Shifting The Nation’s Health Investments To Support Long, Healthy Lives For All

Proceedings of a Symposium

On March 6 and 7, 2023, the Roundtable on Population Health Improvement hosted a two-day symposium at the National Academy of Sciences in Washington, DC. The event, Shifting the Nation’s Health Investments to Support Long, Healthy Lives for All, was designed to explore past calls for and the current state of efforts to:

Increase life expectancy

Eliminate excessive health care spending

Invest equitably to create the vital conditions that all people and places need to reach their full potential for health and well-being

The current state was compared both to the past as captured in two National Academies reports published one decade ago – U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013) and For the Public’s Health: Investing in a Healthier Future (2012).

Statements and opinions expressed are those of individual workshop presenters and participants.1

KEYNOTE SESSIONAnchoring in Curiosity

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  • Tiffany Manuel

    “We don’t want to be a wreck on a wreck.”

    Tiffany Manuel, The Case Made

    Manuel explained that there is plenty of data on and recognition of the nation’s shortcomings and challenges in health and health care, and there is a habit of repeatedly reciting the facts and issues, though little work gets done to address and prevent them. The fixation on the problems can make them seem overwhelming. Because of this, there is a need to shift the perspective to one that centers on ingenuity and achievement.

  • Dave Chokshi

    “The decline of life expectancy in our country is happening on our watch…these are our grandparents, our children, our aunts and uncles, our neighbors who are not able to live their most fulfilled life because of that health disadvantage.”

    Dave Chokshi, NYU Langone Health

    Chokshi suggested the need for new narratives, where issues are communicated differently to the public. In his words, they must be “stickier” than current narratives... like the zero-sum paradigm or the American dream, which are dangerous and unproductive, especially when juxtaposed with the reality of the U.S. population’s state of health and well-being. To demonstrate this new narrative idea, Chokshi gave the example of 16 million birthdays lost each year due to the country’s years of potential life lost. By framing the issue this way, the health disadvantage in the U.S. becomes more personal. Pointing to the power of narratives to shape policy structures, Chokshi asserted that when properly leveraged, they demonstrate that “we can do big things.”

  • Anita Chandra

    “Let’s not make the conversation small. Let’s make it bold and grand.”

    Anita Chandra, RAND Cooperation

    Chandra questioned whether the nation has fully leveraged the opportunity presented to it by the crisis. She asked the audience whether the conversations currently happening on big issues will add up to make a real difference in 10 years. This is where optimism meets worry, that the U.S. is missing “the forest for the trees,” said Chandra. To move the nation forward, she asserted, the full health potential of the country must be considered, new ideas must be supported and sustained, and vision and values must be declared and shared.

SESSION IIShowcasing What is Possible

The second session of the symposium featured a gallery walk, where several speakers presented models of what public and political will-building (using different strategies and at different scales) can achieve in changing the social and economic conditions for population health.

  • Sue Polis Engaging and Empowering Cities

    The NLC Cities of Opportunity initiative bolsters community health by strengthening the capacity of city leaders to advance policy and systems change. Through a focus on data use and analysis, strategic funding/financing, civic engagement, internal resource alignment, structures for equity and race, and multi-sector partnerships city leaders are able to better recognize and address health equity issues in their communities.

    HIGHLIGHTS

    • “How well do we live? How long do we live? Follow the data.”
    • There is no one thing to do that can alone improve community health.
    • Meet cities where they are (not where we wish they were).
    • Strengthen city capacity by:
      •  Designing an initiative that can meet each city’s level of readiness.
      •  Listening to where cities currently are in their work and build on what is learned.
    • Use data analysis and move toward policy change.
  • Dorianne Mason Supporting Families

    Grounded in its work for gender equality and justice in law and policy, the Center illustrates what it means to take an intersectional and holistic approach to health in the United States.

    HIGHLIGHTS

    • Bridge what people perceive as health and what actually affects their health (e.g., through paid leave, child tax credit, community-based services).
    • How a message is presented to people matters, including highlighting the importance of the health perspective in other sectors (e.g., economic, political) is key, and data can help.
    • Current efforts to renew the expanded child tax credit represent an example where a policy’s value and sustainability depend on its connection to economic stability and understanding how the credit frees up household resources to be allocated elsewhere.
  • Speaker Thumbnails Dismantling Poverty

    Washington State has developed a 10-year plan to reduce poverty and to create a more equitable future through equity, anti-racist policy, and program and funding changes. The plan was co-created with a steering committee of people with lived experience in poverty, who set its priorities and guided its development.

    HIGHLIGHTS

    • There have been 70 policy, program, and funding actions since the program’s start in 2021.
    • Centering lived experience is now a mandated practice for agencies in Washington State. “It’s harder to judge someone when they’re sitting in front of you and telling their story.” (Bereskin)
    • The plan is iterative in nature to respond to emerging needs.
    • Work is created to be bipartisan, where the fundamentals of what most people want are examined, and these almost always align.
    • Eight strategies to reduce poverty outlined in the 10-year plan:1
      • Undo structural racism.
      • Balance the power
      • Increase economic opportunity.
      • Ensure foundational well-being.
      • Prioritize urgent needs.
      • Build a holistic continuum of care.
      • Decriminalize poverty.
      • Prepare for the future of work.

    1 The strategies are listed in the one-pager prepared by WA DSHS, available at https://dismantlepovertyinwa.com/wp-content/uploads/2021/11/Dismantle-Poverty-One-Pager.pdf (accessed April 3, 2023).

  • Aparna Mathur Reweaving the Social Safety Net

    The social safety net is a system of government assistance programs and services for needy and vulnerable individuals and families. Currently, the social safety net presents many barriers to those who need to access it (e.g., varying eligibility across states, different or multiple applications per program), and there are experts seeking solutions to address these access barriers.

    HIGHLIGHTS

    • Families and children with access to safety net programs (e.g. food stamps) and tax credits have better health and economic outcomes.
    • Most people do not take full advantage of the multiple safety net programs available to them due to the difficulty of accessing them. Using the Survey of Income and Program Participation household survey, Mathur shared that her analysis shows:
      • 33 percent of people living at or below 130 percent of the federal poverty level (FPL) successfully access more than one program for which they qualify.
      • 38 percent of people living at or below 130 percent of the FPL do not access any program for which they qualify.
      • Results may be subject to under-reporting since they are coming from a survey of households. However, currently there is not one administrative data source to consider multiple benefit usage for households across these programs.
    • The COVID-19 pandemic led to the U.S. seeking solutions it normally would not pursue like direct cash transfers. The government made a proactive effort to find people and give them the support they needed – usually the onus is on the individual experiencing the crisis.
    • Rather than multiple siloed government programs, consider the benefits of providing cash or a “one stop shop” where people apply once and are automatically enrolled in other programs.

“Where is the trust? It’s in how we see each other…our wisdom traditions teach us to love one another as ourselves – not in some transactional way – but literally as ourselves to embrace this.”

Tyler Norris, Federal Reserve Bank of New York

SESSION IIIRevisiting Two Landmark NASEM Reports

The next session of the symposium featured Marthe Gold, professor emerita at the City University of New York, Steven Teutsch, adjunct professor at UCLA who led the committee that authored For the Public’s Health: Investing in a Healthier Future (the Investing report), and Steven Woolf, director emeritus and senior advisor for the Center on Society and Health at Virginia Commonwealth University, who led the committee that authored U.S. Health in International Perspective: Shorter Lives, Poorer Health.

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  • Marthe Gold

    “People don’t galvanize around health.”

    Marthe Gold, City University of New York

    The term well-being may be more accessible and meaningful than health because people do not galvanize around health, Gold said. They care about it when they lose it, but by then it is too late to muster the energy to do something about it at a high level. However, people care about their job security, where they live, and how safe they feel. Considering this, health can be the anchor, but it is not what will help get people motivated and organized to take action, Gold noted.

  • Steven Woolf

    “There are 15 countries that have had higher life expectancy than the United States for 50 years…they have figured this out. We know policies that could work…but promoting them, getting the political and public will behind that, I think is really where our focus needs to be.”

    Steven Woolf, Virginia Commonwealth University

    Woolf echoed Gold’s call for transcending the concept of health for more accessible language on what needs to be improved in order to convince society and policy makers. ... He pointed to five distinctions between the United States and other wealthy countries made in the report: the structure of the health care system; personal behavior; economic and social factors; the environment, both physical and social; and the domain of public policy – the macro factor that shapes the other four factors.

SESSION IVAmplifying Signs of a Movement

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  • James Whitfield

    “Equity is shared ownership where there are multiple owners. Equity in every other context is exactly the opposite - it’s additive every time.”

    James Whitfield, Be Culture

    Whitfield used the example of one’s equity in a company, noting that when a person “buys into a company,” they participate in setting the direction of that company and reap the benefits of that shared ownership. In addition, that company increases its worth. He noted that the same is true of health equity, though there is a common misconception that advancements for certain populations result in losses for others. Equity is additive every time, stated Whitfield. When more people buy into an idea, it increases the value of it, Whitfield explained, and in order for health equity to work, everyone must buy into and contribute to it. In doing so, everyone will experience its benefits in society; however, to achieve that, health equity first requires a shared ownership over a definition of success, as well as a shared ownership over the challenges and barriers to that success.

  • Martha Sanchez

    “Young people aren’t doing that great…young people are in a crisis.”

    Martha Sanchez, Young Invincibles

    Sanchez spoke about the group’s beginnings, with college students advocating for young people being able to stay on their parents’ health insurance up to age 26, something that became a part of the Affordable Care Act. That policy solution emerged in response to a slow-growing crisis of people without health insurance. Young Invincibles is a kind of wordplay on a truism that young people feel invincible, but, she noted, young people are not doing so well, they are in crisis. More recently the group has been working on issues at the interface of health and well-being—paid leave and student loan forgiveness. How does one bring to the attention of Congress the story of a young person on TikTok venting about not being able to afford therapy for a mental health issue, she asked, adding “When you think of movements, they are usually led by young people. We must include them in these conversations and invest to make sure we are able to amplify their voices.”

  • Somava Saha

    “Let’s not make the conversation small. Let’s make it bold and grand.”

    Somava Saha, WE in the World

    “How serious are we? Every system is perfectly designed to obtain the results that it gets, and we are the system.” To move the nation forward, she asserted, the full health potential of the country must be considered, new ideas must be supported and sustained, and vision and values must be declared and shared.

  • Jennifer Bereskin

    “I’m going to go home and I’m still going to be suffering after this…if you’re in a position of power and privilege and influence, how are you going to be able to use that to uplift our people? For us, in our community, greed was a crime…if you were greedy, you were going to kill your entire community.”

    Jennifer Bereskin, Steering Committee for the Governor’s Poverty Reduction Work Group, Washington State

    As a member of the steering committee to the Governor’s Poverty Reduction Work Group, Bereskin advises on health equity efforts for indigenous communities ... in Washington State and she does this with the experience having lived 38 years in poverty. She said professionals, leaders, and people in power must decide what to do and to make real changes because the issues discussed throughout the symposium affect real people like herself.

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1 This page is a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants. These views are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

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