Elizabeth Bradley, PhD Professor of Public Health Yale School of Public Health

1. 1
Elizabeth Bradley, PhD
Professor of Public Health
Yale School of Public Health
Elizabeth.Bradley@yale.edu
Follow @EHBYale
Getting to Better Health:
CONNECTing Care and Community
UNIVERSAL HEALTH CARE
Foundation of Connecticut
Spending More and Getting Less

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

3. 3
Acknowledgements
Robert Wood Johnson
Foundation
Blue Cross Blue Shield of
Massachusetts Foundation
Co-author Lauren Taylor
Presidential Scholar,
Harvard Divinity School

4. 0
2
4
6
8
10
12
14
16
18
20
Health Care Spending as a % of GDP, 2009

5. Knee Replacements
Kidney Transplants
MRIs
Some Very Real Benefits
5

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

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

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

9. 9
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
Total Investment in Health as a % GDP
Social Service Spending,
%GDP
Health Care Spending, %GDP
*Switzerland and Turkey are missing data for 2009

10. 0.00
0.50
1.00
1.50
2.00
2.50
Ratio of Social-to-Health Spending, 2009
*Switzerland and Turkey are missing data for 2009

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

12. Determinants
SOCIAL,
ENVIRONMENTAL,
and BEHAVIORAL
FACTORS
(60%)
GENETICS
(20%)
HEALTH CARE
(20%)
12
HEALTH CARE
SPENDING
(65%)
SOCIAL SERVICE
SPENDING
(35%)
Investment
Mismatch

13. Does it matter?
13

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

15. 15
What about inside the United States?

16. 0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
All Social
Services
Education Income
Support
Transportation Public Safety Environment Housing
16
Social Services Spending by Type of Service
(as % of GDP, 2009)

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

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

19. States with higher ratios of social-to-health
spending have statistically better health outcomes.
Lower mortality among those with lung cancer
Lower rates of asthma and obesity
Lower rates of limitation in daily activities per month
Lower rates of mentally unhealthy days per month
Lower post-neonatal mortality
2000-2009 data, adjusted for region, GDP, and socioeconomic factors
Bradley et al., under review 2015

20. What to do?
Spend more! 28% GDP  35% GDP?
Transfer $$ from health care to social services
20
Incentivize collaboration on health

21. Evidence Supports Integrative Models
Health Care Sector
Community Outreach
Mobile Clinics
Case Management,
Patient Navigators, Care
Coordination
Nutrition support
Housing First

22. Mobilizing collaboration for health
nationally
Mitigate financial incentives to medicalize health
Establish common metrics for health and social services
- % obese, % depressed…
- % on target to finish high school
- % employed
- % housed
Talk differently about health and health care
22

23. Health = Health Care

24. Thank you
Follow @EHBYale
@laurentaylorMPH
24

25. Extra slides for reference
25

26. Public Health Services Defined
Description: Provision of services for the conservation and
improvement of public health, other than hospital care, and
financial support of other governments’ health programs.
Included examples: Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC), protective inspection
services, health related inspections, community health care
programs, regulation of air and water quality, rabies and animal
control, ambulance and emergency medical services (unless
operated by local fire department), and hazardous waste
cleanup. Also includes medical appliances, supplies, or services
as part of public assistance programs as well as construction and
maintenance of nursing homes, homes for the elderly,
orphanages, and veterans' homes.
26

27. Social Services Spending Categories
Education (primary, secondary, and higher education)
Transportation
Environment
Public Safety
Housing
Corrections
Income Support, including:
– Social Security (Old-Age, Survivors, and Disability Insurance)
– Supplemental Security Income (SSI)
– Temporary Assistance for Needy Families (TANF)
– Supplemental Nutrition Assistance Program (SNAP)
Public Health Programming, including:
– Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
– Protective inspection services
– Health related inspections
– Community health care programs
– Regulation of air and water quality
– Rabies and animal control
– Hazardous waste cleanup

28. % State GDP
State Variation in Health Care Spending
(Medicaid and Medicare) (as % of GDP, 2009)
0
2
4
6
8
10
12
WV
MS
ME
VT
KY
AR
MI
RI
SC
NY
FL
PA
AL
OH
NM
MO
LA
TN
OK
AZ
MA
WI
IN
MT
NC
ID
NH
CT
IA
MN
IL
NJ
MD
KS
OR
CA
TX
SD
NE
GA
ND
WA
HI
DE
VA
NV
AK
CO
UT
WY
DC

29. Spending on Social Services
Education
Income Support, TANF, SSI, Social Security, SNAP
Transportation, Public Safety and Environment
Corrections and Housing
Other social services excluding health care
* And public health spending

30. % State GDP
State Variation in Social Services Spending
(as % of GDP, 2009)
0
5
10
15
20
25
30
WV
MS
ME
VT
KY
AR
MI
RI
SC
NY
FL
PA
AL
OH
NM
MO
LA
TN
OK
AZ
MA
WI
IN
MT
NC
ID
NH
CT
IA
MN
IL
NJ
MD
KS
OR
CA
TX
SD
NE
GA
ND
WA
HI
DE
VA
NV
AK
CO
UT
WY
DC

31. 31
Social Services-to-Medicaid & Medicare Spending Ratio, 2009
0
1
2
3
4
5
6
AK
WY
UT
HI
CO
NV
DC
WA
VA
OR
ND
MT
GA
CA
ID
DE
MN
KS
IA
NE
NJ
WI
MD
NM
SD
NH
IL
VT
MI
IN
OH
TX
AZ
SC
PA
AL
NC
RI
CT
OK
FL
MA
NY
AR
MO
TN
KY
LA
ME
WV
MS

32. C-TRAIN (Portland, OR)
32
• Academic medical center
• 570-bed facility
• 33% of patients are un- or
under-insured
• 501c3 serving Portland
• Serving individuals and
families facing
homelessness, poverty
and addiction
• Affordable housing is
primary service, plus
health care, recovery
services and employment
assistance
RCT has found C-TRAIN patients have
lower mortality and better quality of care;
hospital is funding expansion Englander, J Hosp Med, 2012

33. 33
Academic Medical Center
2,600 beds
Community Center with
childhood asthma rates
3 times national average
Bilingual Community Health Workers provide asthma education and
referrals for housing, immigration, and mental health services.
50% decline in emergency visits and hospitalizations;
30% decline in school absenteeism
WIN for Asthma
http://nyp.org/services/acn_outreach_win.html

34. The 10th Decile Project
Works with hospitals to identify the 10% of homeless
people with the highest hospital costs and to find
permanent housing with strong medical and mental
health support.
34
Healthcare costs decreased by 72%,
from $58,962 to $16,474 per person.
http://www.economicrt.org/pub/Getting_Home_2013/Getting_Home_2013.pdf

35. Opportunity costs
1 Emergency department visit = 1 month’s rent
2 hospitalization = 1 year of child care
20 MRIs = 1 social worker for a year
60 echocardiograms = 1 public school teacher for a year
35SGIM Presidential Speech, Dr. Moran, 2015