In determinants of several very common chronic diseases, we see something very different. Seventy percent of colon cancer and stroke is really heavily contributed to by nutrition, exercise, sleep, stress, work environment — social and behavioral factors. And people say 80 percent of heart disease is strongly tied to these factors, 90 percent of adult onset of diabetes. We tend to see it at the very end, when the person has the acute event. They have a heart attack, and they need to go to the hospital. And of course at that time, the angioplasty is the thing, but if we were to look at the lifetime, we would say, "Well, it had nothing to do with the angioplasty." It had to do with what the person was eating and the exercise and the kind of stress environment they had, and the kind of housing they had, and education.
Most of your early research was on how to improve the quality of medical care? How did you come to this project, focused on the nonmedical side of things?
Always in the back of my mind was that no matter how good our medical system is, we are still not as healthy a population. I got to a point, I was teaching a course in the history of health policy and really started thinking to myself: Why has this statistic been here for 30 years? We're just spending so much, but we're not getting so much, and that's when it really hit me: OK, quality of medical care is important, but it's not everything.
In your book, you call for a greater coordination between the provision of health care and other services, such as housing and food and transportation. Are these services typically bundled together in other countries? Why don't you think they are in the U.S.?
In our successful countries, particularly Scandinavia, yes, these are bundled together and the budgeting process is one that happens at the county level, in which the county authority has the full bundled budget to decide how much of this do we spend in education, and how much do we spend in health care. Now, we are not Scandinavians. We do not have the values that are the same; we are not as homogeneous. We're much bigger. Lots and lots of reasons.
But aside from those demographic and cultural reasons in the U.S., our decisions about social services tend to be made very locally, and our decisions about health care services tend to be made at the state or federal level or at the employer level. In other countries, the health care system and the social-service system are being made at the same level, the decisions, and by the same people and in the same public purview. At the U.S., we have complete fragmentation about how these decisions are being made.
Is there a way the U.S. could be spending the money on this sort of bundled health care and social services more effectively?
Absolutely. There is no question in my mind we could be doing this better and more cost effectively. We have had a fair number of people who are really concerned about spending, and Republicans in nature who really liked the book because it's expedient. For example, we profile certain programs where people are coordinating between a major academic medical center and a community center to say we have a joint problem. You really need to house these people, and we in the hospital really need to take care of them when they're in emergencies, but we're really getting all these people in the emergency room when they need housing. How can we coordinate with each other in a way that's win-win and we are seeing benefits?