1. To: President Obama From: Harold Wise, MD, RPSM Founder Re: Beyond Health Care Reform Second Annual Harold Wise Memorial Lecture January 20, 2009 David Kindig MD, PhD University of Wisconsin-Madison School of Medicine and Public Health

8. Social Environment Physical Environment Genetic Endowment Individual Behavior Health & Function Well-Being Prosperity Disease Health Care

9. EVANS AND STODART 1990 “a society that spends so much on health care that it cannot or will not spend adequately on other health enhancing activities may actually be reducing the health of the population”

10. New York Times Says……

15. SOCIOECONOMIC STATUS AND RISK BEHAVIORS Paula Lantz et al Univ of Mich 2001 Longitudinal Study 1986-1994…. Americans’ Changing Lives Survey Four risk behaviors (smoking, BMI, etc) only have modest impact in predicting functional status and self-rated health in low income populations “risk behaviors are not the dominating mediating mechanism for SES health differences”

16. THE “FANTASY EQUATION” “at present we but vaguely understand the relative magnitude of the coefficients on the independent variables that would inform specific policies rather than broad directions, even if we are beginning to see the variables themselves more clearly”. G.Stoddart, 1995

17. Rigorous causal relationships Policies based on anecdotes and opinions Evidence-based and Evidence-informed policies Applied research for policy

20. Health of Wisconsin Report Card

22. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170)

23. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170) African Americans (624) Native Americans (592) (279) (277)

24. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170)

25. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Best state Minnesota (257) Asians (170) Men (367) (225) Wisconsin (296) (225)

26. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) High school or less (459) Native Americans (592) African Americans (624) Worst state Mississippi (519) Wisconsin (296) Best state Minnesota (257) Asians (170)

27. Wisconsin Working-Age Adult Mortality Rates (Ages 25-64, rates per 100,000 population) ABCDFABCDF Some college (212) College graduates (188) Whites (279) Women (225) Suburban (247) Non-urban (275) Rural (319) Men (367) Milwaukee County (424) Native Americans (592) African Americans (624) Worst state Mississippi (519) Best state Minnesota (257) Asians (170) High school or less (459) (212) Wisconsin (296) (206)

32. “The fundamental assertion of this book is that population health improvement will not be achieved until appropriate financial incentives are designed for this outcome.” Kindig 1997

33. Phases of Population Health Improvement Phase 1Debate, acceptance (1997-2000)and research Phase 2Outcome based payment (2001-10)for integrated health delivery systems Phase 3Incorporating the (2011-20)non medical determinants and sectors

35. “Now is the time to explore possibilities that go beyond medical care determinants and fund demonstration programs…in which community leaders from a variety of sectors can experiment with promising ideas”

36. BEYOND HEALTHY COMMUNITIES: STRONG MEASURES, REAL RESOURCES “What is required is a coordinated effort across determinants between the public and private sectors, as well as financial resources and incentives to make it work”.

37. Public Health System Schools Community Centers Employers Transit Elected Officials Doctors EMS Law Enforcement Nursing Homes Fire Corrections Mental Health Faith Instit. Civic Groups Non-Profit Organizations Neighborhd. Orgs. Laboratories Home Health CHCs Hospitals Tribal Health Drug Treatment Public Health Agency

38. Evans and Stoddart, 2003 “Redirecting resources means redirecting someone’s income…most students of population health cannot confidently answer the question… Well, where would you put the money?”

39. IF I WERE CZAR, AND HAD TO WORK WITH EXISTING RESOURCES I would take the 25% of health care expenditures that are thought to be ineffective ($500Billion), and reallocate $100 Billion $300 Billion

40. TO THE NYT EDITOR “It is encouraging and refreshing that Secretary designate Daschle is considering replacing Medicare fee for service payments with a system that rewards “healthy outcomes” (NYT Jan 9). However, if he means broad health outcomes like life expectancy and infant mortality, his colleagues with responsibility for education, economic development and the environment have as much responsibility as he does.

41. Social policy is also health policy, and these determinants are as important as health care. Once universal coverage for health care is achieved, perhaps he can become the first Secretary to focus on strong multi- sectoral efforts for real population health improvement.”

42. Economic Stimulus Package Prevention block grant: $296 million; Chronic disease programs in general: $545 million; HIV/STD/TB/HBV: $335 million; Environmental health: $60 million; Public health workforce: $30 million; Injury prevention: $50 million; Immunizations: $945 million; Occupational research: $40 million; National Center for Health Statistics: $40 million; Health care associated infections: $150 million; Healthy communities: $500 million; Pandemic preparedness and advanced research and development: $900 million.