Against a round ball, sharp contrast to every other sport. Sure. But having the spirit means that is subject to change, and change is not always good, so is not the evolutionary spirit of football is gift and curse . Well, i think its a gift because theres always these controversies about the sport of football, and footballs able to reagent. If you play baseball a hundred years ago, if you were ty cob and you were to appear through time travel on a baseball field today, youd know how to play the game. The game has not changed. Its a stat tick game. Soccers the same way. If you try to change a rule in baseball, you know Something Like instant replay, the traditionalists scream bloody murder. You cant do that. I think so it. Baseball is different. Baseball is a tray traditional game. Football is not. You have the ball that they play with, and that came about because harvard was playing a canadian university, and mcgill wanted to use the rugby ball, harvard with the round ball, and harvard liked the rugby ball and forced anyone playing harvard to, hey, play with the rugby ball. Rules change in that way. You can tell a harvard man, but cant tell him much; right . They had to do it. When football started, the first intercollegiate game between princeton and rutgers, at rutgers, in new brunswick, new jersey in 1969, they kicked the ball into the goal like soccer. They kicked a round ball in the goal. Within a few years, players decided its more fun to kick the ball above the goal than beneath it. Thats where you get goalposts, the ball elongated over time, rule changes like the forward pass and the neutral zone. You know, we talked about the fact that the touchdown, you had to touch the ball down physically. They didnt have end zones, and theres innovations in equipment in rules, in the field of play, and thats changed. No different now. You know, the point i think i made in the speech is that if youre able to change the size of the ball, if youre able to add end zones and say, hey, kick the ball beneath the goalpost rather than above it, add a forward pass, that no game ever did, you dont pass forward in rugby, but you do it in football. They complained that this is grass basketball. There were purists screaming bloody murder at that time. If you are able to do that, if you are able to introduce a running game and pass the ball and negotiate kicking, but still call the game with football, e okay if ncaa officials kick out defensive players who put on hits on defenseless offensive players. Were okay with that. Those are minor tweaks to the bigger picture. What the question may be getting back, the nightmare scenario for football fans is one day we wake up and the players are not wearing pads. They are wearing flags. This is already happened. This happened in a school in new jersey, lawrenceville prep, where the head mistress decided football was too dangerous, and so they got rid of the old tackle Football League in the country, and they replaced it with a flag Football League. In massachusetts in newton, every year there was a powder puff Football Game thats a flag Football Game, its out of hand, but it is flag football, and the principal of the school decided to ban it because flag football was too dangerous. Its not going to stop with football. Its not going to stop with flag football, and if you like some other sport better, they may come after that one next. Let me just close with this. Football has not grown too rough. The message of the book, the war on physical is that society has grown too soft. Thank you so much for coming out tonight. I appreciate it. [applause] thank you, all. Closing notes, visit the following website, our sister group, accuracy in media, www. Aim. Org, and our website accuracy and academia, academia. Org. Mr. Flynns website, flynnfiles. Com. Theres a variety of cultural, political observations on there that are well worth reading, and, of course, check out the book. Again, this meeting was brought to you, as all our sites are, from a generous grant from the frank day fresco and nelly Fresco Foundation sponsoring the cop servetive University Series that we run every year. Thank you, all, for joining us. Have a good night, and stay in touch. [applause] [inaudible conversations] hi, everybody, and welcome. So welcome to the special event hosted by the institutions for social and politic study new health care center. Were here to have a conversation about bradley and lauren taylors book, the American Health care paradox. Theres no shortage of Government Health care in the news right now. You know, weve got democrats defding the act, and republicans attack it, and i think we would all argue they miss what very little might be the key point, which is that the Health Care Systems broken. We spend more, and we get less than virtually every other country, and that Neither Party are talking about what we would do about it. You know, i would argue that our ability as a country to reign in Health Care Spending is going to determine our physical future. This is the largest single factor that is driving our debt. Quite literally, Health Spending is bankrupting the country. If its not under control, theres not a lot of money to spend on anything else. This is the sort of underlying rationale for health. We firmly believe that evidence should be whats driving health care policy, and Public Policy in general. We got three goals for this term. The first is to link extraordinary resources at yale together and produce psychological lores from the medical School Together with economists, political scientists, cosh sociologists, and come together to produce interdisciplinary scholarships. The second is to get students involved. The students here, the future healthcare leaders, and talk about these issues, talk about whats happening, why we care about this, why its so challenging. The third is to connect what we do here at yale to the outside world. Theres no better example of this than the two of you and what youre doing. You know, bradley is a professor of Public Health here at the university, director of the Global Health leadership institute, the master of the beautiful college. I live in davenport, and, you know, she i think more than anybody else personifies these three aims. You know, extraordinary scholar who has done leading work looking at why theres variation in hospital performance, one of the most popular teachers at the university, which was Pretty Amazing thing in and of its own right, and a solar who is not only producing research, but translated it into practice, improving the way hospitalling are managed across the globe. Laurens a president ial scholar at the harvard divinity school, and they came up with the book, the American Healthcare par paradox. Theres a lot of explanations why spend more and get less. Economists say the reason why the Health Care System is expensive is because of technology, the fancy kits in the hospitals. Doctors say its because of malpractice. You two have a different explanation, something where you argued the causes of why the u. S. Health care system is expensive might be outside of the Health Care System. Its an extraordinary book. Were going to talk for hopefully 2030 minutes now and open up for discussion with the audience about the book, what it means to the u. S. Health care system, and what we should do. I guess well start with the first question. Why is the u. S. Health care system so expensive . Why is it that why do we spend more and get less . Thank you so much, zach, a wonderful introduction. Our thesis is that we are depending on a medical system that address social, behavioral, and environmental challenges that are really detouring us from being a healthy population. Look at the most common causes of illness, colon cancer, Heart Disease, adult onset diabetes, and 7090 of the cases are related to social and environmental, economic determinants. Exercise, sleep, nutrition, stress at work, our occupations, what our housing is like, and yet we expect a medical model of physicians, medical treatments, procedures, surgeries to fix this. We spend an enormous amount op the medical side and dont spend as much as other countries on services that really support the more fundamental determinants of health. That results in an expensive system that does not really confer the health we deserve. And why . Why have we evolved in this way . Why is scandinavia, as you talk about in the book, look so different . I think what we found is theres a strong historical press in the United States for letting the system grow organically. Health care in the u. S. , as it did in many places began as a cottage industry. Doctors were entrepreneurs, put a plaque outside the house saying, im open for business. We have continued down that path of an entrepreneurial free market Health Care System because we feel thats the american way to approach the system. Scaped knave ya really movedded, and much of europe moved in the beginning of the 20th century for a more kind of centralized and budgeted system where they decided that health care was not something in the market but socially good they wanted to ensure for people, and i think those are different approaches and tell us a lot about how we arrived where we have. So how do you articulate the paradox, you know, the title of the paradox, how do you frame it . I think its straightforward. It is were spending more and getting less. You usually expect when you buy more, you buy a cadillac, you spend more money on it, you get a better car, but you dont expect its paradoxical to anticipate youll spend 8,000 per capita in the United States whereas the next most expensive country would be twothirds of that. You would expect you should have Better Health outcomes, longer life, less infant mortality, less Heart Disease, less disability. We dont have any of those things, not really. Is the Research Community missing the point . Why dont we have an answer, you know, ten years ago . Why is it taking this long . Yeah, a good point, but this is a historical problem. What is amazing about the paradox is its not the paradox itself, but that we had it for decades, and other authors wrote about it, but why have we not addressed it . That, you have to step back as lauren began to step back and look back at what is the history of the way americans relate to their health care and their health, and who is benefiting from a very large medical system. It is the largest industry in the globe, 18 of the u. S. Economy. This is a system thats benefiting many, many people. It just may not be conferring the health we want, but it makes a lot of profit for our country, and its really set up that way. Do you think profit is the reason we have this paradox . I do think thats part of the reason. Ic thats undenial. I think, you know, the system growing in such an unplanned way is a big part of it also, and the lack of attention to kind of equity and making sure everyone is getting resources in a fairly evenly districted way. Things that respond to medical intervention so we have more People Living with new replacements in the United States than anywhere else in the lead and kidney dialysis. Its that we dont do well on these broad Population Health outcomes where Health Outcomes were we compared industrialized countries. So this gets at the heart of the issue. If you look at the differences in Health Care Spending costs, countries spend more and then you factor in social care. When you look the the collective pie we end up spending i think less than a lot of other countries. How do you define health care wax what is a Health Care System and how do we think about it, what should a Health Care System do . Shouldnt it just be for heart attacks . Should it be for population math and. I do think many people run hospitals and many physicians in the United States probably do see their job as fundamentally, i get medicine, medical care. I maybe operate and i have medical treatments but we also have to look at who is paying from the Health Care System. 50 of the revenues of the hospital typically and sometimes more than that is actually paid for by medicare and medicaid. Thats the public dollar and the question has to be then what is that public dollar dying eyeing . Should it be buying helper health or should it only be buying medicine and the two are really different. When we visited Different Countries there is a different conception of health and other countries. Where health is rob andrews did his medicine is one input but so are many other things. Its also clear in United States we have that integrated view. I think we have a much more separated view it as this is the medical care center and it has a whole different revenue screen and theres education and housing and nutrition completely separate. We dont always do that in this country. So health cares and the key input to health. I agree. What is an example . Whats an example. Talk a little bit more about that. I found that one of the most powerful examples in the book. Do you want me to read it . Sure. I didnt get a copy of the book. Its a passage that we have gotten a lot of feedback on its 100 true story so i will read it and its meant to illustrate as he suggested this kind of power social determinants of health and the way they can drive help their expense. Joe is a 28yearold man with type one diabetes living in the United States. He lost permanent housing and has been saying in a friends condemned boarded up house to avoid being seen near joe interest to the marshlands behind the house. Issues are full of holes but he cannot afford to replace them. Joes diet has similarly suffered from his lack of income. He sometimes go several days without fresh food which negatively affects his diabetes. Also after lifetime of poor insulin control he is starting to lose circulation. Last year to show head to toes removed on his right foot to save his life at a hospital with the cost of 7132. Still drop if he continues to cause decreased sensitivity and increased risk of trauma to his feet. The doctor alessa emphasized the importance of keeping his feet dry and taking proper medicine all of which joe is eager to do. Since that appointment joe has been diligent in taking his insulin but dry feet remain difficult to achieve. His doctor is raise the issue of having to more toaster madonnas photo a cost of 14,000 without immediate changes joe will need to have it below the knee amputation in the years ahead at a cost of over 17,000. He will also likely need a wheelchair. The estimated cost of his estimated expenses will easily top 30,000 paid by state medical assistance programs funded a taxpayers. Metasystem marked by the most advanced medical treatment in the world joe is dying a slow painful and expensive death. A decent pair of shoes costs 50. I think as he said this really illustrates how we place a word in on the medical system to respond to peoples illnesses and diseases but really have roots while outside the Health Care System. And until our medical system in our Health Care System kind of addressed the fact that these determinants lie outside of their scope and are willing to coordinator and collaborate with social services and other parts of Civic Society who can address joes challenges they are going to keep paying a lot of money to fix joe up and send him back out to an environment thats really unhealthy. To think about differently is their health but problem with our health care Health Care System or the welfare state . Another is that the Health Care System is great but we dont have adequate support structures around it. Is that the Health Care System or to Something Else that is missing . I dont think it has to be one of the other. Probably both need tweaking. Its not going to be a problem that is only at the feet of our Health Care System or problem thats only at the feet of the welfare system. Lets think a listed way about what of the services we can get to people. Sometimes subsidies for shoes for someone who is diabetic. Sometimes its going to have to be amputation. Its going to have to be medical treatment but to be able to Plan Services and also Tailors Services so that you are spending you are intervening in the most costeffecosteffe ctive way to the root causes of the disease is ultimately going to make her system better. You said the word we. Who is do we in this space placed . And its an enormous question and who is accountable for help in our society . We believe in individuals taking care of themselves and we are very much formed on the idea of individualism. Of course we have Government Programs and supported for people who cant take care of themselves as starter but its not a widely shared accountability and what we find particularly when we look across the globe is we are one of the only countries that is so individualistic about health not seeing any part of it as related to our social context and not seeing them as lauren s