KAISER PERMANENTE SCHOOL OF MEDICINE Child Health Policy

KAISER PERMANENTE SCHOOL OF MEDICINE Child Health Policy in the US Paul J. Chung, MD MS; Health Systems Science, Kaiser Permanente School of Medicine 1 kp. org/schoolofmedicine November 22, 2020 CONFIDENTIAL © 2016 Kaiser Foundation Health Plan, Inc.

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Stuff You Already Know § Health care spending rises almost continuously § In 1960, 5% of GDP; in 2016, 18% of GDP ($10, 348/person) § More than national defense, Social Security, and public education combined § If we… § reduced health care spending by just 1% GDP § and reallocated that money to existing programs § we could cut US child poverty in half…by ourselves § US spends vastly more than other developed countries § Twice as much by %GDP as OECD median § 40% more by %GDP than world #2 (Switzerland) 2 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Stuff You Already Know, Part 2 § Among developed nations, US worse than median on: § Health status—Life expectancy at birth, life expectancy at 65, infant mortality, potential years of life lost, suicide rate § Health resources—Number of hospital beds, number of doctors § Health care—Number of doctor visits, child vaccination rates, length of hospital days, number of hospital discharges § US wastes up to 1/3 of all health care spending on unnecessary or improper care § Central problem of US health care: § Extraordinary prices for very ordinary service § Health care is not just enormous cost but enormous opportunity cost 3 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE What We Need to Do § Reduce health care spending and investments by 1/3 § 6% GDP = $1. 1 trillion/year § Reallocate 6% GDP to health-promoting non-health care spending and investments § Redesign both health care and health-promoting non-health care systems to increase efficiency, effectiveness, and equity § How to reduce, reallocate, and redesign 1/6 of US economy is the fundamental health policy challenge and opportunity of our lifetimes 4 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE A Question of Value § Value = ∆ Health (or Outcomes or Quality) / ∆ Costs § Origins in quality, cost effectiveness, and outcomes movements § Value depends on how health and costs are defined and prioritized § Health and Costs § What measures should be included? § Whose health and costs should be counted (individual, family, provider, payer, government, society)? § Who gets to decide? § Health, cost, and value are political, not scientific, constructs 5 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE What Is Health? § No one knows § WHO definition (1948) § “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” § Somewhat useful—established physical, mental, and social domains; importance of well-being; but ultimately meaningless § Ottawa Charter for Health Promotion (1986) § “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. ” § More useful—health is not an end, but a means to an end; but what end? 6 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Getting Closer… § Netherlands Organization for Research & Development (2009) § “an inner resource, a capacity, an ability, a potentiality to cope with or adapt to internal and external challenges, to perform (relative to potential, aspirations and values), to achieve individual fulfillment, to live, function, and participate in a social environment, to reach a high level of well-being, even without nutritional abundance or physical comfort” § Perhaps achieving optimal health means: § Maximizing one’s individual potential, and then § Participating in society to best of one’s ability 7 November 22, 2020

Child Health Policy in the US 8 November 22, 2020 KAISER PERMANENTE SCHOOL OF MEDICINE 8

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE A Better Definition of Health § Perhaps health can be defined as: § Expected future net societal productivity § “Expected future” § Present health = future potential through remainder of life course § “Net” § What you give is diminished by what you take § “Societal productivity” § Measured as probabilistic benefit to society (i. e. , others) § Not only economic but also non-economic (e. g. , care, joy) § We find our gift, and then give it away 9 November 22, 2020

Productivity Across the Life Course § Net food production and survival of human foragers and chimpanzee s (Kaplan et al. , 2009) § Light lines = chimpanzees § Dark lines = human foragers 10 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE What Childhood Factors → Adult Productivity? § Physical and mental health status, behaviors, and care …but also… § Fetal development vs. stress § E. g. , fetal origins of adult disease (Barker hypothesis) § Resilience vs. traumatic/environmental exposures § E. g. , adverse childhood experiences (ACEs), injuries, toxins § Social integration vs. isolation § E. g. , child protection, incarceration, racism § Child development and education § Economic security and equality 11 November 22, 2020

1 2 Fetal Origins of Adult Disease § Not only infant mortality but also adult cardiovascul ar outcomes are strongly associated with birth weight (Dover et al. , 2009) 12 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Adverse Childhood Experiences § Childhood exposure to abuse, neglect, household dysfunction § 4+ (vs. 0) ACEs associated with (Felitti et al. 1998): § § § § 13 Alcoholism (OR 7. 4 [5. 4 -10. 2]) Illicit drug use (OR 4. 7 [3. 7 -6. 0]) Chronic lung disease (OR 3. 9 [2. 6 -5. 8]) Sexually transmitted infection (OR 2. 5 [1. 9 -3. 2]) Stroke (OR 2. 4 [1. 3 -4. 3]) Ischemic heart disease (OR 2. 2 [1. 3 -3. 7]) Cancer (OR 1. 9 [OR 1. 3 -2. 7]) Diabetes (OR 1. 6 [OR 1. 0 -2. 5]) November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Youth Incarceration § Youth incarceration >1 year associated with (Barnert et al. , 2017): § Adult functional limitations (OR 2. 9 [1. 5 -5. 6]) § Adult depressive symptoms (OR 4. 2 [2. 5 -7. 1]) § Adult suicidal thoughts (OR 2. 3 [1. 1 -5. 0]) § Adult outcomes even worse when incarceration occurred at <15 years old (Barnert et al. , 2018) 14 November 22, 2020

1 5 Education and Health in US § Remaining life expectancy at age 25 (Rostron et al. , 2010) § College graduate: 62 years (women), 57 years (men) § High school graduate: 56 years (women), 51 years (men) § Less than high school graduate: 50 years (women), 44 years (men) 15 November 22, 2020

1 6 Income and Health in US § Expected age at death for 40 -year -olds (Chetty et al. , 2016) § Top 1% household income: 89 years (women), 87 years (men) § Bottom 1% household income: 79 years (women), 73 years (men) 16 November 22, 2020

1 7 Education and Income in US 17 November 22, 2020

1 8 The Result: Segregation of Health § Family, social, educational, and economic systems define and are defined by neighborhoods § Neighborhoods becoming more homogeneous and extreme over time (Reardon et al. , 2011) 18 November 22, 2020

1 9 Breaking the Cycle: Moving to Opportunity § HUD-sponsored RCT in 1990 s (Chetty et al. , 2016) § Gave low-income families vouchers to move to lowpoverty neighborhoods § Income by ages 20 -28 § Blue = moved before age 13 § Red = moved age 13 -18 § But you can’t move everyone § Also need solutions independent of mobility 19 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Education: Early Childhood Development § Perry Preschool § Preschool plus home visitation program with certified teachers in lowincome black community in Michigan § Compared participants vs. non-participants through age 40 § No long-term differences in IQ scores (non-cognitive!), but less special education, higher achievement scores, higher high school graduation rates, higher incomes, less arrests § 16% annual ROI to participants, 12% annual ROI to society § $17 returned to society for every $1 invested by age 40 § Results partially replicated in studies in New York, North Carolina, and Head Start § Side note—Universal preschools? 20 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE Education: The Importance of Teachers § Teacher value-added § Measured by student test score changes statistically attributable to teacher exposure; limited and controversial measure § Chetty et al. (2014) examined 20 years of school district and tax data for 2. 5 million 3 rd-8 th graders and their Math and English teachers § Exposure to just 1 higher-value teacher in 1 year had no long-term impact on test scores (non-cognitive!), but increased adult earnings and wealth, increased college attendance and college quality, and reduced teen pregnancy § Replacing just 1 low-value teacher with 1 average-value teacher returned $200, 000 in increased adult earnings per classroom per year 21 November 22, 2020

2 2 Is There a Child Health Story to Be Told? 22 November 22, 2020

2 3 Example #1: Many Health Behaviors Are Improving 23 November 22, 2020

2 4 …And Health Insurance Coverage Is Rising 24 November 22, 2020

2 5 …But So Are Chronic Healthcare Needs 25 November 22, 2020

2 6 …And Recently, Mental Health Problems 26 November 22, 2020

2 7 Example # 2: Prenatal Care and Maternal Smoking Are Improving 27 November 22, 2020

2 8 …And Teen Births and Infant Mortality Are Dropping 28 November 22, 2020

2 9 …But Low Birthweight Isn’t Changing 29 November 22, 2020

3 0 …And Maternal Mortality Is Rising 30 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE What Is Going On? § There are limits to what individual/public health/health care system improvements can accomplish § Binge drinking, health insurance coverage, prenatal care, maternal smoking, teen births, and infant mortality are all improving § But to what end? § Social/environmental systems are the sine qua non of health § How do we leverage and/or redesign social systems to improve health? 31 November 22, 2020

Some Social Systems Are Improving 32 November 22, 2020 32

3 3 We Are Becoming a Less Violent Society 33 November 22, 2020

3 4 …And a Less Vindictive One 34 November 22, 2020

3 5 We Are Making Gradual Gains in Education 35 November 22, 2020

3 6 …And Gradually Reducing Poverty Figure 1 a: Official Poverty Rates Vs. Anchored SPM Poverty Rates for Children Aged 0 -5, 1968 -2011 SPM OPM 40. 0% 35. 0% 30. 0% 25. 0% 20. 0% 15. 0% 10. 0% 5. 0% 19 6 19 8 7 19 1 7 19 4 7 19 7 8 19 0 8 19 3 8 19 6 8 19 9 9 19 2 9 19 5 9 20 8 0 20 1 0 20 4 0 20 7 10 0. 0% 36 November 22, 2020 § In 2017, child poverty in US 15. 6% (SPM) instead of 17. 5% (official) after accounting for such things as: § Refundable tax credits (e. g. , EITC, CTC) -6. 1% § SNAP (food stamps) -2. 0% § Social Security -2. 0% § Housing subsidies -1. 2% § School lunch -1. 0% … § FICA taxes +1. 9% § Work expenses (e. g. , child care) +2. 4% § Medical OOP expenses +3. 1%

3 7 But Inequality and Segregation Haunt Us § Expected age at death for 40 -year-olds (Chetty et al. , 2016) § Large gradient by household income in every city § Cities begin to diverge below median household income § At bottom 5%, gap between New York and Detroit is 6 years 37 November 22, 2020

3 8 …And It’s Even Worse Than You Think § Life expectancy at birth in LA County (LAC DPH, 2010) § Difference between highest and lowest neighborhoods is 16 years § Strongly correlated with neighborhood-level gaps across all key determinants 38 November 22, 2020

3 9 Plus There’s This. Holy Hell. 39 November 22, 2020

Child Health Policy in the US KAISER PERMANENTE SCHOOL OF MEDICINE What Should Child Health Policies Look Like? § Individual, family, and health care system policies are important § But they are incomplete and relatively ineffective without broader social/environmental system policies (e. g. , schools, neighborhoods, local institutions and infrastructures) § Policies should be focused on key childhood determinants of adult health § Policies should deliberately address segregation and disparities by place, race, gender, and other factors 40 November 22, 2020