1. International Society for Systems Science Madison, WI July 14, 2008 International Society for Systems Science Madison, WI July 14, 2008 Syndemics, Simulation Scenarios, and Social Change Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention BMilstein@cdc.gov http://www.cdc.gov/syndemics Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention BMilstein@cdc.gov http://www.cdc.gov/syndemics Crafting a Health System that Protects Us All

2. Public Health Systems Science Addresses Navigational Policy Questions 17% increase Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed October 23, 2007 at. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; April 15, 2008. How? Why? Where? Who? What? 2010 20252050

3. Widening Systems View of Health Centers for Disease Control and Prevention. Dynamic models. Atlanta, GA: Syndemics Prevention Network; March 11, 2008..

4. Americans’ Views on the Health System Poised for Significant Change? Over 75% of Americans think the current system needs fundamental change Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health care in the 2008 presidential primaries. New England Journal of Medicine 2008;358(4):414-422.

5. Lessons from Previous Health Reform Ventures Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999. Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at. Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982. Prior efforts were largely disappointing because of… Piecemeal approaches Complicated schemes that were opposed by special interests Assumption that healthcare dynamics are separate from other areas of public concern Conventional analytic methods make it difficult to… Observe the health system as a large, dynamic enterprise Craft high-leverage strategies that can overcome policy resistance Prior efforts were largely disappointing because of… Piecemeal approaches Complicated schemes that were opposed by special interests Assumption that healthcare dynamics are separate from other areas of public concern Conventional analytic methods make it difficult to… Observe the health system as a large, dynamic enterprise Craft high-leverage strategies that can overcome policy resistance Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself. -- Meadows, Richardson, Bruckman

6. Expanding Options through Boundary Critique -- Julie Gerberding CDC Director -- Julie Gerberding CDC Director Rubin R. CDC campaign hopes to make USA healthier nation. USA Today 2008 July 7. Park A. Time 100: the people who shape our world. Time Magazine 2004 April 26. “The debate about healthcare reform needs to be enriched by including the concepts of health protection and health equity…and [we] have never had a better opportunity to truly influence how we get from where we are to wherever the new health system will be.”

7. The Promise of a Syndemic Orientation A syndemic orientation clarifies the dynamic and democratic character of public health work Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. http://www.cdc.gov/syndemics/monograph/index.htm “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying Studying innovations in public health work where there are multiple interacting problems The word syndemic signals special concern for many kinds of relationships: mutually reinforcing health problems health status and living conditions synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens) Studying innovations in public health work where there are multiple interacting problems The word syndemic signals special concern for many kinds of relationships: mutually reinforcing health problems health status and living conditions synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens) Health Living Conditions Power to Act “Health Policy” “Social Policy” “Citizen- ship” Explicitly includes our power to respond, while understanding its changing pressures, constraints, and consequences

8. Epi·demic The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“ Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972. Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/ Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873. A representation of the cholera epidemic of the nineteenth century. Source: NIH “The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.” -- Gil Elliot “The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.” -- Gil Elliot

9. Syn·demic The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena It acknowledges relationships and signals a commitment to understanding population health as a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways Confounding Connecting* Synergism Syndemic Events System Co-occurring * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

10. Time Series Models Describe trends Multivariate Statistical Models Identify historical trend drivers and correlates Patterns Structure Events Increasing: Depth of causal theory Robustness for longer- term projection Value for developing policy insights Degrees of uncertainty Leverage for change Increasing: Depth of causal theory Robustness for longer- term projection Value for developing policy insights Degrees of uncertainty Leverage for change Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Tools for Policy Planning & Evaluation

11. CDC’s Growing Portfolio of Health System Dynamics Projects Selected Health Priority Areas… Diabetes Obesity Infant health Cardiovascular health Syndemics Overall Health Protection Enterprise… Neighborhood transformation National health economy Chronic illness dynamics Upstream-downstream investments Health protection game Communications, Training, Funding… Publications, special issues, monographs Interactive workshops, symposia Funding announcements Website, listserv Professional network Selected Health Priority Areas… Diabetes Obesity Infant health Cardiovascular health Syndemics Overall Health Protection Enterprise… Neighborhood transformation National health economy Chronic illness dynamics Upstream-downstream investments Health protection game Communications, Training, Funding… Publications, special issues, monographs Interactive workshops, symposia Funding announcements Website, listserv Professional network

12. Where to Begin with a Problem as Vast as Health System Change? Learn to How Succeed in a Simpler, Simulated System Madon T, Hofman KJ, Kupfer L, Glass RI. Implementation science. Science 2007;318(5857):1728-1729. Milstein B, Homer J, Hirsch G. The health protection game: prototype design, preliminary insights, and future directions. Atlanta, GA: Centers for Disease Control and Prevention; May 8, 2008. Is it too audacious to think about representing the entire U.S. health protection enterprise?

13. Definitely, if we study every detail up close…

14. Not if we take a macroscopic view, from a very particular distance… Trajectory of Hurricane Andrew: August 23, 24 and 25, 1992 Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: Univ. of Pennsylvania Press, 1991. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Rosnay J. The macroscope: a new world scientific system. New York, NY: Harper & Row, 1979. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

15. Ingredients for Transforming Population Health A Short Menu of Policy Proposals

16. Expand insurance coverage Improve quality of care Change reimbursement rates Improve operational efficiency Simplify administration Encourage provider training/practice Enable healthier behaviors Build safer environments Create pathways to advantage Strengthen leadership Expand insurance coverage Improve quality of care Change reimbursement rates Improve operational efficiency Simplify administration Encourage provider training/practice Enable healthier behaviors Build safer environments Create pathways to advantage Strengthen leadership Ingredients for Transforming Population Health A Short Menu of Policy Proposals

17. Rules of the Health Protection Game Goal Navigate the U.S. health system toward greater health and equity Task Prioritize intervention options across 10 policy domains Decisions Craft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five years Scoring Achieve the best results across four criteria simultaneously Save lives (i.e., reduce the mortality rate) Improve well-being (i.e., reduce unhealthy days) Achieve equity (i.e., reduce unhealthy days due to Disadvantage) Lower healthcare spending (i.e., reduce expenses per capita) Appropriate implementation expenses (i.e., subsidy, program cost) Game Setup A population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costs No changes due to trends originating outside the health sector (e.g., aging, migration, economic cycles, technology, climate change) Goal Navigate the U.S. health system toward greater health and equity Task Prioritize intervention options across 10 policy domains Decisions Craft health protection strategies over 8 rounds (from 2010-2050), using feedback available every five years Scoring Achieve the best results across four criteria simultaneously Save lives (i.e., reduce the mortality rate) Improve well-being (i.e., reduce unhealthy days) Achieve equity (i.e., reduce unhealthy days due to Disadvantage) Lower healthcare spending (i.e., reduce expenses per capita) Appropriate implementation expenses (i.e., subsidy, program cost) Game Setup A population in dynamic equilibrium, with fixed rates of birth and net immigration, experiencing high starting levels of mortality, unhealthy life, social inequity, and healthcare costs No changes due to trends originating outside the health sector (e.g., aging, migration, economic cycles, technology, climate change)

18. Navigating Health Futures Getting Out of a Deadly, Unhealthy, Inequitable, and Costly Trap Four Problems in the Current System: High Morbidity, Mortality, Inequity, Cost Death rate per thousand Unhealthy days per capita Health inequity index Healthcare spend per capita 10 6 0.2 6,000 0 0 0 4,000 20002005201020152020202520302035204020452050 How far can you move the system?

19. High-Level Map of Health System Dynamics Most parts of the health system—so often discussed separately—are in fact connected Adapted from: Milstein B, Homer J, Hirsch G. Leading health system change using The Health Protection Game. Syndemics Prevention Network, Centers for Disease Control and Prevention; Work in Progress, May 2008. DRAFT: May 8, 2008 Strong public leadership is needed to change the modifiable drivers (shown in italics)

20. ParameterProxyInitial Values (~2000)Sources Advantaged & Disadvantaged Prevalence Household Income (< or ≥ $25,000) Advantaged = 79% Disadvantaged = 21% Census Selected Estimates for Model Calibration

21. ParameterProxyInitial Values (~2000)Sources Advantaged & Disadvantaged Prevalence Household Income (< or ≥ $25,000) Advantaged = 79% Disadvantaged = 21% Census Symptomatic Disease/Injury Prevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMA Asymptomatic Chronic Disease Prevalence High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron – Symp Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) NHANES JAMA Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPH Morbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSS Health Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSS Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 Census Sufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin Study Emergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCS Unhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin Study Unsafe Environment Prevalence “Neighborhood not safe” Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study Selected Estimates for Model Calibration

22. Intervention Options & Scoring Criteria

23. Illustrative Intervention Scenarios Scenario Name Policy Options Insurance Coverage Quality Care Reimb. Rates Efficiency Simpler Admin Provider Incentives Healthier Behavior Safer Environ Advantage Stronger Leadership Cut Reimbursement* Universal Coverage Higher Quality Upstream Protection Others/Combos… * The reimbursement cut is relative to health care input factor costs (labor, services, overhead). In model, this is done as an absolute cut. In real life, it could represent a freeze in reimbursements relative to ongoing inflation in factor costs.

24. Exploring Intervention Scenarios Cut Reimbursements to Office-Based Physicians by 20% Scoring Criteria: Deaths, Unhealthy Days, Inequity, Spending Death rate per 1,000 Unhealthy days Health inequity index Healthcare spending per capita >>>> These results are from a prototype model.<<<< Please do not cite or quote without permission.c 10 6 0.2 6,000 7.5 4.5 0.15 5,500 5 3 0.1 5,000 2.5 1.5 0.05 4,500 0 0 0 4,000 20002005201020152020202520302035204020452050 Prototype Model Output

25. Exploring Intervention Scenarios Cut Reimbursements to Office-Based Physicians by 20% Quality of disease & injury care Quality of DI care for the managed Sufficiency of primary care providers Advantaged Disadvantaged Prototype Model Output 1 0.9 0.8 0.7 0.6 20002005201020152020202520302035204020452050 1 0.75 0.5 0.25 0 20002005201020152020202520302035204020452050 Advantaged Disadvantaged 1 0.875 0.75 0.625 0.5 20002005201020152020202520302035204020452050 Acute nonurgent event visits to ER or OPD 70 M 55 M 40 M 25 M 10 M 20002005201020152020202520302035204020452050 Advantaged Disadvantaged Prototype Model Output

26. Additional Preliminary Findings Universal Coverage (with Leadership) Lowers morbidity and mortality quickly Increases cost significantly (greater volume of mediocre services, which do little to prevent disease) Worsens inequity (greater demand exacerbates pre-existing provider shortage for disadvantaged) Quality of Care (with Leadership) Lowers morbidity and mortality quickly, more so than “Universal Coverage” (more people benefit) Costs rise initially, then fall (the benefits of disease prevention accrue gradually) Worsens inequity (better quality exacerbates pre-existing provider shortage for disadvantaged) Upstream Health Protection (with Leadership) Consistent pattern of strong, sustained improvements in morbidity, mortality, cost, and equity Takes time to generate significant effects (~10 years) Works in three ways, all favoring the disadvantaged: (1) fewer upstream risks lower disease prevalence, which in turn (2) eases demand on scarce provider resources; and (3) reduces costs and improves health care access Universal Coverage (with Leadership) Lowers morbidity and mortality quickly Increases cost significantly (greater volume of mediocre services, which do little to prevent disease) Worsens inequity (greater demand exacerbates pre-existing provider shortage for disadvantaged) Quality of Care (with Leadership) Lowers morbidity and mortality quickly, more so than “Universal Coverage” (more people benefit) Costs rise initially, then fall (the benefits of disease prevention accrue gradually) Worsens inequity (better quality exacerbates pre-existing provider shortage for disadvantaged) Upstream Health Protection (with Leadership) Consistent pattern of strong, sustained improvements in morbidity, mortality, cost, and equity Takes time to generate significant effects (~10 years) Works in three ways, all favoring the disadvantaged: (1) fewer upstream risks lower disease prevalence, which in turn (2) eases demand on scarce provider resources; and (3) reduces costs and improves health care access Average unhealthy days per capita Health care spending per capita Health inequity index (morbidity) 6 5.5 5 4.5 4 2000201020202050 Protection Coverage Quality 20302040 Prototype Model Output 6,000 5,500 5,000 4,500 4,000 20002050 Protection Coverage Quality Prototype Model Output 2010202020302040 0.2 0.15 0.1 0.05 0 20002050 Protection Coverage Quality Prototype Model Output 2010202020302040

27. Game-based “Wayfinding” Dialogues Combine Science and Social Change Potential champions need more than visionary direction. They want plausible pathways and visceral preparation.

28. Transforming All Dimensions of the Health System Health Living Conditions Power to Act Efforts to Fight Afflictions Efforts to Improve Adverse Living Conditions Efforts to Build Power Equality of Agency Equality of Outcomes Equality of Opportunities

29. Syndemic Orientation Expanding Public Health Science “Public health imagination involves using science to expand the boundaries of what is possible.” -- Michael Resnick “Public health imagination involves using science to expand the boundaries of what is possible.” -- Michael Resnick Epidemic Orientation Problems Among People in Places Over Time Boundary Critique Governing Dynamics Causal Mapping Plausible Futures Dynamic Modeling Navigational Freedoms Democratic Public Work Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008.

30. For Further Information http://www.cdc.gov/syndemics

31. Health Protection as a System Health Response Adverse Living Conditions General Protection Demand for Response Safer, Healthier People Vulnerable People Afflicted People without Complications Afflicted People with Complications Dying from complications Tertiary prevention Secondary prevention Primary prevention Targeted protection Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Jackson DJ, Valdesseri R, CDC Futures Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004. Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003.

32. Main Health System Dynamics Risk, Disease, Health Status, and Costs

33. Main Health System Dynamics Effective Health Care is Powerful—and Expensive

34. Main Health System Dynamics Insurance Coverage Enables Access

35. Main Health System Dynamics Disadvantage Creates a Double Vulnerability

36. Main Health System Dynamics Demand Affects the Sufficiency of Providers

37. Main Health System Dynamics Cutting Reimbursements May Control Cost

38. Main Health System Dynamics Reimbursement Also Affects Quality

39. Main Health System Dynamics Reimbursement Further Affects Profit and Attractiveness

40. Main Health System Dynamics Health Equity Captures the Consequences of Differences in Vulnerability, Health Status, and Access to Care Strong public leadership is needed to change the modifiable drivers (shown in italics)

41. 1999200020012002200320042005 System Change Initiatives Encounter Limitations of Logic Models and Conventional Planning/Evaluation Methods Diabetes Action Labs* Upstream-Downstream Dynamics Obesity Over the Lifecourse* Fetal & Infant Health Milestones in the Recent Use of System Dynamics Modeling at CDC AJPH Systems Issue 2006 CDC Evaluation Framework Recommends Logic Models SD Identified as a Promising Methodology Neighborhood Grantmaking Game National Health Economics & Reform Syndemics Modeling* * Dedicated multi-year budget CVH in Context* 20072008 Science Seminars and Professional Development Efforts Health System Transformation Game* SDR 50 th Issue ASysT Prize Hygeia’s Constellation NIH/CDC Symposia Series

42. Poised for Significant Change

44. Adverse living conditions + Absence of protective efforts = Vulnerability

45. Re-Directing the Course of Change Questions of Social Navigation Prevalence of Diagnosed Diabetes, United States 0 10 20 30 40 19801990200020102020203020402050 Million people Historical Data Markov Model Constants Incidence rates (%/yr) Death rates (%/yr) Diagnosed fractions (Based on year 2000 data, per demographic segment) Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164. Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494. Markov Forecasting Model Trend is not destiny How? Why? Where? Who? What?

46. Growing Portfolio of System Modeling Studies in Public Health

47. Wayfinding Combines Science and Social Change Ideas for Extending the Work Getting Beyond the Prototype Review and Refine the Simulation Model e.g., SD methodology, health system content, parameter estimates, user interface Develop an Effective Instructional Design e.g. stakeholder roles, facilitated debriefing, policy insights, implications for leadership Discussing Tradeoffs (Competing Values) e.g. cost vs. health vs. equity; short-term vs. long-term Stakeholder Engagement & Action Certify Wayfinding Consultants e.g., cadre of public health innovators trained to support stakeholders in playing the game Convene Wayfinding Dialogues e.g., a series of nationwide events, convened by CDC and conducted by the National Network of Public Health Institutes Getting Beyond the Prototype Review and Refine the Simulation Model e.g., SD methodology, health system content, parameter estimates, user interface Develop an Effective Instructional Design e.g. stakeholder roles, facilitated debriefing, policy insights, implications for leadership Discussing Tradeoffs (Competing Values) e.g. cost vs. health vs. equity; short-term vs. long-term Stakeholder Engagement & Action Certify Wayfinding Consultants e.g., cadre of public health innovators trained to support stakeholders in playing the game Convene Wayfinding Dialogues e.g., a series of nationwide events, convened by CDC and conducted by the National Network of Public Health Institutes

48. Selected CDC Projects Featuring System Dynamics Modeling (2001-2007) Syndemics Mutually reinforcing afflictions Diabetes In an era of rising obesity Obesity Lifecourse consequences of changes in caloric balance Infant Health Fetal and infant morbidity/mortality Cardiovascular Health Preventing and managing multiple risks, in context Syndemics Mutually reinforcing afflictions Diabetes In an era of rising obesity Obesity Lifecourse consequences of changes in caloric balance Infant Health Fetal and infant morbidity/mortality Cardiovascular Health Preventing and managing multiple risks, in context Milstein B, Homer J. Background on system dynamics simulation modeling, with a summary of major public health studies. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; February 1, 2005.. Grantmaking Scenarios Timing and sequence of outside assistance Upstream-Downstream Effort Balancing disease treatment with prevention/protection Healthcare Reform Relationships among cost, quality, equity, and health status Chronic Illness Dynamics Health and economic scenarios for downstream and upstream reforms Health Protection Game Learning to transform our troubled health system Grantmaking Scenarios Timing and sequence of outside assistance Upstream-Downstream Effort Balancing disease treatment with prevention/protection Healthcare Reform Relationships among cost, quality, equity, and health status Chronic Illness Dynamics Health and economic scenarios for downstream and upstream reforms Health Protection Game Learning to transform our troubled health system

49. Growing Portfolio of System Modeling Studies in Public Health

50. Applied Systems Thinking (ASysT) Prize The size of the problems addressed, combined with the diversity of the SD-CDC team and their long track record of practical engagements were decisive factors in the selection. -- ASysT Institute The size of the problems addressed, combined with the diversity of the SD-CDC team and their long track record of practical engagements were decisive factors in the selection. -- ASysT Institute Applied Systems Thinking Institute. CDC-NIH System Dynamics Collaborative Wins 2008 ASysT Prize. Arlington, VA; July 9, 2008..

51. Poised for Significant Change

52. Appreciating the Wider Scope of the “Health Challenge” Health > Healthcare

53. ParameterProxyInitial Values (~2000)Sources Advantaged & Disadvantaged Prevalence Household Income (< or ≥ $25,000) Advantaged = 79% Disadvantaged = 21% Census Symptomatic Disease/Injury Prevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMA Asymptomatic Chronic Disease Prevalence High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) NHANES JAMA Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPH Morbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSS Health Equity Unhealthy days (or deaths) attributable to disadvantage Attrib. fraction (unhealthy days) = 14.1% Attrib. fraction (deaths) = 14.4% Census BRFSS Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 Census Sufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin Study Emergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCS Unhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin Study Unsafe Environment Prevalence “Neighborhood not safe” Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study Selected Estimates for Model Calibration

54. ParameterProxyInitial Values (~2000)Sources Advantaged & Disadvantaged Prevalence Household Income (< or ≥ $25,000) Advantaged = 79% Disadvantaged = 21% Census Symptomatic Disease/Injury Prevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMA Asymptomatic Chronic Disease Prevalence High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) NHANES JAMA No Health Problems Prevalence Self-rated health is excellent or very good No HBP or HC Overall = 33% Advantaged = 36% Disadvantaged = 24% BRFSS NHANES Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPH Morbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSS Health Equity Unhealthy days (or deaths) attributable to disadvantage  Attrib. fraction (unhealthy days) = 14.1%  Attrib. fraction (deaths) = 14.4% Census BRFSS Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 Census Sufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin Study Emergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCS Unhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin Study Unsafe Environment Prevalence “Neighborhood not safe” Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study Selected Estimates for Model Calibration

55. ParameterProxyInitial Values (~2000)Sources Advantaged & Disadvantaged Prevalence Household Income (< or ≥ $25,000) Advantaged = 79% Disadvantaged = 21% Census Symptomatic Disease/Injury Prevalence Self-rated health is good, fair, or poor Overall = 27% D/A Ratio = 1.60 (= 38.5%/24%) BRFSS JAMA Asymptomatic Chronic Disease Prevalence High blood pressure (HBP) High cholesterol (HC) Asymp = Tot Chron - Symp Overall = 40% (54.5% tot chron - 14.5% Symp) D/A Ratio (tot chronic) = 1.15 (= 61%/53%) NHANES JAMA No Health Problems Prevalence Self-rated health is excellent or very good No HBP or HC Overall = 33% Advantaged = 36% Disadvantaged = 24% BRFSS NHANES Mortality Deaths per 1,000 Overall = 8.4 D/A Ratio = 1.80 Vital Statistics AJPH Morbidity Unhealthy days per month per capita Overall = 5.25 D/A Ratio = 1.78 BRFSS Health Equity Unhealthy days (or deaths) attributable to disadvantage  Attrib. fraction (unhealthy days) = 14.1%  Attrib. fraction (deaths) = 14.4% Census BRFSS Health Insurance Lack of insurance coverage Overall = 15.6% D/A Ratio = 1.82 Census Sufficiency of Primary Care Providers Number of PCPs per 10,000 Overall = 8.5 per 10,000 D/A Ratio = 0.71 AMA Austin Study Emergency Care for Nonurgent Problems Acute non-urgent visits in ER or outpatient department Overall = 19% D/A Ratio = 5.5 NAMCS Unhealthy Behavior Prevalence Smoking Physical inactivity Overall = 34% D/A Ratio = 1.67 BRFSS JAMA Austin Study Unsafe Environment Prevalence “Neighborhood not safe” Overall = 26% D/A Ratio = 2.5 BRFSS JAMA Austin Study Selected Estimates for Model Calibration

56. There Have Been Remarkable Successes in Redirecting the Course of Change 600 500 400 200 100 50 195019601970198019901995 Age-adjusted Death Rate per 100,000 Population 1955196519751985 300 700 Peak Rate Rate if trend continued Year Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke -- United States, 1900-1999. MMWR 1999;48(30):649-656. Available at Actual Rate Overall Decline is Linked to… Reduced smoking Changes in diet Better diagnosis and treatment More heath services utilization Overall Decline is Linked to… Reduced smoking Changes in diet Better diagnosis and treatment More heath services utilization 684,000 fewer deaths in 1998 alone

57. Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs 0 4 8 12 16 20042000199619921988198419801976197219681964 1960 Consumer price index (CPI-U) relative to 1960 Healthcare Total economy Consumer Price Indices for Healthcare and the General Economy United States, 1960-2004 (1960=1)

58. American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007.. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Affairs 2005:hlthaff.w5.63. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1 Fox M. Half of Bankruptcy Due to Medical Bills -- U.S. Study: Reuters; February 2, 2005. Total Personal Bankruptcy Filings, United States, 1994-2005 Total Personal Bankruptcy Filings, United States, 1994-2005 Healthcare Cost is Also the Leading Driver of Personal Bankruptcy 61% of the filers surveyed failed to seek needed medical treatments

59. Entrenched Inequities

60. Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med 2006;3(9). Available at Entrenched Inequities Life Expectancy at Birth in the Eight Americas (1982-2001)

61. A Dynamic Model Simulates Policy Scenarios

62. Are these ingredients connected? How? Does that matter?

63. Trends in Self-reported Health & Health Care Spending United States, 1982-2004 National Health Interview Survey, National Health Expenditure Accounts Trends in Self-reported Health & Health Care Spending United States, 1982-2004 National Health Interview Survey, National Health Expenditure Accounts Data Sources: National Health Expenditure Accounts (NHEA), US Census; National Health Interview Survey (NHIS), CDC Homer J, Hirsch G, Milstein B. Chronic illness in a complex health economy: the perils and promises of downstream and upstream reforms. System Dynamics Review 2007;23(2/3):313–343. Health care spending per capita (year 2000 dollars) 40% 50% 60% 70% 80% 90% 100% 200420022000199819961994199219901988198619841982 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 Percentage Reporting Excellent or Very Good Self-reported health (i.e., excellent or very good) oscillated within a narrow range of 65% to 69% Health care spending per capita in year 2000 dollars more than doubled in 20 years

64. POLICY CHOICES SCORING CRITERIA (Averaged from 2000—2050)* Save Lives Improve Well- being Achieve Health Equity Lower Healthcare Costs Appropriate Intervention Expenses Mortality rate (or YLL) Unhealthy days (or QALY) Unhealthy days attributable to disadvantage (or attrib deaths) Healthcare spending per capita (or % of GDP) Total outlay for subsidies and program costs 1Expand insurance coverage 2Improve quality of care 3Change reimbursement rates 4Improve operational efficiency 5Simplify administration 6Offer provider incentives 7Enable healthier behaviors 8Build safer environments 9Create pathways to advantage 10Strengthen leadership Intervention Options & Scoring Criteria * Other metrics could be developed to explore policy consequences beyond the health sphere, such as economic prosperity, environmental quality, civic engagement, etc…