Changing of the Guard: Strategies to Advance Public Health in the Obama Administration

TOM BURKE: OK, so it’s
about one minute later now, and we’re going to start. I’m Tom Burke. And Scott Klein, who organizes
these things so well, saw me getting ready to
come up on the stage. And he said, I thought the– OK, just a little technical
difficulty there as we broadcast out to the internet
and the entire world. So Scott said, Tom, I
thought the big dean was going to be here. And I said, no, it’s
just the tall dean. So I’m actually associate dean
for public health practice and training, and I’m
delighted to be here in the first of our new moments
in leadership grand rounds. And I’m delighted. So the big question– and
we’ve all seen changes. So it’s been 70 days, 71 days,
and so well, the president’s preoccupied now with
the queen but is thinking about public health. And we’re going to
get insights tonight. And we have a great
group of speakers to examine the
changing of the guard, strategies to
advance public health in the Obama administration. This effort has really
been a team effort. And I want to thank, first
and foremost, my colleagues in the public health
practice committee and the Department of Health
Policy and Management, who put our heads together,
were able to put together the concepts for this
grand round series, and get a little funding
and support from Pfizer and a lot of support from the
school to make this possible. And I want to mention the
other groups that help us so much, the Maryland
Health Officer Association, and we have Fran Phillips
and Roger Harrell here– the Maryland Public
Health Association. I want to really thank Molly
Mitchell and Melanie Byrd from the Mid-Atlantic Public
Health Training Center– the Mid-Atlantic Health
Leadership Institute and also the Department of Health
Policy and Management, for putting up with us
as we pull this together. And without further ado,
I want to turn it over to my colleagues who will be
introducing the first speaker. So Keshia Pollack. KESHIA POLLACK: Thank you, Tom. Good afternoon, everyone. Thank you. So our first speaker
who will be coming up to share some insights with
us is Dr. Linda Degutis. It’s always nice when you can
invite a colleague and a friend to come here. And I’m so grateful,
we’re all grateful, that Linda traveled down from
New Haven to come be with us today. Dr. Degutis is an
associate professor of emergency medicine
and public health, an associate clinical professor
of nursing at Yale University. Her bio was very
long, so I’m just going to highlight
a couple of things that I think are
important and really, I think, characterize
some of Linda’s work. She was, first of all, a Robert
Wood Johnson Health Policy Fellow working in the
office of Senator Paul Wellstone for a few years. Her research area has
been mostly related to alcohol and injury
with a particular focus on interventions
and policy issues. Her current work
at Yale is focused on disaster preparedness, public
health systems, and services research development. She’s also the immediate past
president of the American Public Health Association and
has served two terms as chair of the APHA executive board. Dr. Degutis is
currently a member of the National Advisory Board
for the Robert Wood Johnson Foundation Health
Policy Fellow program and board of directors for the
advocates for highway and auto safety. So please join me in
welcoming our first speaker Dr. Linda Degutis. LINDA DEGUTIS: Thanks, Keshia. It’s great to be here and
good to see so many of you in the audience. I’m going to talk a
little bit about what I think needs to be
done in order to advance public health in the
new administration, but I hope that you
will see this as a call to action for
everybody, who is here and who’s listening,
for things that you need to keep in mind and things
that you need to do in order to make things change. Because you can’t
depend on somebody else to do it or depend
on somebody else to– except for the AV– depend on somebody else to
take care of it for you. We all have to be advocates for
public health, and I think– Great, thanks. OK, so that’s the message. So really think about how
you can use this information. And I think what the
other speakers are going to present in order
to really make some change and get public health into
the debate about health reform because it hasn’t
been in there before, and we need to be the
ones to make that change. First of all, we have
this great opportunity at this point in
time, there really is political will and
public will to do something about health reform. And I think more so than any
of the prior attempts we’re hearing people in communities
talk about health reform. They’re talking about
things that they need. They’re talking about
what is missing– what they can’t get access to. And there is now,
also, political will to do something
about health. But one of the challenges
that we have, and I think it’s one of the
biggest challenges, is moving from the
focus that there has been on health care
and treatment of disease to focusing on health and
the health of the community. How do we make the
community healthy? How do we do
population-based health? How do we make sure that
we’re meeting the community needs and local needs with the
regional, national efforts. And those are policies. Those are programs. Any of those kinds of things. Because most of
what happens really occurs at a community level. And it really involves
looking at what the values are of a specific community,
what the culture is, what those people in
the community need. And the final challenge
is prevention, is getting people to understand
that prevention is important, that prevention is the way
that we are going to reduce costs, the way that we’re
going to really prevent larger costs in the future. And it’s one of
the things that has had very little focus in any of
the talk about health reform. Keep in mind some of the factors
that contribute to health. Obviously, the social
determinants of health are something,
again, that have not been discussed a lot in
talking about health reform. We talk about the economy. We talk about how it
might impact health how, especially now that
we see a lot of people who have very high
paying jobs who don’t have health insurance anymore. We’re hearing now about
how it’s affecting them. But we haven’t looked at the
economic status of people, you know, the 48 million
people who are uninsured, and the number that
keeps going up. Think about education
and how that impacts health and housing. Nutrition, obviously
the built environment. Transportation, we have a great
opportunity this year as far as transportation goes
with the reauthorization of the transportation bill. SAFETEA-LU is what the
bill is being called. There’s lots of
opportunities in there not just for things
related to safety, you know, passenger
safety, pedestrian safety, that kind of thing,
but there’s things related to building of roads
and to advocating for when roads are built, to have
places for people to walk alongside the road that are
safe, for places for people to bicycle, so that
they get exercise, so that we help prevent obesity
and prevent other diseases. Agriculture, obviously,
is another issue. And we’re seeing a lot of issues
right now with food safety– certainly, a big
piece of health– and then access to
services, and those are preventive services as
well as treatment services– and coverage for those services. So I think what I
wanted to really see is the core principles I think
that we need to get across in order to include
public health, is that health is really
central to any kind of community that functions well. If we want a community to
be viable, to be growing, we need to have it
be healthy, and we need to do something
to create that health. And it’s not only health care. Treatment for illness is
just one part of health. Unfortunately, it’s where we
spend a whole lot of money, but we also spend most
of the money in treatment in the last six months of life. We’re not spending a lot
of money in prevention, and that’s what we need to
start looking to see where we can have some of those savings. And I would encourage
you to think about prevention and prevention
being primary as Larry Cohen would say. It’s not just the preventive
health services either. One of the things that
happened that I encountered when I was working on
The Hill and I was going through orientation, we’d go in
and we’d be talking to somebody in the orientation, and I’d say,
well, what about prevention? And they’d say, oh, you mean
mammography and colonoscopy? And I go, no, I
mean speed limits. And they go, well,
that’s not health stuff. I go, well, yeah it is
because people crash, and they get killed. And then there’s no trauma
system to take care of them, and all these things happen. Oh, no, but you know,
we’re only focusing on reimbursement for
mammography or flu vaccines. Not that that’s not
important, but there’s a broader area of prevention
that nobody’s looking at. They’re not looking at
the built environment. They’re not looking
at these other things that we in public
health look at. So I think we need
to keep that in mind, and we need to remind
people that these are really important pieces of health. And so some of the critical
elements of health reform and things that we
need to really work on making sure in
health reform, investing in population-based and
community-based prevention, addressing the underfunding that
we’ve had in the public health system itself. We know the system
is underfunded. We know that there aren’t enough
services in the public health system to go around. We haven’t integrated
the public health system as well as we can with other
organizations and agencies that actually deal with
projects and programs that affect health. We need to be better about
assessing cost savings that result from prevention. We have some
studies, but we don’t have enough to really
effectively convince people that prevention really
is making a difference. We need to reduce
disparities, and we know that those exist in
essentially any community. And we need to look at the
impact of policies on health. And that’s not just
health policies, but it’s policies that we do
in general– any kind of policy that’s passed at a state level,
a local level, a federal level. How does it impact health? Does it take money away from
health services or prevention? Does it actually create
something that is a hazard? And that really puts
people’s health at risk. We need to do
something about having, maybe, a health
impact score when we’re passing policies or
putting policies together. We don’t do that very well. Nobody, I don’t think anybody’s
really been doing it at all, not even not very well. So somebody can come up
with a brilliant idea for doing this and
calculating the health impact on any policy. It will be great, but we
need to advocate for it being included in any policy. And we need to start asking
those questions we need to say. So what’s the health
impact of this? What are you going to do? You’re going to build this road. Well, what’s going to happen
in the health of the people? You’re going to put this
power plant over here? How are you going to
protect the health of the people who live near it? You know, what are
you going to do? So ask the questions when
you have an opportunity. Some other critical elements,
comprehensive coverage for services that
includes the preventive services, and they
should be evidence-based. I think that’s our
other opportunity, is that science actually is
now considered believable. So I think we have that
opportunity to use science, to use the information
that we have about what works, and promote
getting programs that work and services that work
out into the community. We need to include behavioral
health in any kind of coverage that we provide. It’s mental health and substance
abuse treatment parity. Some people think that now that
we have it on certain levels, it’s there. And it’s not there. We don’t have access. We don’t have parity
for everybody. We need to not just
pay for performance, but we need to pay
for prevention. Paying for performance is great,
and we really focus on quality. But I think we need to pay
for prevention as well. And a lot of people
will tell you that the reason they
don’t do things, they don’t implement
preventive services, is there is no
reimbursement for them. So they can’t really
afford to do it. Public programs, we
really need to make sure that the functions of
the safety net that includes community-based
services are there. And we need to
take the focus away from emergency departments
as a safety net. They’re overcrowded. They are really functioning
way beyond their capacity. I don’t know what will
happen in some places if we do have any
major events that really increase the need
for emergency services. So it’s really not the place to
have people go as a safety net provider. And we need to really
include insurance options, public insurance
options for people. The workforce is
another big area. We know that the
workforce is aging. We know that even in
affluent communities, people can’t get access to
a primary care provider. Because what happens
a lot of people go to Med school and go
into specialty programs. I was just up at a state
school where they have 120 students who graduated. Generally most of
their students, or 50% of their students,
would go into primary care. This year, only two students
are going into primary care, and that’s probably
because the reimbursement isn’t very good for
people in primary care. We pay pediatricians less than
we pay cardiothoracic surgeons or plastic surgeons. You know, we pay primary
care practitioners a lot less than we pay people
who are doing elective surgery. So I think we need to look
at that and kind of figure out how to equalize
that and really pay people to provide good
care and good preventive care to the population. And then we really
need to have provisions for funding the
research to find out what really works in
policy and prevention, so that we can advocate for it. So what do we need? We need, as I
said, consideration of health in the broad sense in
all policy, a focus on health in a broader sense than
disease treatment including the public health system
and health reform– universal coverage and
access because coverage doesn’t guarantee access. You can have coverage, but
you can’t find anybody to see, or the clinic’s only open during
the time that you’re working. And you can’t take a time off
from work to go to the clinic because you don’t have
that kind of time. And we need to pay
for prevention. And I think those are the
only ways that we’re really going to get to the goal
of actually of having a nation where we have healthy
communities that can help support our economy, that can
help support what we really want to be. So I’d ask all of you to get
out there and start advocating for public health, and
advocate for including it in health reform, talk to your
neighbors, talk to your friends about it, and really help
us all move this forward. Thanks. BETH RESNIK: Thank you, Linda. I’m Beth Resnik. I’m going to be introducing
our next speaker who is Dr. Shelley Hearne. I think a lot of
you might already know Shelley Hearne
was a teacher here. But actually, I
think it’s great when you get to read someone’s
bio you get to learn lots of new things about them. Good things, good things. When we started to put this
idea of this panel together, we really wanted to
think about who really could make change happen. Shelly Hearne immediately
came to all of our minds because really she has such
a tremendous background. But in addition to all of the
things she’s accomplished, she really has something
unique in the sense that she has different perspectives. She’s been here, so she
has the academic piece. She’s been in the
practice world. She was at the New Jersey
Department of Environment– Environmental protection,
she’s been an advocate. She was a founding
director of the– you’ve been in so many places,
I forgot the name of it. Trust for America’s Health,
which did a lot of advocacy work in terms of
trying to promote public health in the
public health system through state and local
health departments. And the other things I found out
about her that I did not know was that she has the
science background too. She has her bachelor’s
in chemistry and environmental
studies, and then she also had her doctorate
in environmental sciences from Columbia University
School of Public Health. So with all of that, I’d like
to introduce Dr. Shelley Hearne. Thank you. SHELLEY HEARNE:
Beth was very kind. She knows that with
all my stupid jokes, it’s a little
shocking that there would be a science background. BETH RESNIK: I figured
this would be policy. SHELLEY HEARNE: Policy, right. Policy in science. Well, I’m here to talk
that, as a good Jersey girl, they’re perfect together– and talk a little bit why,
at this point in time, in fact, there’s
more hope than ever. But that wouldn’t sidebar. I know this is on the web, but
I am a little disappointed. I was supposed to go
last, and my understanding was there is another speaker. And I’m going to fill in,
but that if she was late, that Tom was going to talk
instead about his injury prevention work and Wii
fitness and do a demonstration piece about how to use
the hula hoop properly. Didn’t you say that? All right, let’s
get back to science. Actually, I appreciate– Linda’s
always a wonderful person to tag team with. We’ve had the opportunity
with American Public Health and other places– to take a look at, how
do we advance issues? How do we move policy? But, in a key way, to how
to do it pragmatically, and it’s been a challenge
in the past few years. And we’re actually, as much as
we have a new administration in, and I know hope
is an operative word, let me let me just be a
little grim for a moment and have some reminders of
the challenges that we face. I’m one of those
people that thinks that we’re not in a recession. We’re in fact not
using the d-word. Am I allowed to use it here? I think this is the
new Great Depression that we’re about to enter,
that we have started to. Record home
foreclosures, we have banks no longer functioning. We have an unparalleled time
in terms of economic crisis. We are now owners,
we, collectively, of some of the major car
manufacturers, insurance companies, and
some of the banks. This is a time we’ve
never experienced before, and it’s going to be
a challenge in terms of how do we move
some of the issues that we care deeply about,
that the science tells us needs to be fixed today, when
we have a struggle going on for actual economic
viability of this country? You asked me to be optimistic. Did I start off
well enough here? Thank you, yeah. David, I knew I could count
on you for a good cheer there. I think it’s important because I
also appreciate Linda opened up with health care
reform, and my optimism is, I do think we are going
to see this issue finally have its day. I’m actually one of those people
that is rooting for the house to put in the
reconciliation provisions, so that the Congress
will be the Senate, could actually have a 51 vote
to get budget dollars through, so that there actually would
be an investment made– have breakthroughs of
some of the old politics– and have a chance for
both health care reform. And the other major issue out
there is global climate change. If we’re going to do the blend
of politics and public health, to borrow from a past
presidential candidate, the giant sucking sound
out there on policy reform is health care and
global climate change. So that’s the good news. That sounded like
good news, right? But there are many fundamental
issues on public health that are critical
to our issues, that are not necessarily in those
titanic policy issues that are moving. Issues such as drug safety
reform, issues such as conflict of interest in our
medical schools, the roles of pharmaceutical
industry and education to physicians, the
role of food safety, the role of childhood obesity
and many policies associated that should be there time– issues such as basic
consumer product safety. I even include issues
such as credit card reform as a public health
issue because if we have a majority of
Americans being impacted with losing their
discretionary income because of predatory practices that
are hidden and embedded in their loans, whether
they be home foreclosure issues or actual use
of the credit card, those are public health issues. And is now the time
that we can pass those? Well, I’m actually going to keep
looking for political advice in terms of my helpfulness. I look at President
Obama’s chief of staff, and I think there’s a critical–
his rule number one is never waste a good crisis. Never waste a good crisis. And in fact, that’s
the experiences we’ve had in the past. The Great Depression was an
extraordinary pivotal time for massive change and reform
in political practices. I follow and cheer
for the two Roosevelts that we’ve had at the
helm, that we’ve had some extraordinary lessons– that Franklin Roosevelt
seized that opportunity of an extraordinary
depression to put in place some of the most profound public
health programs in our history. Teddy Roosevelt is
actually one of my heroes. In New Jersey Republicans,
Democrats, they’re kind of one and the same, really. People are not normal
from New Jersey, are they? It gives me that little
hope– that I often look at public health issues
as an equal opportunity. They’re not owned by one party. And I think it’s
a critical– we’ve had some of the best
champions for public health from alternating
sides of the aisle. And maybe this because no
one always wants it or is the champion of
it, but in fact, is some of the greatest
opportunities to advance political change. Teddy Roosevelt is actually
the greatest consumer advocate that we’ve ever had
in the presidency. Back in 1906, he was the one
that put in place the rules to have our current FDA. He championed the
food safety laws. He championed the
drug safety laws. Upton Sinclair was doing
quite a bit of journalism, at that time, to put
the issues out there. But it was Teddy Roosevelt,
who actually without even that stimulus, was spending
his political capital at a time of crisis to
move these issues forward. And I actually think
this is, in as much as we have a crisis
in front of us, it is a crisis the public
health can effectively seize to help move
many of the issues that we’re passionately
caring about. And it’s not simply
by attaching ourselves to the coattails of
health care reform or trying to weave into
the global climate change debates, which we all
talked about for this year. I think that, may in fact,
be the 112th Congress, but I wouldn’t put
money on that one. I think that what it
really comes down to, the hope that I have in terms
of doing the political calculus as to why I think we’ll
actually see the food safety law pass this year– it might even pass before
health care reform. I think they’re going to be some
very significant drug safety laws that have a chance of
moving also during this term. I think that we
may, in fact, see some of the credit card
reforms simultaneously move. Where in the past, if you
wanted to pick a losing bet, credit card reform was the
best one to put your money on. Because the banking
industry was absolutely impossible to have any hope to
pass legislation in that arena. Well, all bets
are off right now. And the world as we know
it is quite different. And there are three pieces
that I take a look at to make determinations as to
how we’re going to move them, and why I have extraordinary
amount of help right now. One is, leadership matters. Leadership matters profoundly. And you take a look at
the appointments that are coming down the pike, and
the issues that we care about in public health. And I particularly want
to pull out the hula hoop, and do the jig, and despite
the possible injury threats out there. I’ll stick to science. We have Peggy Hamburg as
the proposed leader of FDA. I don’t know how many
of you know Peggy, but Peggy has been an
extraordinary champion right from the get-go. I think she started at age 12,
perhaps because of her parents, but from the helmet, New York
City’s Department of Health, to the federal
government, to actually had the good fortune for her
to serve on the board of trust for America’s Health. She was a stalwart in
terms of tell the truth, trust the people. Put the information out there. Put the facts out there
and stick with them. And riding right with her
is one of my absolute poster child for a physician
advocate is Josh Sharfstein. And I am going to do a jig right
now just in pure happiness. And if that’s the two,
the team that we’re going to have at FDA, it is
been the Cinderella agency of the Public Health Service,
the largest regulatory agency in the country, and
the most forgotten one. And if any of you are working
for the FDA right now, I thank you immensely for
having the bravery to a state, because we need you there. But I actually hope that
we have now an opportunity to put more and more and
furthermore more experts back into the agency and making the
decisions that they’re finally going to have a chance to make. Because what has happened
is, as a paralyzed agency, it’s not been able
to do its job. So whether it’s
making a decision that they wanted to
do 30 years ago, which was to ban the non-therapeutic
use of antibiotics and industrial farming, which
the veterinarian community said, you absolutely must do. FDA wanted to do, but the
politics got in the way. And here we are
debating it today. I think that’s a reform
package which actually has a chance, probably
not this year, but two years and part of
it is because the leadership is going to be coming
into the agency to once again stand up
and let the science speak for what needs to go
forward on the facts. So leadership matters. I could go on in the
litany of who else is coming in in
various agencies, but then I’d be doing too much
dancing up here rather than talking. Leadership matters–
science matters, that’s the other message that
we’ve gotten loud and clear. And I almost got a little
weepy with the inaugural– it’s not really an inaugural. I’m sorry the quasi
State of the Union, the first time President
Obama spoke to Congress wasn’t technically a
State of the Union, but that’s Washington speak. Where in there,
he noted that he’s making a commitment to restore
science to its proper place. Just a few little words,
but got me all choked up. And it should give
all of you the reason to have faith that
we have a chance here for true public health reform. Because if science matters
then that’s the opportunity we have to put special
interests aside. If facts can be in a place to
help drive decision making, not just politics, not just passion,
but facts that are translated and engage in the science
making, and the policy making– that’s what’s going
to also give us a chance to have actual
public health policy reforms. And the last part that
is a critical element is that the public
and their reengagement in the political
process is going to be the winning ingredient. A lot of these basic
public health consumer safety issues have been
off the radar screen, and people have
not paid attention. The public is mad. Whether it’s food safety,
it’s peanut butter yesterday, pistachios today, and it will
be something else tomorrow. And it’s finally on
the radar screen. We’re starting to understand
the role and relationship with the pharmaceutical
industry burying science from informing good decision
making in pharmaceutical drug use. Along with a long line
of other activities, the public is recognizing
that it’s not OK, their voice matters,
and is reengaging in a political process– that the polling data
that we’ve been tracking in terms of many issues that the
public just didn’t care about, and didn’t think were going to
change, and what did it matter? Today, many of these issues
that were back burner are off the charts. And that combination
of political will, the leadership in
the right place, and the return of science
to decision making, is where I think that it’s
truly a changing of the guard– not just of new people
and new administration, but it’s a new political will
out there and revitalization. So I actually
think this is going to be public health’s time, not
just health care reform, not just global climate change, but
an extraordinary advancement of some very basic public health
fixes that, in some instances, haven’t been fixed since
Teddy Roosevelt in 1986. So now I’m going to
do a jig and leave you to thinking about all that. Thanks. SHANNON: Well, thanks, Shelly. And I think if
you’re going to do a jig, the least we could
have is Tom some hula hoop demonstration. It’s all fair. Well, our third speaker
today for the afternoon is Dr. Ellen-Marie Whelan. And as Tom, Keshia, Beth, and
I were planning this event, sitting around the table
on many afternoons, trying to decide who we
could bring to the school to speak to this
issue, it was very easy for us to come up with Linda
and Shelley right off the bat. We’re prevention folks. We knew who the
go-to people were. But we realized that it was
very important to also include health care policy in this talk. It’s a huge part of what’s being
talked about in the nation. It’s a huge part of
what is happening with the new administration. But we weren’t really
the experts to do that. So as we were sort of
exchanging emails one night, trying to figure
out who we could tap to speak to health issues
in this grand round seminar, I decided to send an email to
our friend, Gerry Anderson, who I’m sure all of you
know is on faculty here at the school and a
preeminent authority on the issue of health care
and how to do it right. So I sent an email to Jerry
late at night and said, we’re putting together
the seminar series. We need someone from
inside the beltway who can really speak
with authority as to where health care
reform is headed under this new administration. And as is often the case when
I email my Hopkins colleagues at the wee hours of the morning,
I got an email right back. Jerry said, well,
the person you need to contact, without a doubt,
is Ellen-Marie Whelan. She will do a fantastic job. She’s got her finger
on the pulse of what’s happening in Washington. She would love to
come back to Hopkins. She’s the person
you need to get. And I knew Ellen-Marie
when she was here. And I was happy to take
up that suggestion, and reconnect with her, and
invite her to participate. So at whatever hour in the
night or morning it was, I sent her an
email, and expected to hear back in a day or two. So I went back to my work
that I was doing and up popped a message. Sometimes, you know, that
part of Hopkins, I think, never leaves you. So Ellen-Marie
immediately responded that she would love to come. She was thankfully
free on this day, and here she is to
talk to us about what’s happening with regard to health
care reform and the Obama administration. Let me tell you a little
bit about Ellen-Marie. She has, in addition
to completing a post-doctoral fellowship here
at Hopkins in primary health care, she was also
instrumental in sort of the early days of the
urban Health Institute here. She has worked at the
University of Pennsylvania doing work with
adolescent health there, so she’s been on the faculty
of Schools of Public Health, of nursing, up and down
the mid-Atlantic coast. She has also been the recipient
of a Robert Wood Johnson Health Policy Fellowship. She has worked in that capacity. She worked in that capacity
for Senator Tom Daschle. She’s also worked around
Senator Barbara Mikulski. And she is currently with the
Center for American Progress where she serves as a
senior health policy analyst and Associate
Director of health policy. Again, Dr. Whelan, we’re
so pleased to have you here to talk to us about what’s
going to happen with our health insurance benefits and all the
good things that are happening under this administration. So thank you for being here. ELLEN-MARIE WHELAN:
Thanks, Shannon. Yeah, it is crazy when we’re
all online at the same time. We’re immediately communicating. I remember when,
like, G Chat came on. I’m like, isn’t that
what email’s about? You just kind of go right
back and forth so quickly. I also can’t believe this is
the room where I had statistics. It looks completely different. It’s such a beautiful room now. Yeah, it’s this warm
environment now. So I’m actually
going to hopefully be a little bit more optimistic. I will try to move
where we’re going. And I am going to be focusing
not on the primary prevention that these folks
took care of, and I’m moving towards across in HPM. And as Shannon’s said, I did
a post-doc in primary care policy. And that was a while ago. And at the time everyone was
like, two years, primary care policy, what are
you doing that for? Now suddenly, it’s
kind of the way we’re going with payment reform. And people are like, really,
you studied primary care? So it’s been really
fun to be in D.C. now when we’re looking
at hopefully trying to move Medicare and payment
reform a little bit more in that direction. So what I’m going to talk
about today– it’s first, I’m going to be a little
depressing talking about the state of health
care in the United States and none of this stuff is
probably going to be new. But I think when you’re
painting in the picture, it’s very clear on the
direction we need to be going. Why now is the time for reform? Why we shouldn’t wait waste this
great crisis as they’re saying. The two goals that we’re
trying to make sure that we do simultaneously– and some
are pulling us in different directions is that you’re
covering everyone while we’re trying to save money,
and is that something that we actually can do– and then a couple of solutions. So first of all, are we
getting what we pay for? And Hopkins is so international
that it makes sense to look and see where we, on
the end here, of the 30 states, what we’re spending on health
care over nearly $7,000 per person on health care. And you can see, of
the 30 states here, that no one’s even close to
spending that much per person on health care. And this shows, actually,
how we’re growing, so it’s not just a
single point in time. But this is over
the past 25 years. Look at the growth rate of the
United States, the top red one here, how we’re
growing cost-wise, whether we’re looking
at a per person capita here, or a percent of
the gross domestic product. And you can see the other
countries are all clustered and growing at different rates. So there’s something
very different going on in the United
States, and this is what we have to focus on
as we’re making these changes. And are we getting
what we pay for? Well, of course, you all know,
here is the United States here. And this is life expectancy. Once you hit 60, how many more
good years of healthy years do you have left? And you can see, Japan,
Switzerland, here, once you hit 60
you’ve got about 20 for women, a little less
for men, of good years left. And we’re way down here. In years-wise, it’s
not a whole lot, but you can just
see in terms of how we have spent the money in terms
of what we’re actually getting. And I love this one, as
especially a primary care person, mortality, so when
you die because you didn’t get the right health care– mortality amenable
to health care. And these are things like
diabetes, heart disease, that if you’ve gotten the
proper health care maybe you wouldn’t of, but you
ended up dying from this. And this is a
measure, obviously, that is used internationally. And we, again, we
have more people dying from preventable
or from diseases that would have been hopefully
taken care of if you got care in the right place. And where is the right place? And as Linda said,
part of the problem is we’ve got folks going
into the emergency room. And you can see
here, this is folks that went to the emergency
room when they probably could have or should have
been treated someplace more appropriately. And the United States
is way up here. We’ve actually done a little bit
better in the past two years, but you can compare it to
Germany, Netherlands, New Zealand, UK, Australia, Canada. These folks, the
percentage of adults who are going to the
E.R. when they should have gone somewhere else. And of course, infant
mortality rate, and this is probably something I don’t
have to talk about here. You can see where we
are internationally, but this is also
interesting to show. Here is the United States
where we are, babies dying before their first birthday. And then you look
at the top 10%, the best states in the union. And the best states are
still not doing as well as most other countries. And of course, the worst states
are almost up around 10, 11– the states that are not doing
so well in infant mortality. And this is at the
global big country level. If we go down to more
personally having us compared to other
countries, what are we spending out-of-pocket,
individual, spending on health care compared
to other nations? And this one is what
percentage of people with a chronic condition
are spending less than $500 of their own– this is
after you’re insured or whatever else. So 31% are spending under $500,
and you can see more like half or up to 81% are spending it. And of course, the
reverse, then, over here. What percentage are
spending more than $1,000 of their own dollars
on health care if you’ve got one
chronic illness? And again, are
they doing as well? These are the same countries– people with a chronic condition. How many times did you
not fill your prescription because it was too expensive? How many times did
you not visit a doctor when you had a medical problem
and didn’t get the recommended test. And over here, 43% of
people, 36%, 38% of people. And of all of these, so people
with a chronic condition, over half said– people in the United States
with one chronic condition, over half said that they
answered one of these things– that in the past year, I did
not do one of these things because I couldn’t afford it. So we’re spending
way too much money, and we’re having all
of these people still not getting the health
care that we need. Why now is the time? And as Shelley said, we don’t
want to waste a good crisis. And I think part
of the issue is– and I when I was in
Tom Daschle’s office, and we were driving
through South Dakota, and there’s no press
around it, we’re hearing these
stories about people. And he said, Ellen-Marie,
I don’t understand. Why aren’t all the members
of Congress hearing this over, and over, and
over again, that we have to do something on health care? And the problem was
it never is urgent. And as you’re
pointing out banking and all these other things, they
end up getting to the urgency. And I was in the
leader’s office, and you had that view
of, oh my god, look at all the things they’re
trying to address, and it never got to be urgent. And it will never
get to be urgent except now we’re beginning
to talk about health care as an economic. And that’s one of the
big differences I think with the Obama administration. They’re realizing– his
top Economic Advisers are realizing– we will not
fix the economy unless we simultaneously fix health care. America’s businesses, Starbucks
is spending more on health care than coffee beans. GM, who knows where they
are, but they’re also spending way more on health care
than they’re spending on steel. They can’t stay competitive. United States businesses
spend about $1 for every $0.63 that other countries
are spending on health care per individual. You can’t compete that way. Personally, almost 50%
of all home foreclosures are not because of the subprime. Almost 50% of home
foreclosures are because you’ve had
some kind of a health issue in the past year. And at least 50% of
personal bankruptcies are because of
health care issues. And state and
local governments– you’ve been through what
just happened in Maryland. You’ve been hearing what’s
been happening in California. States have to
balance their budget, and they can’t do it because so
much of what they’re spending is on health care costs. This shows that for
every percentage increase in the unemployment rate. And you know that you’ve
been hearing those. We’re now at about 8%. What percentage of people are
on uninsured and Medicaid? And you can see it growing,
the light at the top. So with every percentage
increase in the unemployment rate, the number of
people that are uninsured and the number of
people that are on Medicaid or the State
Children’s Health Insurance Program. And over here is how much then
the states are paying for it. Here we are again at 8%. They’re spending $20
billion on average. But if we keep
moving to 10%, which we think is going
to happen, states will be spending $32 billion. And they can’t afford that. And when they’ve got
to balance their budget they’re taking it from
someplace else, education, other services. And this is just visually,
over the past two years, what could happen both
with the insurance rate and also then with
the unemployment rate, because obviously they’re
so tied hand in hand. First steps, I won’t
go through all this. You’ve probably been following. That one of the
first things that I think within two weeks
of the inauguration, they signed the Children’s
Health Insurance bill. An extra 11 million children are
going to be covered under that. And one of the big things was
dropping a mandatory waiting period for legal immigrants. They had to wait five years,
now, they don’t have to. The second thing
when he was here, when Obama was in for a month,
was the stimulus package. And the stimulus
package was huge. We’ve got– it doesn’t look like
a whole lot– but prevention and wellness programs,
a billion dollars. In these days, a billion
doesn’t sound like much with these trillions at
worth, but that’s not a bad amount of money. We’ve got comparative
effectiveness, and that’s the science that
Shelly’s talking about– better understanding,
what works and what doesn’t compared to
a placebo, compared to another– which ones
should we be moving towards? NIH, $10 billion, that was
a third of their budget. They went from $29
to $39 billion, huge. Health IT and workforce issues. And the workforce
issue we’re moving towards is trying to
encourage primary care, as Linda pointed
out was important. So health care reform,
Obama, when he first started talking about
health care reform, he started talking
about making sure that we build on the current
building blocks of what we do well in the nation. And these were the kind
of the three tenants that he was talking
about, quality affordable portable
health coverage for all, modernizing the US
health care system to lower costs and
improve quality– can we do that simultaneously? I think folks in public health
probably know that we can– and then promoting
prevention and strengthening public health. And I’m going to focus a
little less on the latter because we’ve talked
about that, and I’m going to talk about the top two. These are the seven principles
that President Obama put into his budget when
he said, I wanted to create this reserve
fund of $634 billion. And I found money in the
budget, the administration found that money
and said, here’s a down payment on
what I think we need to move health care reform. And this is what he
challenged Congress, very different than what the
Clinton administration did. The Clinton administration
wrote the health reform bill and presented it to Congress. He’s challenging Congress. Here’s a pot of money that
we found in the budget. And here are the seven things
that I want you to focus on as you move forward and as
you create moving this brand new health care reform bill. So I’m going to do
the, who’s covered, covering all, making sure
that we have the most number of people, we’re
spending all this money, having them all be insured. And then the second
piece I’m going to focus on is
cutting costs, and why we can do it in a way that
ultimately increases the value. So this group probably knows
this, but I’ll just quickly– who is covered by what,
because this will be the areas that we need to focus on. So can see from here,
over half of all Americans have their health insurance
through their employer. About 15% are uninsured. And what’s different
about the next side is if we take the seniors
out of the picture, if you take those that
are mostly on Medicare, you see that 61% of folks
are getting, right now, their insurance through
the employer-based system. So we have to look
at that as something to move forward and expand that. We’re going to
expand all of these, but that’s something that’s
so critical and on the table. And then I think
this is something that’s so important over here. The work status of the
folks that are uninsured. 70% of them almost are working. 70% have one or more full time
workers, 70% of the uninsured. And 12% have someone
who’s working part time. So only 19% of folks who are
uninsured live in a family where no one is working. Family income, just showing
that the poorer you are, obviously, the more likely
you are to be uninsured. And the age breakdown. And you can see that folks
often talk about this 19 to 29-year-old, but you can
see a huge chunk where also 30 to 44 also probably working. And this slide just shows
when folks are talking about– I was just in a
meeting the other day and the Business Roundtable
was there, and they said, yeah, the problem is there’s all
these really wealthy people who are not buying the insurance,
and they can afford it. And it’s true, there are a group
of people in the United States that choose not to
purchase health insurance. But when you look and
see 35%, the green here, is the percentage uninsured
according to poverty level. Over a third of the
poorest are the ones, so the disproportionate
poor folks are the ones that
are not insured. And does it matter? Does it matter,
health insurance? And this is going to be
similar to the next slide. These are questions that
we asked of people– that we didn’t ask– Kaiser asked this question
because of Family Foundation. And folks that had no
usual source of care, you can see the difference. The purple is uninsured. The green here is
employer-based. And the four is a public
plan, Medicaid, Medicare. No usual source of care. Obviously, almost everyone
that answered yes, that they did not have a usual
source of care, were uninsured. Postponed seeking
care due to cost. Almost everyone
that answered yes was because they were uninsured. You can see the purple, being
the uninsured, didn’t get care, but didn’t get it
because of what it cost. Last contact with the physician
was greater than two years ago, and this is kids. This is really
important here too. Unmet dental needs due to cost. You probably have all heard
about Deamonte Driver, who was a young man in Maryland
who died because he didn’t have access to a dental. And so the last two
there are dentist. And the same, although
the lines are different, the same for adults. So the folks that are uninsured
are not getting the care that they need. So now, I don’t know
whether you guys have heard, but all over D.C.
everyone’s talking about we have to bend the curve. We have to look at that
projection of growth in the United States. We’ve got to bring it back down
again, and how do we do that? The current head of the Office
of Management and Budget, Peter Orszag, who used to be
the head of that Congressional Budget Office said the
single most important factor influencing the federal
government’s long term fiscal balance is the rate of
growth in health care cost. So the whole economy, the most
important thing is health care. And so this is just
over the past 45 years, how health care is grown. You can see the growth. And we just took
that same growth and then projected it
for the next 75 years. And right now over 16% of
the gross domestic product is on health care. And as we project
out in 2080 50% of our gross domestic product
would be spent on health care if we didn’t do anything. So one out of every $2
spent in the United States would be spent on
health care costs, and we just can’t afford
to keep doing this. So then folks say, well, why
is– what is happening here? What’s causing this excess cost? And many people are
speculating it’s because of the baby boomers. They’re putting us over. And in fact, they’re not. You can see here, the
percentage at the bottom, the effect of the aging
population on this growth. But the rest of this here is the
effect of excess cost growth. And what does that mean? Well, there’s a group
up in Dartmouth. Some of you may know about them,
the Dartmouth Atlas project. They started to look at
what this excess cost was, and was there a way
that we could actually get a handle on it? And here’s a map, and
this map shows the cost per Medicare beneficiary. How much per Medicare
beneficiary are these regions– and they’re smaller
than states– are these regions
spending on Medicare? And they controlled
for sickness, they controlled for the disease,
they controlled for everything. And what we see here is down
here in Texas, Louisiana, the dark places, bits
of California here, and some of the folks up
here in the northeast, are spending up to
$14,000 per person. Yet the same population, we’re
talking about Medicare, folks– and you look at the big
red square states up here, North Dakota, Minnesota,
Wisconsin, they’re spending only $5,000 to $6,000.
$5,000 to $6,000 per person. $14,000 per person. Same people, same
diseases, they controlled for all of that stuff. Why is this happening? Why are we doing this? Well, so then you
would ask, well, which one is the right one? Which is the right number? We don’t really know the answer. Maybe the folks down here
in Texas and Louisiana are getting the
proper amount of care. So the next thing we looked
at is what are the outcomes? We spent all this money,
what are the outcomes? And what this shows is the
ratio here, the axis on the left here, is the quality rating. How high are the
outcomes of per state? And here is the
cost, up to $8,000. And here, wouldn’t you know,
for only $5,000, this cluster, here, at the highest
rating are Iowa, Wisconsin, Minnesota, the states that,
in fact, are the lowest cost. The lowest cost are getting
the highest quality. And down here, as
you can expect, is Texas, and California,
and Louisiana. So the places where we’re
spending so much money, worse outcomes. And that’s where we’re focusing
now on what we do with policy. How do we move forward and
change that payment structure? And surprising, no,
it’s prevention. It’s wellness. It’s primary care. And that’s the difference. We’ve seen they’ve
done a ton of studies here over the past 20 years. And they’ve looked at
proportion of specialists. And specialists, because
where there’s the opportunity we have created an incentive
in reimbursement to move towards what’s expensive. So to go on that, we
have created an incentive with the way we reimburse. We reimburse for high value,
high volume, high intensity services. And the practice of medicine
has moved in the direction of providing care that way. As Linda said, there is no
incentive for primary care. There’s no incentive
for wellness. And it’s not that
providers wouldn’t want to be offering
this care, but they have to balance their own budgets. And we’ve created a mechanism
for, if there are not enough primary care providers,
we move them into the hospital. Is the hospital the right
way to take care of diabetes and chronic conditions? No, so we have to change the
way we reimburse health care. And we’re going to start with
Medicare, hopefully– and look at how we’re reimbursing it. Move it more towards
value and less on volume. Evidence-based care. We now know that probably lots
of those things on the map, in the dark areas, are
not necessary services. JAMA came out
recently, reinforcing a study that said most
folks with arthritis do not need
arthroscopic surgery. Why are they getting it done? We’re now learning that a lot
of these stents are unnecessary and actually causing more harm. We need to understand that more. And more is not always
better, and that’s something that we have to
convince Americans. More is not always better. Sometimes watchful waiting,
see how you’re doing, drug management is
the right way to go– and care coordination,
and that’s what folks all over the
place are talking about. When you’ve got
these individuals with chronic illness, one
of my favorite statistics is of all the people
with diabetes, only 10% only have diabetes. So 90% have something else, and
who’s helping them manage it? And that’s something else we’ve
seen different internationally. They do a much better job
helping someone manage that system, helping them coordinate
care, and here we don’t. Everyone is in a
silo, and in some ways it’s because of the way we’ve
created a reimbursement system. And then having
patients involved more in decision making, what
the Dartmouth folks have found, that if you really
tell them what’s involved in these
services, they might go, you know what,
let me wait a bit. Let me see how I’m doing
because I don’t necessarily want to go there. But in fact, when we
go to our providers, we say, what do you
think I should do? And we take that advice. How do we cover the uninsured? The way we’re thinking
about doing it, and the policies
that we’re looking at if you’d like to see
kind of where, I think, that the movement is probably
with Senator Baucus, who is the chairman of the
Senate Finance Committee. He put out a white paper,
talked in broad strokes but kind of the direction
that we needed to go. And quite frankly, when
you talk to experts, they’re all kind of
convening that we have to look at the public programs. We have to expand
Medicaid, and have it be into more population
than just women and children. Do we need to have folks
that don’t have children also be eligible if
they’re poor enough? We need to have some states
increase who’s eligible. It shouldn’t be just 33% of
the federal poverty level. Let’s increase it to 100%, and
there’s no standardization now. We need to allow all
those uninsured folks who can’t afford to buy in
the individual market, the individual
insurance market, which is so expensive because they
don’t have the bulk buying that the employees have. We need to create a system
where they can buy in at the same rate,
or a similar rate, that some of the big
companies are doing it. And we need to then strengthen
the employer-based system, and some are saying that we need
to require some level of care by some level of
guaranteeing health insurance by certain companies
and how big they are. And so lastly, what can you do? And one of the things I think
that’s the best way to begin, if you wanted to
get involved, is to hook up with your
professional organization. Everyone probably has some
professional organization that they’re involved with. And they’re down in
D.C., and they’ve got their finger on the
pulse of what’s going on. And one of the
things that I suggest is every time you
turn on your computer and you go to your Internet
Explorer, your Firefox, some home page opens. And if you really
want to keep abreast, have that home page be
the American Public Health Association or your
physician specialty group because a lot of
those folks are going to let you know you need to send
a letter to your congressman. And usually what
they do is they have the information right there. You fill in your name
and address, hit send, and now your representative
has heard from you and let you know what
you think is important. The second is, if
you can, get to know who your congressional members
are and their staffers. One of the things
that struck me, and you probably heard
over and over again, is how young and inexperienced
a lot of these staffers are. However, they’re
very empowered to be moving lots of this
legislation for their bosses. And if you have a
relationship on an issue that you think is important,
for example, injury prevention, you can bet that if there’s
some kind of a bill that’s happening down there and
you call them and say, hey, it’s me, remember. And let me help you figure
out how does this bill affect the folks back home? They will love that input. Now, if you call
and say when they’re in the middle of budget season. Hey, this is who I am, and
this is an idea I have. It may not work, so
timing is everything. But if you can let
them know when there’s a piece of legislation
that’s happening, that you’re out there and you’re
willing to help, I think that’s a great thing and
usually a really good resource. And then you get to know them. You establish this relationship. And quite frankly, a new bill,
a new piece of legislation that you might have an idea,
you’ve got this relationship. And remember the reason
that they’re in office is because the folks back
home have voted for them, and they want to hear from you. And I think that
whenever you’re down in D.C. for a professional
organization meeting, make sure that you make
an appointment to meet with the staffer. The staffer usually
has flexibility, ask for 15 minutes. Let them know who you
are, what your issues are, and especially now as we
move with health care reform. There are so many moving parts,
And if there is a certain issue that you think needs
to be part of this, I think take that opportunity to
let those folks down there know and also then offer to help
them work at any of the details. Remember you are the experts. It’s one of the things
that I think people, when you’re in a
place like Hopkins, you realize, oh my goodness, all
these folks know so much more. But when you’re
comparing yourself to back down there
on Capitol Hill, you really are the experts
on all of these things. Thank you. TOM BURKE: So what an
amazing agenda and what amazing optimism. There was some scary messages,
a little bit of pessimism, and great common themes. What I’d like to do now is open
it up and have a discussion there. Clearly, we saw
very strong messages about the importance of science. Perhaps, that friction between
prevention and primary health care, as always,
as we know here, is there in terms
of the spending. We heard a little bit too
much about hula hoops, but that is a part of my daily
work out as Shelley knows. But I would I would like to
open it now for questions. I also want to
welcome folks who’ve been listening
over the internet, and I know that they might
be writing in with questions. Yes? AUDIENCE: Thank you
so much for coming. My question is [INAUDIBLE]
but I mentioned [INAUDIBLE] professional
organizations, and I wanted to ask your opinion
about avoiding the fracturing within the public health
community and the health policy community in terms of universal
care versus, you know, guaranteed coverage. How do we get one voice together
so we don’t end up fracturing in like we did before? TOM BURKE: And if you
could just say a little bit about the question, so that
the folks on the internet can hear that better. ELLEN-MARIE WHELAN: So
are you asking questions like single payer versus
universal coverage? AUDIENCE: Right, because those
seven goals are fantastic, but how do we make
sure that those get passed in terms of so many
opinions within even the health care options? ELLEN-MARIE WHELAN: I think
it’s a really important question because I think once we get into
the details– like for example, there’s folks talking about,
we want to cover everyone, and we want to provide universal
coverage, provide insurance. And then there’s
folks that say, well, that should be a
single payer system. We like the way
it’s done and very successful in other countries. And when we get down
to these details, I think that there is
sometimes folks saying, but it needs to be like this,
or we won’t move forward. And I think backing
up and remembering what are– which is why
I started with the three basic pillars and then
to the seven– what is the most important thing? And I think also then
a dose of realism. We are not going to fix
the system completely with a bill that’s going
to be marked up in May, go through the committee
process in June or July, debated in August, and
then passed in September. It’s just not going to happen. So I think part of
it is also to think about what are the
building blocks that might help us to get there? Well, having more people
part of the system, especially if we’re going to
look at cost cutting measures, we don’t want those
cost cutting measures to go to balancing the budget. As much as I think
is important, we have to make sure we
use that right now to cover the uninsured. So looking at what
our priorities are at the top most
level, and it’s having most people having access
to the system and the best– and realizing that we can then
suggest ways to get there, but can we as a
professional organization agree on what the
principles that we think are the most important? TOM BURKE: Other
comments from the panel? Shelley, I’d like to ask you
a question about food safety. We’re all very happy about
Josh and Peggy at FDA. And you’re right,
FDA hasn’t been on the radar screen for
many of us in public health quite as much as other agencies. And you said, you
think it’s time. And I’d like to get your
comments on that, particularly how it might relate. And I invite all of
you, when you comment– we have many of our colleagues
from state and local practice here. And there’s the there’s the big
picture of the national agenda, but then there’s an awful
hard time these days in the real world of the
cubicles of our health departments. And I’d like to ask you
how this might reflect on the practice of public health
at the state and local level as well. So if you might talk about
food safety a little, Shelley? SHELLEY HEARNE: How many
of you eat peanut butter? How many of you still
eat peanut butter? Good. Food safety has been
on the radar screen. In fact, the Government
Accountability Office has put it as one of
the top priorities for the incoming
administration to be fixed, which is a sea change
in terms of that issue. Finally, it is time. But it has been broken
for over 20 years. And much of it, it is
a reflection of it’s always someone else’s
job to be dealing with the various problems. Right now, there
are approximately 35 federal agencies that are
responsible for different parts of food safety problems. So depending on if the
pizza has meat on it, it is regulated by one
agency versus another. If it’s an open face sandwich
versus a closed sandwich, it goes between two
different agencies. That is true also
at the state level where there is often a
mix of responsibilities. No one’s really sure is who’s
on first and what’s on second. We’re going to start
doing that comedy show. But food safety has
been, unfortunately, in this forgotten elements
with such a Byzantine maze of regulatory responsibilities
but no money, few people, and no one clearly
following the ball. This most recent incident,
with the Peanut Corporation of America highlighted
many of the challenges that have been long known
where FDA was having Georgia Department of
Agriculture inspectors playing a role, but
they had not been trained in the specialty of
peanut contamination problems. Many of those companies
were relying on third party inspection processes, but those
had become captured operations, that if you didn’t
give good ratings, you probably weren’t going
to get the business again. It’s not a very good
check and balance system. So I think it’s finally, whether
it was spinach last year, tomatoes miss-appropriately
being identified as a recent Salmonella
outbreak when, in fact, it was jalapeno peppers. It’s a Keystone
Cops type of scene. You have so many industries
who have actually recently been hurt this most recent recall. And it’s important
to point out, FDA does not have recall authority. So when there is
bad food out there they can’t order a recall. When they are
actually bad medicines they can’t order a recall. It’s voluntary. They have to ask the
company to voluntarily take those contaminated items
out of the food supply. It’s where we did not
know where the peanut butter was, which products
might have been contaminated. Many businesses got hurt. And we’re actually
at a [? sea ?] change point because
industry is now stepping up where in the
past they’ve been saying, don’t regulate us. We’ll take care of it– to a realization that there
is a role and responsibility of government to set baseline
standards to have assurances about the quality of the
consumer products you’re using. And everyone gets hurt when that
basic health is at is at risk. So when you have Grocery
Manufacturers America stepping up and willing to now
negotiate, that’s significant. When you have Kellogg, the
CEO, I think it was last week, testified before
Congress saying, we fought it in the past. We’re ready. We need change. We’ll play a leadership role. You have only a handful
of public health experts in Washington who
have been championing this for years, who’ve
been lonely and forgotten, who, now is their time. But it is political will. It is having people
like Peggy and Josh, but also leaders in industry,
willing to also step up and say it is time. And the science has been a
slam dunk for quite a while. So there’s some very
specific reforms whether it’s the de
Loro package or Durban package there will be some kind
of modification near future. I’m quite convinced it will
pass this year, which, it’s only taken 100 years to get here. I think just two other
points about that. It’s become urgent. It’s one of those things that
we needed to do it for so long that now it’s so visible. And I can tell you when being
on Capitol Hill, everyone’s writing it. When that spinach crisis
happened, everyone heard. And it’s also not
partisan anymore. Everyone’s eating peanut butter. This is affecting
everyone in a way that everyone is
looking out for this. And you see the big
square red states who are growing this
stuff, and they’re affected when you put this– look what happened
with tomatoes, and it wasn’t even
tomatoes– and everyone that were the growers of that. So I think you’re right
that this really has come, and we have to take
this opportunity and really use it to move ahead. TOM BURKE: Fran. FRAN PHILLIPS: OK, so there’s
just so many great ideas here. I don’t know where to
start, but [INAUDIBLE]. Shelly, I want to say that you
talked about some of things that the new
administration has done to revitalize the whole
landscape such as recognizing the value of science. One of the things
that I think is going to have a profound impact
is recognizing the value of government service. And whether it’s at the
federal, state, or local level, the ripple effect
is that to say this is an honorable thing to
work in public service. It’s something that
can make a change, and that it is
something that people, who are mission-oriented,
young people, can really have
their careers to. So I think that there’s, all
the way through the levels of government, I
think that that’s going to be very positive. Now, OK, peanut butter. And we all love Josh, and
we’re so [INAUDIBLE] I gave him a list [INAUDIBLE]. But here’s the thing about that. The things that’s the most
unsafe about our food supply is something that FDA, as urgent
as this is, can’t address. And that’s what’s
really burdening kids. If you look around
in classrooms, it’s not because there’s
some random salmonella in some sandwich. It’s the food environment. And so it’s coming
back to something that’s primary prevention. It’s tough to regulate. I’d love to see the
CEO of Kellogg come out and say, OK, we’re going to take
a whole new look at childhood cereals not from the
food safety but from what we’re doing in developing
the next generation of chronic disease. So OK, having said all that,
what can public health primary prevention interests,
how can those interests be advanced in this moment
of the time, which is very, very sympathetic to
looking at insuring people, cost containment,
looking downstream. But how can we get more
of that part of prevention embedded in the discussion now? SHELLEY HEARNE: Can I
start, and then I’ll– I look at food safety. I actually use the
language, food safety, to be a more systemic
conversation about food. Food safety, for me,
is the excessive levels of salt in processed
restaurant foods. AMA challenging our regulators,
our members, our policymakers, that a 50% reduction
in that excessive use is not for taste purposes,
it’s for preservation, and weight addition
in foods would save 150,000 lives per
year according to AMA if we had those reductions in
processed and restaurant foods. Sugar, getting into
the obesity issues. Whether it’s trans
fats, looking at how we’re producing food overall. I mentioned of anti-microbials,
that is just the tip of the iceberg of how
we’re functioning in terms of our food production system– or what I would actually
beg to say that we’re not producing properly, food. The amount of investments,
subsidies, and activity going on in the
food supply, is not about a healthy food supply. And I actually just came this
morning from a conference that was sponsored by
Kellogg and [INAUDIBLE], and many others to bring
together the sustainable egg, the food nutritionist, the
childhood obesity arenas, these different silos
in public health– to pull together and say,
we’ve got a food crisis taking place whether it’s
on the production end or on the quality. And quality, again, the
pathogenic issue is just– it’s almost. I didn’t say that publicly, but
it is the tip of the iceberg– kind of start doing
lettuce things– we must approach this
systemically, and we’re not. But I think that we actually
are signs of leadership– Secretary Vilsack, I appreciate
almost the food fight that’s starting to line up of
him as USDA leadership talking about food safety and
in a vacuum as we don’t have an FDA commissioner,
actually making a move of, they are going to lead the
charge on reforming our food safety issues. I’d love to see
that type of fight take place– that Obama has
made a commitment to a White House-based working group
that is going to force all of the agencies, the
many that are out there, looking at food issues,
again, not just in terms of pathogenic
contamination issues but looking at the broad scale. How can we do it, and
how can we do it better? And I applaud Michelle Obama
out there with her shovel. I think that it is a symbolic
first step that we are going to focus on food
and whether it’s about an epidemic with
our children obesity, or it’s that they
shouldn’t be worried about Sasha eating peanut butter
sandwiches three times a week– that food is going to become
foremost a health issue. And in fact, four years now
we have a farm bill coming up. And many in this room have
been thinking about and talking about perhaps next
time, it’s food bill. There’s some big changes
coming along and big signs, and in fact, this food
safety bill is just step one. TOM BURKE: Linda. LINDA DEGUTIS: I think
another piece of it too are some local
issues that people need to start dealing
with, and that’s availability of healthy
foods in the community. So there’s so many
communities where there’s lower
socioeconomic status, and you can’t get fresh
fruits and vegetables. So what are they
going to eat, and what do the kids learn how to eat? What’s advertised
and marketed to kids? You know, what do they say? They see unhealthy foods
really marketed to them. So a Happy Meal at
McDonald’s, you know, is what they grow
up on or something, and this is how
they learn to eat. So we have to also look
at some of those issues and focus on that, advocate
for making those changes. TOM BURKE: Molly, do we have
questions coming in from– that we would like to read yet? No? OK. SHELLEY HEARNE: Could Tom show
the hula hoop demonstration? MOLLY: Wasn’t going to
read that one aloud. TOM BURKE: It’s a true
story, but it’s not appropriate for this forum. And there’s this great
California website that has great weighted
hula hoops that I recommend. But yes, in the back. AUDIENCE: Hi, thank you very
much for the presentation. I was very impressed in
seeing the relationship between the quality
of care and the cost. And obviously, we are now
entering in a new public health paradigm in which the
information systems should produce better
performance measurements. I think there is a need
of new metrics, I think, public health. Most of our tools are
outdated, and they are needed to be adjusted. And I think we don’t have
accountability measurements and metrics that
will allow us also to monitor the responsibility
of the industry, the private sector, the
civil society, and even the scientific community because
the knowledge that has been available has not
be applied, and we need to accelerate
that in public health. What do you think about the
addition and the development of these new metrics
that will better monitor the performance of
our work in public health? ELLEN-MARIE WHELAN:
I think that comes up in almost every discussion that
we’re having on payment reform. Because we can talk
about, let’s reimburse based on how you
deliver the care, but ultimately it doesn’t
matter how we deliver the care. What matters is that
the patient does better. And to date, you’re right. We have not had the ways
to measure it and be accountable to the
patient improving. Because we can pay
more for the person who delivers good
primary care, but if we can’t measure the patient
ultimately doing better. So we’re actually
working closely with some folks who are
looking at health IT. And make sure– I don’t
know whether you saw it, but there was $19
billion in the stimulus package looking at health IT. And we want to make sure
that that doesn’t just mean everyone gets new computers. We want to make sure that
when we develop the health IT, it happens simultaneously
with payment reform, with the eye towards
not only individual, but how do we look at
community issues that are being influenced in the
health delivery system level? And what we think is if we start
to create a mechanism where someone says, you’re
going to get paid if you can measure outcomes. We think there’s
probably a whole group of innovators out there
who are ready to help us try to do that. The knowledge is there. It’s a hard thing to measure. And you know, I
finished a post-doc with Barbara Starfield and
Chris Forrest on primary care. And one of the reasons
was because when you do primary care,
you prevent it, and there’s nothing to measure. So how do you measure
good primary care? So whenever I was
on Capitol Hill, and we started to
talk about something, and we wanted to see if
this did a better job. And people said, yeah,
we can’t measure that. Let’s measure this because
it’s easy to measure. Well, then we’re going to
just have everyone playing toward the test of what’s
easy to measure instead of saying yes, it’s hard– but unless we put that in there. And I think health IT and
thinking about health IT simultaneously, and then
having payment reform not just be an
extra payment on top of if you did a good job putting
these mechanisms in place, but it’s kind of the
pay for performance. But it’s also making sure
it’s broader than that. And having the patient involved. Should the patient be
the one holding that? And I think those
kinds of questions– and what we’re
going to try to do is have the health IT
discussion come simultaneously with an eye towards
those things. I think it’s a great question. TOM BURKE: In the back. MARGARIE BUCHANAN:
I’m Marjorie Buchanan from the University of
Maryland, and I have a question about the silos situation. We still continue to talk
a lot about patients, and I think the population
focus is an essential discussion that we have to have. And for every investment that
we make in health care dollars, often the outcomes are, from
a long term point of view, are felt in the education
field, in the work place, in the criminal justice field. And the intersection
of the economics in each of those sectors
don’t sufficiently overlap, so that our investment
ends up in a cost savings on those ends. And I don’t think we’re
doing it well enough to bring those forces together. TOM BURKE: Any comments
from the group? A lot of nodding of agreement. ELLEN-MARIE WHELAN: And for
those of you who don’t know, Margarie’s been doing public
health for years and years. He is a great
public health nurse. He’s been doing this
for a long time. It’s such a great point, and
I think one of the things is it’s so hard to do again. And one of the
things that I think could really advance it is if
we were able to get some pilots. People that are in the field,
knowing that if I do this, and I do this prevention
here, and this kid is not going to go into the
juvenile justice system, can we then start to
measure things like that? And you know, that’s really what
folks, like at Hopkins can do– people that are
thinking about the data and how they maybe
could overlap. What we’re hoping– and what
I’m seeing now just with payment issues, but I think
will happen otherwise is we’re looking to good ideas. What are some of
the innovations? What are the ones that are
happening at a local level? Could we beef them
up to a state level? And are there enough
data– and it goes back to data collection–
that we can say, this is enough to then
implement broader. But quite frankly, those
silos is what could kill it. And if you have folks
at the local level who can come up with some good
ideas and try to branch it out, hopefully we now have
an administration that might be able to
think about those things as demonstration projects and
move it into some legislation. Because that’s the only way. I mean, public health, that’s
the problem with public health, that it is every where. And there is no
single– you know, we’re doing appropriation
bills right now. And there’s this bill. And there’s this bill. And public health
is beyond that. And Medicare and Medicaid, you
do a better job in Medicare, and you prevent Medicaid from
paying for the long term care. Even in that little silo,
it’s hard to figure out how to do that. And what you’re talking
about is the direction. And I think we have to help
those folks, who are now open to hearing these things,
give them some ideas of what we might be able to do. TOM BURKE: Yes? AUDIENCE: Dr. Hearne,
you talked about having leadership in the right places. But just– I don’t know if
it’s today or yesterday– there was 61 votes
against the reconciliation process for climate change
and a lot of surprising votes against that. How do you reconcile such
inertia for the status quo with leadership, with
our heads of agencies who are in the executive
branch that wants change in advancing these [INAUDIBLE]
the legislative inertia that is really going to
work against that. TOM BURKE: That’s
a good question. SHELLEY HEARNE: How do you
reconcile many of these pieces? Global climate change has
had phenomenal shifts. 10 years ago it would not
have passed the lab test to even have as many bills
up for consideration today that we do. Actually perhaps,
it’s the gray hair, but as I look to
where we are today, I am stunned that something
as esoteric as this issue– and it’s esoteric
in terms of this is one of the most
challenging issues to wrap your head around, that
has been because of some very significant leadership in
many different places that has put this on the radar screen. And in fact, the
political will angle is one that’s
going to move this. I actually think this can go
forward in the next few years. I think you’re going to see an
extraordinarily sophisticated political campaign
activity take place that has been responsible
for getting it to this point, which
I don’t know how many of you been tracking it. But again, I think it’s stunning
to the achievement of the bills that are out there. I think that you’re going
to see a sophistication that is unheralded, unprecedented,
in the public interest community from the
amount of money that’s going into
[? C4 ?] activities with the advocacy community. You have literally
hundreds of millions of dollars that are going into
phone bank operations, that are going into very targeted
districts in the Congress of where you see some that
recalcitrance and some of that hesitation. They are being targeted
in the activities, whether it’s now shifting
into political giving, to advertisements that are
targeted to either we’re going to vote you
out or we’re going to put the pressure on that
you’ve never seen– and also industry leaders. Some of the top businesses that
have stepped forward and said, they will start spending some
of their political capital. I would not have
bet on this issue 10 years ago that
you’d see change in 10. It is here today. You’re going to watch what
happens because it’s something republic health can
learn significantly from the sophistication of
moving complex issues that are against some very
strong opposition. And we’re going to
see not the best bill, but there’s going to be
some significant compromise provisions that are
going to go forward. Watch, it will happen. Ruthie. AUDIENCE: So I think it’s great
that health reform has finally come to be a front burner
issue down in Washington. But part of the
reason is that it has become an issue is that it’s
tied with the economic crisis, that health reform is
becoming an economic issue. And so I’m wondering what
you think the public health implications are
of making health reform an economic issue
instead of just a health or a public health issue? TOM BURKE: So I think the
quote was, to fix the economy, we have to fix health care. I wrote that down. Good question, Ruthie. LINDA DEGUTIS: Yeah,
it is a good question. But I think the public
health implications are that it’s actually
now this opportunity to do something about it. I’m not sure it’s a
bad thing that it’s being tied to the economy
because people weren’t going to look at it before. And in fact, the way
people have tended to view public
health is, oh, that’s sort of those services
for all those people who don’t have any money. And it’s not in something
that is well understood by the general public. In fact, how many of
you who are here, do your families
understand what you do? You know, right? If you’re a doctor or a nurse,
they can kind of get that. You know, but if you
work in public health it’s a little hard, sometimes,
to explain what it is. So I think it’s
maybe to our benefit that it is being
tied to the economy and that people are
realizing that you have to do something
about health in order to have a good economy. TOM BURKE: So we’re getting
a little short on time. I’d like for each of
you, maybe, to close. So we’re in this ivory
tower here at Hopkins, and we see all this great
change happening down the road. And I get a little
nervous that there’s a disconnect between the schools
of public health in general and the reality of the issues
of leadership and science and moving things forward. So I was wondering
if you might be willing to close with some
recommendations for how the school can be more involved,
better prepare our students to participate in
this process and help move public health ahead? So starting with taking
Shelley’s course, which I know she has to teach
right after this– SHELLEY HEARNE: How many
of you are in that class? We’re going to be a little– TOM BURKE: You’re going
to be a little late. SHELLEY HEARNE: I’m still here
reconciling your question. And I’m going to
start there because I want to point out
because Congress did not pass reconciliation. Reconciliation is
considered, right now, a nuclear bomb approach. And I think the fact that
it’s not being voted on and being saved potentially
for the budget and health care is a reflection that global
climate change has actually become a bit of a
bipartisan issue. And you do have bills
that have both parties on. And I don’t think they’re going
to need the reconciliation piece in order to have passage. And a part it comes
back to, there’s some lessons that have been
learned over this past 10 years of moving this that
apply to public health. And I’m going to
go back to what I said at the podium, which
was leadership, science, and political will. And the translation piece for
schools of public health that I think it is now more than ever
the time for the public health field– in particular, our
next generation sitting here– that those leadership
positions are desperately needing the people who
are trained in science, and how to translate
it, and how to take risk in those leadership spots. It’s not by happenstance that
people like Peggy and Josh are coming in. Many of you are the
next Peggy and Josh’s. In fact, Josh I think is– well, he is younger than–
and I won’t go into– TOM BURKE: Josh really is 30. SHELLEY HEARNE: Yeah,
I think he’s 29. Your point– I actually
don’t know your name– but it was a very important
one on public service. It is an honor,
and in fact, I pray that many of you in
this room do take a stint in government service. I think it is not only
desperately needed, but I think it is a
public health duty. And it is where some of the
best opportunity for change and impact having
come out and had time in a government agency,
I’ve never learned more. And I’ve also never
had an opportunity to have as much inside influence
to actually move change. So the public health agencies
desperately need you. They are extraordinary
learning opportunities, and it is how it will stage you
to play those leadership roles. Science matters, and it’s
places like Johns Hopkins that keeps its eye and is
focused on the quality and credibility of the
data, and making sure that the data is not used to try
to make a point that it’s not meant to, but really staying
true to what the science says, and being the truth teller,
that plays that role to make sure there really is
evidence-based decision making. And political will is part of
which you were talking about. The room here, your expertise,
has extraordinary power and credibility. The American Public Trusts– nurses most, doctors come
in a very close second. Public health leaders– well,
I think they’re off the charts, but I don’t think we’ve
actually polled specifically on public health because
no one knows what it is. But you’re trusted. And use that
credibility, honor it, but use it to speak up
because public health is about translation. It’s not sitting
in a research lab. It’s about taking your
information, knowledge, and showing up at those offices. That’s where Johns
Hopkins and the field can make the most
powerful difference, is bringing your science,
bringing your leadership, bringing it to the people
who need to hear from you. TOM BURKE: Linda. LINDA DEGUTIS: I
would also like to add that the faculty need to serve
as role models for students in doing that. It’s a little bit
more of a challenge. But I think that often we
don’t see faculty really engaging in advocacy or
in taking their science and translating it so
that it can be used. TOM BURKE: Thanks
for saying that. LINDA DEGUTIS: And I
think that’s a challenge. Yeah, the translation is
the real piece of things. And I think teaching students,
as part of their program, how to translate data so it can
be used by advocacy groups, how to speak to
the media and not be afraid that things
are going to be twisted– because you have a
lot of people who are scientists who worry
about talking to the media and getting the data out
there because they’ll say, well, you know, they’re
just going to twist it. So the question I often
ask is if you write a paper and it sits on somebody’s shelf,
yeah, it gets you promoted, but does it make a
difference in the world? You know, you need to be
able to take that paper, and take what’s in
it, and translate it so people can use it when they
go to talk to policymakers on the hill, when
they go to talk to people at the local level. And we’re not always very
good at teaching people how to do that or at
doing it ourselves. So I think it’s one of the
reasons I’m not a professor. I haven’t written enough. I spend too much
time doing advocacy. TOM BURKE: We are working on
that here, believe it or not. LINDA DEGUTIS: But you
know, I think that’s really a critical piece of it. And I think that the
other issue that I have with a lot of
schools of public health is that often their policy
divisions, or sections, or whatever focus so much
on health system policy that they really ignore public
health policy or policies that affect health. And I think we need to make
sure that we have people who have similar kinds
of roles– you know, economists, other
people who are thinking about the impacts of policy
but are looking at broader policies that affect health. And sometimes we have to
reach outside the walls of this school of public
health to get people from other parts of campus
or from other disciplines to work with us on
some of those things and teach them how much their
policies are affecting health.

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