former head of health i. T. This article talks about Public Health 3. 0. Investing inart the infrastructure necessary to achieve these same goals . How can we take what they are doing and have that be relative to the rest of the country . A lot of what they were talking about was this same thing. It is not as much that there is not enough money, but there needs to be a reallocation of funding. The second piece they were talking about was this upcoming partnership. How can you leverage the knowhow and ingenuity in technology and apply it to the huge, gnarly publicsector problem. If you guys have not read it, i would recommend it. It is a good way to see how technology plays into this. Getting into this from your perspective, what role do the scientists have to address this issue and help scale your work . Dr. Iton i think the wonderful thing about what we are discovering in looking at Population Health and the things that improve, the health of a whole community, is it is not rocket science. It is the kind of thing your grandmother taught you. The challenge is taking technocracy and applying it to democracy. Optimize democracy and our communities, because ultimately that has the effect of giving people agency, some control, and a sense that they have some sort of way of shaping their own destiny. When you see communities that are suffering from poor health, they feel they have very little control. How can Technology Help optimize democracy . I think those are the big challenges for us. We have seen clearly, and i dont want to get political, but we have seen clearly that our democracy is kind of broken. And the challenge with that is it is not just bad in terms of people want to manifest their particular policies and express their ideas. That is a problem, but it has helped the publications. It has pretty profound Health Implications. If we care about optimizing the Health Status of our communities, we have to optimize how our democracy works. To the extent that technology can help and i am not a Silicon Valley technologist like you and your friends. But Something Like voting. The last set of elections, we had 28 of registered people voting. How can Technology Help that . How can we get more people to vote . How can we make voting easier so people can participate more in nationaljust elections, but local elections and conversations on how to use resources . All of these are very technologically possible. Can you vote from your smartphone . Can you create technology that allows people to express their opinions and views easily so we can get a broader range of percent addition of participation. Vanessa a lot of what we see from startups is they are trying to address the things you are talking about. How do you connect people to nonclinical resources, so getting out of the Doctors Office . But some of them are trying to address the Health Issues as unmentionables. How can we use technology to address addiction or Mental Illness or loneliness . That is a social problem that has profound Health Impacts on not just the elderly, but a lot People Living in rural and urban areas. I think a lot of what my cofounder and i talk about when we talk about the intersection of Public Health and tech is, yes, Public Health is underfunded and tech hasnt paid attention to a lot of these issues, but that allows us to solve problems. For those of you looking for start up ideas and are curious about it, i would encourage you to take a look at dr. Itons work, but there is a lot of research that gets published that is highly effective that can be delivered Via Technologies that address these problems with these populations, like low income, like homeless. A lot of what we see when we connect with different universities is they say, we have done this research and proven this thing and it got published in a journal, but we dont act in the commercial space. We dont know what to do to get this out of the ivory tower and have it show up in real life. To the extent we can start looking outside our doors, full technologist in the valley, academics, yourself in the community, coming together, that will represent a great opportunity to move things forward. What is one thing the audience can do today to support your work in the work of making communities more equitable . Dr. Iton yeah. [laughter] dr. Iton hi. [laughter] let me explain our work a little bit. And questions and answers, if you want more specifics. My job is a very strange job. I was hired under the following conditions. My boss, who is a pediatrician, i like the work you are doing in Alameda County. And we have this plan. And our goalllion, is to improve the Health Status of californians in a measurable way over one decade. And i would like you to come in and design how we do that. I said yes, he said there is one copy at. One caveat. You cannot spend one nickel on health care. Find a way to measurably improve the Health Status of californians over a 10 year. By focusing on low income areas with no money being spent on health care. And i said, i will take it. And the reason that was really exciting for me is because of the years over the years of having practiced medicine and working in health policy, i that is this notion fundamentally detracting from Peoples Health across race, class, geography is the sense of feeling connected. The sense of feeling they belong in a society where people Work Together, where people were working on something that was bigger than just their self interests. Bringing people together to Work Together on issues that are challenging, not just to individuals, but the whole community. Not only is that good for creating policy, but it also improves the individuals health. The people working on that work feel better. You get a double bang for your buck. The question is, what can this audience do to help advance that . First of all, you are amongst the people that we perceive as our obligation is to help the Health Status of everyone in california. Part of the way we do that is we believe it is critical to rebuild californias social compact. I am talking about that policy and strategy that our investments in the wellbeing of the entire population across the age spectrum, the race spectrum. Things Like Universal Health care. Things like subsidized postsecondary education. Things like paid sick leave, paid vacations for people who are employed. Andstments in Public Art Community facilities. Those are health protective investments. The challenges that most of us see health as health care. Careur argument is health is necessary, but not sufficient. It is worefully insufficient. Communitieslarger in improving health is essentially rebuilding our social compact in california, and that starts locally. That starts with local schools, parks, transportation systems, it starts with infrastructure, water in some of our communities. We want to change the narrative about what health is in california. We think that is already happening. And we can only do that when folks like you are engaged in this conversation to essentially change how we think about how and move it away from just of care and individual behaviors from Just Health Care and individual behaviors. Invest 10 per person per year in communitybased interventions, that yields savings of about 16 billion. This is a case of investing in that social impact, not just paved in outcomes, but dollars as well. I think we are getting close to questions, so just to close this out, what is one tweetable call to action you want to share with our livestreamers and social media as well . Dr. Iton good god. [laughter] vanessa it helps. Dr. Iton my fallback tweet your code matters more than your genetic code. That should not be the case. Matters moreode than your genetic code. That should not be the case. The reason those things march together is we have allowed it. Or ine created policies many cases we have ignored the need for policy and the face of abject need that has created conditions for people that are essentially stress incubators. We have stress incubators of all throughout the United States. Anymore. Ystery it is not a mystery anymore. Mostake some of the prestigious Health Institutions across the country, Johns Hopkins, cleveland clinic, and you look at where they are located, and you see the communities in which they are located are the most unHealthy Communities in the United States. We have to understand why that is. We cannot turn a blind eye to that. Health care is important, but it is woefully insufficient to address the fundamental Health Status of americans. Vanessa definitely, and we are seeing that all the time and they are starting to say, we realize we are not actually doing enough in terms of whether it is addressing the needs of their Immediate Community or broadly serving their mandate. Looking atis about the key to saving lives and money requires looking at stream. How do you Leverage Technology to determine health and invest in technologies that in sure everyone has a fair shot at living an entire lifetime . Dr. Iton i should say, this is not tweetable, but many of you have heard this phenomenon of white workingclass mortality. It is referred to as the opioid epidemic. It is a dramatic be a genealogical phenomenon epidemiological phenomenon. This is about the same number of deaths as the entire u. S. Hivaids epidemic. This is over the last 20 years. It is driven primarily by three things. Drug overdose, suicide, and alcoholrelated morbidity and mortality. Selfinflicted injuries is driving one of the largest epidemics we have seen in modern Public Health in north america. I put it to you that what is driving that epidemic is exactly the same thing that is driving the epidemic of premature deaths in all those maps i showed you in places like east palo alto, east oakland, east baltimore. It is fundamentally people losing hope and losing a sense of control over the things that are impacting their lives. That is being driven by a lack of a social compact, a lack of solidarity across this country, which has led to the absence of universal policies. That is why we dont have universal health care, because we see people as my tribe needs to benefit and we can only benefit if that tribe loses. That is an american phenomenon that is literally killing us. In california, we have the ability and we have a narrative in this state to approach this issue collectively, to recognize we all do betty we all do better when everyone does better. We are moving that narrative to rebuild our social compact, which will take the burden off the healthcare care system and improve the health of all californians. That is our charge, and it is no small charge. The gentleman in the white house is not helping us in that regard. We are going to do Something Different in california and show the rest of the country how it gets done. [applause] vanessa all rights, we have a huge stack of questions, so i will try to get through as many as possible. This one has two. Can you share a good example of municipalities that have changed and achieved these outcomes . Do Health Insurance Companies Understand and what are they doing about it . Dr. Iton there are some great examples. Richmond, california is one of them. Richmond, you probably know enough about it, it has got chevron in it. It was a ship Building Community for many years, and it experienced enormous white flight, and is now rebuilding a 21stcentury model. One thing that richmond has done that the rest of the state has followed if they looked at their general plan. The general plan is the bible for how development happens in the community. Richmond introduced the first held a moment in a general the first Health Element in a general plan. It requires them to look at the Health Consequences of that development. It means, we know now that sprawl creates obesity. Sprawl kills. It is essentially a design that makes it harder for people to walk or use bikes. And separating land uses by great distances, so people have to get in their carts to go to the store or the schools. Land use which is the dominant pattern for modern california has Adverse Health consequences. In richmond and 40 or so other cities around the state, there are now Health Elements and the general plan that dont allow you to make those design decisions without understanding the Health Implications of those designs. That is one example. There are multiple examples around the state of cities that are recognizing that help is an asset that they want to invest in. They recognize that they can encourage people to come to their communities if they of theirhe health communities, both in design and the general be general ethos of health. What was the second question . Vanessa Health Insurance companies and what do they understand about it . Dr. Iton i was part of a group that has a number of Health Insurers on it. They get this. And healthenges care institutions get this, too. Whatesearch that suggests actually shapes Population Health is health care is about 10 of what shapes health. And 90 ofetween 70 what shapes health has nothing to do with a Doctors Office and pills. They recognize this, they see this in their Large Population data sets, and they are working in a reimbursement paradigm which has incentives to only work shortterm. That, wet to change have to create a new set of incentives, which includes policy change. They will not do it on their own, they are motivated by their bottom line. That incentivizes shortterm decisionmaking, not longterm inking about making investments. Primarily social services and investments in their populations to reduce the demand on the americans. Vanessa you do see some Insurance Companies being more progressive. Dr. Iton kaiser is a great example. Integrated are they provide the health care and insure you because they are incentivized. They reduced opioid prescriptions by 40 . , a majornsurer system and utah which is pretty progressive a major system in utah which is pretty asgressive, has made changes well. These institutions get it, but something brought up earlier is in terms of the aca, a lot of people focus on the health care exchanges, but what a lot of people dont realize in terms of policy is one of the biggest changes is helping to drive toward valuebased care. Peoples of health care, make money off of doing more, regardless of what happens to you as a patient, if you get better or worse or pass away, it does not matter. They get paid by performing things on you. What they are trying to do now is focus on, we are going to pay you on performance. Does this person get better . Do they return to the hospital shortly after, signaling you did something wrong . Starting to align money with behavior, that is what our Health Care System is trying to move toward. But we are in this transition period. We have this issue that most stakeholders are making their money from the old system while they are trying to plan for the future, so it is a little gray and gnarly, and the same with the guy in the white house. They seem to be taking steps to roll back what seemed to be an innovative step to getting our Health Care System to where it needs to be. It is a wait and see period. Next question, in terms of your analyses, have these been done in other countries . Dr. Iton the answer is yes. The much longer version of this social shows the gradient, which shows how Life Expectancy decreases over geographic space. The u. S. Has a relatively steep meaning whennt, you move relatively short distances, your Life Expectancy gets shorter quick. Most countries have a social gradient. Thant is much shallower the United States. There are consequences to living ina low Income Community other countries outside the United States, but those consequences are mitigated by a social concept a social compact. Create a basket of opportunities and benefits for them. Related hows much does capitalism drive Health Care Outcomes and expenditures . Dr. Iton i get this question a lot and i try to remind people i grew up in canada. A capitalist country, sweden, norway, denmark are capitalist. France. The difference is they have democracy that essentially is more important than their capitalism. Their economics system. In this country, we seem to thek, and interestingly, word capitalism does not a cure does not occur anywhere in the constitution. But we act as if it does, as if somehow this holy notion that trumps democracy. And that is why we have corporations are people, they can make unlimited finance contributions. There is no other country in the world that has this bizarre construction of capitalism. Profound and it has consequences. The goal is to enhance and optimize the marker put checks capitalism. That the countries with some of the best help in the world our capitalistic countries. Vanessa even if you are looking this from a purely marketbased standard, the fact that we are sicker as a population is that for capitalism. If you are sick, it is hard for you to work. If you dont work, it is hard for you to consume things. That would seem to undermine capitalism. Even if you are a strict economist, this is something you should want to support as well. This question is about agency. Having more agency doesnt lead to greater control, so how much benefit are you getting from addressing agency alone as opposed to other factors or interventions . Dr. Iton i am not sure i understand the premise of the question and im a challenge it a bit, but i use agency and control synonymously. Andme give a quick example, there may be doctors in the room who understand this. When you are a position, there are two types of patients. Basically two types of patients. Patient, the v. A. Patient. They come to see you and are slumped in the chair. They have diabetes, they have chronic obstructive pulmonary disease or emphysema, they have high Blood Pressure and are on a list of medications, and they do not make eye contact with you, and they say, yes, whatever you say. You are listening to that end know there is no way to that and know there is no way this person will follow instructions. Find a senseg to of control. They will participate in this encounter as a partner. The other end of the spectrum is a patient who comes in with a stack of things a printed off the internet. [laughter] dr. Iton i think i have this, tell me why i dont need this. Ok, can we focus on three problems today and the other 27 . [applause] patients havee agency, they are in a partnership with you. They are looking to you as a guide, not someone who will disgorge information into their waiting beeks. That partnership is so much better for help than a passive kind of partnership. Agency is a sense that you have some kind of control over what happens to you, so you approach the world differently. What we have found in our work is we have communities that feel like that patient. Whatever you say, doc. Whatever you say, mayor. They are passive, they have given up, they have lost hope, and that is very bad for the health of the community. The goal is to build agency. Winstart small, small. People see themselves making change. You bring them together with similarly situated people and they see they have some control. That changes their physiology. It makes them more hopeful, and that hope is health. I use agency the question about absolute control, none of us has absolute control. It is all relative. We are talking about trying to build a relative sense of agency, so people have more control over what happens to them, not absolute control. If i did not get that question right, asked afterwards. But ie quite agency i equate agency and a sense of control. Vanessa do you think an integration of nhs and hud can help with control . Dr. Iton i love that question and i will answer that question affirmatively. Yes, i think so. One of the most interesting meetings i attended was with the british chancellor of the treasury, which is the secretary in britain. They have an accountability role in the british government, and they recognize that their Public Health system and their Public Education system were the same thing. And so they merged those two systems. Publicid that if our Education System is not promoting Public Health, there is something very wrong. Systemsd the two together, gave them the same outcomes, and started to see improvements in health and education. I think it is similar that when you finalize or fragment governments and give them parallel goals, they tend not to work synergistically. Ealth and housing together is absolutely critical, and to the extent it requires breaking the silos, i think back to potentially have some benefits. Vanessa great. You are going up against big medical institutions. Will they align with social spending . A good spending allocation question. Iton i gave a talk at give a talk at Johns Hopkins every year, stanford, harvard ata. T the same basic d people get it. There is no question they get it. They are being driven by a set of incentives. To the extent that the will they is asking, ignore their primary incentives to essentially invest in the things you are talking about . The answer is no, they will not. Because they are rational and get rewarded for Different Things than i am encouraging them to pursue. Until they see aligning with this work, nothing will change. You have very good leaders who recognize that the future requires them to make these investments, so they are placing some bets now, but the overall Reimbursement Structure is incentivizing them to do what vanessa was describing, this shortterm kind of, the more you procedurize someone, the more you get reimbursed. The more you do, the more you get. They are business people, trying to stay in business, trying to compete. They will optimize their current scheme as long as they can. Vanessa exactly, and that is one of the reasons we are excited there are opportunities coming with the shift of valuebased care that creates opportunities for more businesses, because there are incentives. Needs, butot nwew new incentives to address these needs. Once again, like money drives everything. I think with one of the things is starting to better understand how does Health Care Get paid and starting to understand that and seeing how that works, because it is very complicated. This is very complex. Where do we sign up to support your work by becoming a collaborative member of the movement, and will this help with singlepayer in california . Dr. Iton i am speaking for myself, not california. I am a big supporter of singlepayer. I hate the term singlepayer. Call it medicaid for all. Agrew up in canada with singlepayer system that works beautifully. If you ask canadians what is the thing you love most about being canadian, they will talk about the medicare system. Many countries around the world will say similar things. There is no american that will say it is the u. S. Healthcare system they love most about being an american. [laughter] dr. Iton singlepayer makes sense, it minimizes costs, and it maximizes what we want, which is care. You can have a private system of care, private doctors, private hospitals. The insurance system is a public system. It is not interested in competing, it is not making profits. It is maximizing tear. The thing you want is care, and i think care is best delivered in a privatized system. I think that the system needs to continue to be incentivized to innovate, and that happens better in a private kind of setting. As far as insurance goes, there is literally no other country in the world that has decided that profit taking and Health Care Delivery is the most important thing. We are very unique in that way. So, singlepayer is a great system. I forgot the beginning of the question. Vanessa where do we sign up to support your work . Dr. Iton yes, so go to our and there are multiple opportunities for people to sign up for various campaigns. Run a series of Health Campaigns across the state that include campaigns related to criminal justice run and its heh and locations, to immigration and health applications, the massive incarceration system and its Health Implications, the School Discipline system and its Adverse Health implications, particularly for boys and men of color. We are running campaigns statewide on these issues. You can participate in those campaigns, if you are social clicksavvy you can support or whatever and move from there in terms of actually participating in rallies, writing letters, writing opeds. This might be for both of us. How do you get businesses to invest in these communities to provide diverse food options and still profit . Dr. Iton ok. One of the things we did, and i am a doctor. We doctors know a little bit about medicine, we know pretty much nothing about anything else. And when i came to work at the alifornia endowment, this is funny story, we were sitting around eating lunch and talking about all of these food deserts. Those are communities where there really isnt access to healthy food. You have got liquor stores, tons of fast food, but you cannot find a grocery store, farmers market, other things. How do we get people to eat healthy if they cannot find healthy food . We are talking about this as and doctors, wonks and there were a group of investors who work for us. We have people who actually manage our 3. 5 billion. They said, why dont you start a fund . And we were like, shut up investors. And they were like, no, seriously, start a fund. And they were right. We started the fund. Our goal was to raise about 200 million to help build Grocery Stores in low income food deserts. To matchother people that, to participate, and by 18 months, we had 300 million. The California Fresh Works Fund builds Grocery Stores in food deserts. We have built 25 of them across the state. I did not know you could do this. I have learned the lesson in this which is that money loves money. [applause] [laughter] dr. Iton the second aspect i learned is that no one wants to be the first one in, Everyone Wants to be the second one in. If you put your money at risk, which is what we do. Ifwill take the first hit things go sideways on this, and we multiplied our money tenfold. It isund exists today, building Grocery Stores across the state. It is something that can be done if there is a bill and someone who is willing to take that initial risk. Vanessa i have to say, this thatpread misconception people who are living in low income communities do not buy things. That is ridiculous on its face and in terms of evidence. People need to buy close, use transportation, use technologies for leisure and work. Thatrms of this idea providing healthy food options on the surface what seems like not a good market doesnt make money doesnt make any sense. And we see in other startups that have popped up and got solely focusedre on helping people who live on food stamps manage their food stamps. Everything from how much money they still have on their accounts, it helps them connect to discounts in Grocery Stores so Grocery Stores can see where their consumer buying patterns are. Folkssly, it is helping budget food better and have better access to healthy food. It is one of those Everybody Wins situation. I think it was a 70 million market if i am remembering correctly. That is just one example. There are other food related startups. Drive market is a b or c related company. They are an Online Grocery store in that they have a lot of Specialty Products at decent prices. But they take folks on the food stamp program. People living on food stamps can buy Products Online that are healthy if they are living in a food desert and want or need ridiculous products if they have health need particular products if they have health needs. People are willing and ready to take them on hand and pulled make money and address and both make money and address these issues of food and security. This is in cursive and i cannot read it. Do you support health care for all. I am a guessing that is the universal Health Care Bill . Use practitioners in the community . Dr. Iton the question about allied health professionals, insularitydr. Iton health prof, and other forms of practitioners, i am married to a nurse practitioner. I would trust her much more with my care than i would trust me. [laughter] at sann she works Francisco Health center. She deals with complex patients. Anhave just closed out initiative in california, a 90 Million Initiative where we made investments almost exclusively in Nurse Practitioners and physician assistants and other primary care providers to build a californias health workforce. I went to medical school and graduated in 1989. Which into a residency, was one of the first in the country at the time. There was talk that at some point, 70 percent of people leaving medical schools would go into primary care. I went to a school that actively discouraged primary care. It was a struggle to even find a residency that my dean would write me a letter to support. That was 1989. As of last year, less than 12 of medical School Graduates in california chose a primary care career. The incentive structure does not incentivize primary care, so we will not be able to build health withworkforce just doctors. We are going to have to use other forms of health care in order to meet the demand for an aging population in california and across the country. And quite frankly, i think the quality of Nurse Practitioners, physician assistants, and primary care are very good. They are welltrained, they have practical experience, and provide better care because their training is much more focused on holistic approaches to health care. As the daughter of a nursing professor, i would have to completely agree with that. For those of you who do not know, the physician shortage is and will continue to be a problem, but another one that doesnt get as much Media Attention is the nursing shortage. We dont have enough nurses. Again, we need to be able to extend the nurses and doctors we have in the workforce and allow them to operate and shift tasks to other professionals even better. This is a multipart question. You mentioned stress is a major factor about Health Care Outcomes. If you only have enough resources to address one component of stress, what should you address . At the community, state, or federal level . Dr. Iton hmm. Entirely i unless youre talking about policy interventions . Vanessa i think it is a resource question. You have limited resources to address the stress, at what level should those resources be allocated . Dr. Iton that is one of those sophies choice kind of questions. I used to say that i had a budget of 120 million. We were part of an agency of about half 1 million. I wouldnt give my budget to anyone who could increase the Graduation Rate to 85 . People would say, that is a generous offer, why would you do this . 85 if we had 85 Graduation Rate, i would not need my budget. There are social determinants that are more important. Education is the most important determinant of health by far. If we can educate young people, get them through high school into a post secondary credential, give them away to participate in a 21stcentury economy, our health would improve dramatically without any new innovations from technology or pharmaceuticals. And we know this. Justst dont. Do it we dont do it. Level, isdictional would invest at a state level. The state is constitutionally required to ensure high quality education for all of the residents of the state of california, and i would enforce that. I think that is absolutely critical and would have profound Health Impacts across the state. Those are all of our questions for this evening. Thank you, guys, for your listening, for your lovely questions, and we are here to answer them afterward as well. Dr. Iton thank you. [applause] [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] thoughts about the latest report on security and challenges in the region. After washington journal, we had to the Bipartisan Policy Center to discuss u. S. Turkey relations live at 10 00 a. M. Eastern. Then we take a look at private Sector Development and on cspann live beginning at 1 00 p. M. Eastern. We will have live coverage of two significant hearings, the Senate Banking Committee Considers drum eyewall as the next head of the federal reserve. Wednesday, the focus is on president trumps picked to replace tom price as health and Human Services secretary. Atre consider his nomination 9 30 a. M. Eastern on cspan3. Tuesday and wednesday on cspan and cspan3, online at www. Cspan. Org, or with the radio cap. Radio app. Cup isdocumentary underway and students across the country are at work sharing their experience with us on twitter. It is not too late to enter. Is january 18, 2018. We are asking students to choose a provision of the u. S. Constitution and create the video illustrating why it is important to you. It is open to all middle school and high school students, grades 612. 100,000 in cash prizes will be rewarded. A grand prize of 5,000 will go to the student with the best overall entry. For more information, go to our am. Org. , studentc next, a look at how character and other attributes or control significant to the presidency. With New York Times columnist david brooks and historian ronald white discuss the presidency, comparing past administrations to the trump white house. This is one hour 15 minutes. Ey also talked on the messaging strategy. [applause] so character and the presidency is quite a subject, isnt it