Why Healthcare Policy Needs To Focus On Prevention

Policymakers need to help Americans make the healthy choice the easy choice.

Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman, that's Pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And today's conversation I think will matter if you care about your health, the health of our country, and trying to find solutions to our chronic disease epidemic that's crippling everyone in this society in one way or another, whether it's someone you love or yourself. or economy or just all the crazy crises of health that we have in this world today that we really find are mostly unnecessary because we can prevent them. And that's why I've invited Dr. Anand Parekh who's an extraordinary physician. He's the chief medical advisor for the Bipartisan Policy Center, which is a group of policy makers, physicians, scientists come together to solve difficult problems around health in the country. It's pretty extraordinary and many other issues. He's provided incredible support to our nation through his work in the government. He's basically been focused on work that he did through his decade of service at the US Department of Health and Human Services. He was the Deputy Assistant Secretary for Health from 2008 to 2015. He developed and implemented national initiatives on prevention, wellness and care management. At the BPC now he's focused on areas of aging, prevention and global health. really an important figure in our country in trying to think differently about how we solve our big chronic health issues. He's a board-certified internal medicine doctor. He's a fellow of the American College of Physicians. He's an adjunct professor of health management and policy at the University of Michigan School of Public Health and assistant professor of medicine at Johns Hopkins. He's spoken widely and extensively and written a lot about topics on health, including his new book, Prevention First: Policy Making for a Healthy America, published by Johns Hopkins press, which is an amazing book. I read it. It's a little dense, but it is full of the solutions that we need to solve our chronic disease crisis. All right, welcome, Doctor.

Thank you, Dr. Hyman.

Great to be on the podcast with you. So we met a number of years ago when I came to Washington. I was at Human Health and Human Services advocating for lifestyle interventions for chronic disease as treatment. And I went around and met with many leaders in healthcare at the time, the head of the Senate Committee, Congress, Secretary Sebelius, Nancy-Ann DeParle in the White House, trying to advocate for a simple idea, which is we could take these patients with chronic disease and use aggressive lifestyle interventions in groups to help them transform their health and get better. And everybody was 100% on board and nobody wanted to vote against it, but it ended up on the cutting room floor in the Affordable Care Act because there was all the back room of course trading, I think that happened. But everybody was on board with the idea because they realized that we really have this global crisis and in America we're leading in that global crisis. We have the best trained doctors in the world. We have the best hospitals. We have the best technology. We have the most cutting-edge treatments and drugs for a whole multitude of problems. Patients come from all over the world to get health care here. But on the other hand, our own citizens are pretty unhealthy. In fact, we have pretty crappy life expectancy. I think we're 43rd in the world. Yet we spend more than twice any other nation on health care. We have services aren't guaranteed to everybody. We have uneven quality of care. We have health disparities. And we're lagging behind almost every other country in health metrics, including infant mortality, life expectancy. How come?

It's a great question. A lot of, I think, important reasons for that. I think you're absolutely right. There are significant disparities in the United States, and I think that's one of the reasons why we're different. Just take income. If you compare life expectancy of the top 1% wealthiest Americans, you compare it to the 1% poorest Americans, there's a 14-year life expectancy difference for men and a 10-year life expectancy difference for women. matters. Take race. Though infant mortality has gone down in this country, we are behind many of our peer nations. And one reason for that is disparities based on race and ethnicity. African American populations, American Indian populations have significantly higher infant mortality rates than other subgroups. So race is also important. Our system also, Dr. Hyman, our health system is different in the sense that, you know, we only have about 90% of Americans with health insurance. Most of our peer countries have of 99 to 100%. So a lot of differences that way. I think the final difference I would note is lately there's been a lot of research on how much we spend in this country on healthcare versus social services.

And if you compare... We're paying for the wrong end of the equation, maybe.

That's right. That's right. We spend nearly 18% of our GDP, as you know, in the United States, on healthcare, compared to many other countries.

That's almost $1.50 of our entire economy.

That's exactly right. $3.6 trillion, and we are headed to $4, $5, $6 trillion in the near term. And if you compare that to our peer countries, many well-developed countries, that's almost twice as much on the social services side. So what does that mean? That means investments in housing and nutrition and transportation and education and income supports. We spend probably a little bit less than our peer countries or about that much. But if you look at the ratio, so social services to healthcare, we're at about one to one, whereas most of the countries that we compare with are close to two to one. And that ratio matters because there's been research even domestically that looks at the 50 states in our country and those states that have a higher social service to healthcare services ratio, they have better outcomes. They have less chronic disease risk factors. They do better with chronic diseases. lower mortality rates. So it's really that ratio of social services to health care services as a country were out of whack.

So they take care of people before they get sick. And we wait till they get sick.

Absolutely, so whether it's children's and child care, whether it's seniors and in-home supports and home delivered meals, whether it's paid family leave for working Americans, the social service reports, supports in those countries, we have them here. But the ratio of social services to health care service report, a service spending, that is really what's different in this country.

And I imagine what's not captured in that is, and we're spending twice as much on health care because we're not taking care of those people early, is also another invisible cost, which is productivity.

Absolutely.

Because if you have a population that's healthy, they're more productive, more engaged with their communities and families, when you have our population, which is super sick, you lose all this productivity value in the economy. So the costs are probably even more.

Absolutely. And that's not to take into account even from a national security perspective. Our military, this is the number one reason for new recruits who want to enter the military. The number one reason that they're not allowed to join is because of obesity and high body weight. So all of these issues, whether it's economic, military, national security, our standing, that we're all connect back to the need to focus more upstream.

Yeah, I mean, even, you know, I mean, General Jack Keane, I knew him, he was a big commander in Iraq War, and he said, you know, 70% of the recruits from the military are rejected because they're unfit to fight. Kids in school, you know, their academic performance is terrible. In America, we should have very high academic performance. We're, I think, 30 first in math and reading in the world, and I think Vietnam is better than us. So if a very poor developing country does better than us, what's going on? It's really speaking to the food we're feeding our kids, to school lunches, to the amount of toxic food environment that we have that we're all exposed to that's driving these choices. And it's pretty much unregulated in this country.

Absolutely. And I would say that this is the right time to be talking about this very subject because this is the first time we're experiencing in a hundred years in our nation's history since World War I, where in this country we are now experiencing three consecutive years of life expectancy declines. And that's because of the opioid epidemic, the obesity crisis, as well as what's considered the plateauing and the decline of deaths from cardiovascular disease as well as cancer. The CDC estimates that every year there are 250,000 potentially preventable deaths in the United States. So that's just taking the five leading causes of death: heart disease, stroke, cancer, chronic lower respiratory disease, and unintentional injury. If the states that had the highest mortality rates did as well as the states in this country that had the lowest mortality rates, we would save 250,000 Americans every single year. year. And so I think the timing of this conversation is really important.

And you know, it's interesting if you take a map, you can go in the CDC and see these maps of obesity, diabetes, and life expectancy, they completely superimpose in terms of the states with the highest rates of these problems.

That's right.

And the worst are the Southeast, Southern CrOok, I guess, where there's more obesity, there's more disease. And when I graduated medical school, probably you did too, there was not a single state that had an obesity rate over 20%. That's right. And now there's not a single state that has an obesity rate under 20%, and many have 40, and many more are encroaching on 40. So when you think about 40% obesity rates, 75% overweight, I mean the entire country is a fat nation.

Absolutely. And unfortunately, many of the states that you cited have that ratio of pretty low spending on social services to help your spending. And they also have high uninsured rates as well. So they're finding themselves spending a lot of money on the healthcare side of the equation for things that are preventable if we try to tackle them up front.

And you know, you were in key positions in government trying to think about these problems and create policies to help overcome some of these challenges. And that's not an easy job because there's so many competing forces that are at odds trying to solve the problem. We don't want to have a nanny state. You write about in your book, this nanny state idea. And I'm like, well, what's wrong with nannies? What do they do? Their job is to protect our children. Shouldn't we protect our children? I mean, think about it. If there was a foreign nation that was doing to our children what we're doing to them, we would go to war to protect our kids, right? Absolutely. And yet we just kind of let it go.

How do you break through that challenge of changing those policies? I thought a lot about this while writing the book. We all agree that prevention is important. But why has it not been that policymakers have sort of elevated, why haven't they elevated this issue to the top? And I came up with a couple of reasons that I'd be happy to share. I think the first is, and you touched on this, a lot of policymakers are just reactive in general, and prevention requires a proactive approach. And the reason they're reactive is whether you're in the executive branch or you're a member of Congress, There are oftentimes so many emergencies, either real or imagined, or crises, or political controversies, that oftentimes you spend a lot of time reacting.

Putting out the fire.

Absolutely, as opposed to thinking about proactive policies to improve health. And then, prevention oftentimes takes time as well, so you have to have that patience, and oftentimes the results are, at least from a public health perspective, are often invisible when things are working and health is being protected. And so I think the first reason is that the mindset of policymakers needs to shift from being reactive to proactive. I think the second reason is it could very well be that policymakers are just not as attuned to the evidence base, whether it's lifestyle medicine, whether it's prevention, whether it's a social determinants of health. understanding the evidence now that has been generated about the effects of all of these other modalities, I think is critical. And when you don't know the evidence, then you tend to think, well, that might be a slush fund. You know, those dollars in prevention might be a slush fund. And, you know, why should we support it? There are others then, as you said, who may think of prevention as, you're right, part of the nanny state. Prevention is about individual responsibility and the government shouldn't be involved. So I think those are a couple of reasons, but then I think it goes beyond that. You know, prevention and public health, they require resources. And right now in this country, if you look at our national health expenditure accounts, only about 3% of our dollars go to public health. Only about 5% go to primary and secondary prevention. And so Even though we're in a tight fiscal climate, we're always going to be in a tight fiscal climate, finding opportunities through our discretionary budgets or mandatory budgets, CBO doesn't always help with their.

10-Year budget window in terms of scoring. So just to clarify for people, the Congressional Budget Office is the watchdog that looks over the costs of things for the government. That's right. The policies and laws. And they score policies based on their impact over a 10-year period, but the benefits of prevention might be over a 20-year period.

Absolutely. It seems like a cost center instead of a cost savings. Absolutely, absolutely. And I think that's a very important point. And I think, so there needs to be more focus on finding the will, really, the political will to expand resources using our discretionary budgets as well as our mandatory budgets and through Medicare and Medicaid because that's really how we scale things. So I think that's also a critical point. I think Dr. Hyman, another reason why policymakers haven't gravitated towards prevention is we have a $3.6 trillion healthcare system and frankly, can't make as much money on prevention as you can on treatment. So the incentives there in the system are not as much there.

Not from the government, but from the people running healthcare.

Absolutely, now value-based healthcare transformation with the focus on payment based on outcomes as opposed to volume, should change that over time, but that's gonna be a long haul. So we were just to clarify for.

People, the way typically doctors get paid and hospitals get paid is like widgets. The more stuff you do, the more you get paid. The more angioplasties you do, the more surgeries you do, the more colonoscopies you do, the more visits you do, the more money you make. That's right. And it doesn't care if the product is good or not. It's like imagine paying for a car, but it didn't work. You're not paying for the outcome. And so value-based care is a new way of thinking that's incentivizing health care systems and doctors to be accountable for the outcomes of their patients' health. So keeping them healthy, if now if somebody bounces back to the hospital, the hospital makes money. In the future, the hospital won't make money. It'll be making money by keeping people out of the hospital. And that's a very different paradigm shift.

But we're not quite there yet. Absolutely. Absolutely. We're about a decade into this, but still the vast majority of health care payments are still currently paid based on the services provided and a fee per service. So we're not quite there. And I think the last reason why, you know, this hasn't really, you know, gotten the attention of policymakers is really, I think if you look at the general public as well, we haven't galvanized the American public and whether that's, they don't realize the power of prevention or we haven't realized or where we haven't communicated to them the importance of sound policies to support the healthy choice. Policymakers need to help Americans make the healthy choice the easy choice. And so I think galvanizing the public, you know, there are not a lot of lobbying firms or interest groups going to members every single day in the halls of Congress preaching the power of prevention. But you do need a grassroots movement. You do need the American public to say, hey, I'm doing everything I can every day for my family to eat well, to exercise, to avoid substances, to stop smoking, to drink alcohol in moderation. I'm doing everything I can. But if they're not community supports, if they're not policy supports, if there aren't policy systems and environmental change helping me and my family, it's going to be very, very difficult to do. And I think that's a critical message in this book.

I think it's pretty important because if you don't actually provide an environment that allows people to make easy, healthy choices, it's hard to do the right thing. And I think one of the biggest challenges in this conversation is the dichotomy between the idea of personal responsibility and the nanny state. The environment we live in, how do we change the toxic environment? And I think, most of the messaging from most professional associations, much of our government policy, and certainly the food industry, is that it's your fault you're overweight, it's your fault you're sick, it's a personal choice. Just like smoking is a personal choice. And they talk about moderation. There's no good and bad calories. A thousand calories of broccoli is the same as a thousand calories of soda. There's focus on exercise as the solution. There's focus about moderation. It's really interesting and it's a culture that's really focused on personal responsibility, but it ignores the fact that you actually can't be personally responsible in a toxic environment. If you can't go in your neighborhood and buy a vegetable or you have to take two hours of buses to buy a carrot, that's a problem. And if we don't address the environment we live in, we're not going to be able to get people to make healthy choices. I remember reading a study where they looked at people who were overweight and diabetic who lived in very low socioeconomic neighborhoods. They moved to a slightly better neighborhood and their blood sugar went down and their weight went down without any other intervention, just giving them a better zip code. So basically the zip code we have is a bigger determinant than our genetic code when it comes to our health. And we don't really seem to acknowledge that in our policies. We said it's all about choice. And I think one of the areas I wanted to talk about in this is the whole SNAP debate. Now, the Bipartisan Policy Center, you write about in your book, Prevention First, did a very important report called Leading with Nutrition that outlined some of the challenges with our food stamp or SNAP program, Supplemental Nutritional Assistance, which is, I don't know what should be called that because it's supplemental food assistance. It's not nutrition, I would call most of it because 75% of it is junk food, 10% of it is soda. And it's very clear that people who compared to an income eligible person who's not on SNAP is less healthy and they drink more soda and they have more health consequences. So, people go, well, we can't really limit people's choice when it comes to soda. They have to be able to buy that. It's gonna stigmatize them. And you're right, the policymakers are influenced by big food. I mean, soda companies, Coca-Cola, I think 20% of their US income is from food stamps. Walmart of the $750 billion in a farm bill for food stamps, about $138 billion goes to Walmart. So they don't want this to change and it's a real challenge and you're right. I remember walking into Senator Harkin's office, it's a really great center, he's no longer a senator but he said, well what organization are you from? And I'm like, well, none, just representing the science and the policy and my patients and I want to get science Into policy, he goes, well, that would make too much sense. So when you've got all this evidence that this is true, we know as doctors and scientists that this is really the problem. But the policies really are being heavily influenced by lobby money. How do you deal with that and sort of break this cycle of blaming the victim and not changing the environment and not helping people make better choices?

Sorry, that was a little windy. Terrific, and thank you for raising this topic. The SNAP program, previously the Food Stamp Program, The purpose of the Bipartisan Policy Center's Task Force was really put the end back in SNAP, which is exactly your point that nutrition and diet quality ought to be a key factor of that program. The program has been around for several decades now. 40 million Americans rely on the SNAP program every year. It has substantially reduced food insecurity in this country, which is really important. And food insecurity does have indirect health benefits for children, for new mothers, for seniors as well. But with our obesogenic environment and the last several decades, the program has not evolved to ensure that diet quality and nutrition is paramount as well. And you're absolutely right, the number one consumption of SNAP enrollees are soda products. Now that's not too different than the rest of the population. so it is number two. But it does sort of beg the question that are we doing the best job that we can to incentivize the consumption of healthy food and disincentivize the consumption of unhealthy food? And what our task force did is, you know, there were Republicans on there, Democrats on there, and we asked ourselves some pretty tough, tough questions. SNAP is an important program. It reduces food insecurity.

For sure.

But how do you improve nutrition? When we looked at sugar-sweetened beverages, Dr. Himmelfarb, as you know, there is no nutritional impact in soda and sugar-sweetened beverages. And yet- well, there is, it's harmful.

It's absolutely, yeah, in terms of- Not only a lack of benefit, but it's.

A tremendous harm as a leading cause of obesity and diabetes. And what we saw in the retailer community, in fact, during the period when SNAP Enrolees were purchasing their food. Sugar, sweet, beverage and soda were really the ones that are being marketed to them. And I think we all found it.

I want you to hit on that for a little bit because people don't realize that when the first of the month comes, people get their benefit cards. That's when these stores that are in these poor neighborhoods highly advertise.

Disproportionate marketing.

Yeah, and in better neighborhoods that are more affluent, they don't advertise. Absolutely.

So they're literally, it's race targeting, it's poverty targeting. It's terrible. Yeah, yeah. And that adds to issues about health equity and it adds to health disparities as well. And so the task force recommended, it was a difficult recommendation, but that sugar-sweetened beverages ought to be excluded. And that doesn't mean that individuals can't purchase these things out of their own pocket, but from a health perspective, and a taxpayer-funded program, we ought to be again incentivizing healthy food and disincentivizing unhealthy food. In fact, there was a follow-up study from Tufts University and Harvard School of Public Health that actually looked at the mix of both incentives and disincentives over time and excellent simulation and found that you could prevent a substantial amount of heart disease and diabetes and save health care costs. Billions of dollars. Billions of dollars. the Venn diagrams between SNAP and, for example, Medicaid overlap in such a way that this could have significant impacts on state Medicaid programs. So I think there's a lot there.

We.

Really wanted to elevate this issue that, yes, the SNAP program is important, but if it can evolve to elevate nutrition, then we can really do something for the public.

But you've got the hunger groups completely opposed to this. That are focused on food insecurity and hunger. And they're like, well, you can't restrict that. It's going to stigmatize these people. They should have the same opportunity to purchase as everybody else. But you can purchase a two-liter bottle of soda, but you can't purchase a rotisserie chicken on food stamps. So there are restrictions. You can't buy cigarettes, you can't buy alcohol, you can't buy cooked food. There's a lot of restrictions. Absolutely, absolutely. And the other programs we have in the government, like WIC, it's women, infants.

And children, and school lunches, they have nutrition guidelines that ensure quality nutrition. But we don't have that. There's so many groups opposing any change.

So how do you see that happening? It just seems like a hopeless cause.

Yeah, yeah. Well, I think we talked about that a little bit in the book that we released the recommendations and there weren't a lot of people who were cheering because on both sides there were folks who said, Leave it alone, don't touch it. We want to focus just on food insecurity on the other side. There were folks saying, Hey, well, we questioned the fiscal integrity of the program. And so we again had both sides involved. That's what we do at the Bipartisan Policy Center and said, you know, for looking at from a health perspective, improving on the current program is the way to go. And that's been our message to lawmakers and policymakers as well. You know, the farm bill passed recently, but every several years these issues get resurfaced. So I think we have to keep on, you know, ensuring that there's a drum beat to ensure that the N in SNAP, the nutrition part, becomes a paramount principle.

And that's part of what you talk about in terms of the social determinants of health. We've talked about in the show before, but people understand that the environment when you live is a bigger determinant of your health outcomes than anything else, even than your diet or exercise or smoking. And those things are not addressed in healthcare. We sort of ignore them. And so you talk about healthcare without walls. What does that look like? What do we have to think about differently? and how to address these things.

Yeah, healthcare is slowly moving in this direction, but they are and probably they're in a better place to address social needs. And there's an important distinction, I think, between social needs and social determinants of health. Social determinants of health for housing, let's say, is building affordable housing. Addressing a social need is modifying the home to reduce falls, for example. For nutrition, social determinants of health are ensuring that healthy food financing initiatives, you can increase the availability of healthier food. farmers market, you know, social needs is ensuring there's a home delivered meal. For transportation, social determinants of health is improving community infrastructure through land use or zoning policy. For social needs, it's ensuring that there's ride sharing available so people can make their appointments. So, healthcare is getting into the business of social needs because they see it connected to the value proposition of improving outcomes and potentially reducing preventable health costs. And I think that's all fine. But healthcare is not going to take care of the broader social determinants of health. We still need focus and resources on education and income and housing and nutrition and transportation because you're exactly right. Those have profound implications on the health of the population and are also connected to a lot of the behavioral risk factors that are driving chronic disease.

Yeah, so it seems to me, and I'm obviously biased because I'm focused on food a lot, but it seems to me that the food and the food system, if we had to pick one thing to target would be the biggest thing. Because that's affecting the chronic disease burden. The majority of chronic diseases are caused in part by diet. 11 million people die every year around the world from diet-related disease. I think it's an underestimate because when you add in the additional causes such as diabetes and heart disease, it's like in the 40-50 million range. And so, When you have that level of impact, it seems like we can't address all these issues unless we fix the food system. And that the forces that are opposing that are quite big, just the farm bill alone is a half a billion dollars of lobbying on it just for that. And majority of that is food stamp. So how do we, you've been in government, you've been in these conversations, you're not just sort of talking about it from a think tank. You've actually been there. What's your perspective on how you move the needle? I mean, do we have to wait for an administration? Do we have to wait till the community of activists rises up and like abolition and changes our government? I mean, what do we have to do to see change? 'Cause it's discouraging for people to sort of feel like they can do anything about this.

Yeah, yeah. Given the political winds in this country, change, you know, pretty regularly. I think it's important, Dr. Hyman, that we, take incremental progress whenever we can. But you're absolutely right, your premise that.

I-- so take a base hit.

I think you have to educate policymakers. That's what part of this book is. We should go for the whole-- it shouldn't be that we're just going for base hits. We should go for the home run. But it's also important when there are incremental opportunities to take them. I agree 100% with your premise. I call sort of obesity the public health challenge of our century. I mean that is the critical challenge. Cancer will soon in this country be the leading cause of death for Americans and it'll surpass heart disease and the reason for that is really obesity and poor diet.

So people don't understand this but obesity is linked to cancer. It's not just heart disease and diabetes.

Yeah, at least a dozen cancers are now very well, the establishment, the link between obesity and cancer is now pretty well developed.

The most common cancers, breast, colon, prostate, all the big ones.

Yeah, yeah. So I think that we need to, so when I talk about incremental progress, so for example right now, try to look at things as glass half full from a policy perspective. You look at the Food and Drug Administration. I think there's an important in the next several months a new change to the nutrition facts label in that all foods will need to have information about added sugars. and that's pretty important. In fact, there was a recent study done that if in fact this is done over the next, you know, two decades, there would be substantial reductions in both diabetes and cardiovascular deaths and significant healthcare cost savings. Now, if the industry actually then reformulated their foods, given that now this is transparent on the label, there would be even more, a doubling of an impact over 20 years, I think, It would go from $30 billion in health care cost savings to 60 billion, and from 1 million cases of heart disease and diabetes to 2 million. So these are substantial pieces. Salt, voluntary sodium reduction. So it's voluntary. This was started in-- Good luck with that. This was started in the Obama administration in 2016, but this current administration is moving forward with voluntary sodium targets in 150 different food groups, and if indeed manufacturers are able to meet these targets, within two years we can reduce the average consumption of sodium in this country, which is about 3,400 milligrams to 3,000. Within 10 years we can get to 2,300 milligrams, and that could save substantial lives down the road in terms of heart disease and reduce health care costs. So I think there are some things that don't get a lot of attention I think that are important. There are then more challenging things. Sugar-sweetened beverages and the taxation of that and the politics of that. Portion size, which I think is a really important issue also over the last several decades. The portions of food that we get are so large. So Deborah Cohen, who's a researcher at RAND, has done some important work on portion sizes and has shown that as portions have increased, our consumption has increased, of course, as well. And she's actually advocated for standardizing portion size, just like we do with alcohol. So if you have a certain amount of alcohol, there's a standard size, there's standard size of portions, you could reduce consumption there, particularly for unhealthy foods.

This takes away the whole idea of personal choice. It's sort of like mandating different portions. So there's Dan Buettner, who wrote the book Blue Zones, Create Initiative, and I think it was in some Midwest state, and essentially got community interventions that were invisible. So everybody switched out their plates to 10-inch plates. What was it, the checkout counters, the grocery stores changed to healthy options instead of candy. They built walking paths. They basically created initiatives that were just sort of frictionless. They allowed people to make better choices. And that made a huge difference in healthcare costs. and health outcomes. I mean, it's stuff that we think of as sort of the nanny state, but it's actually stuff that's proven to be effective.

And I would say that it doesn't just, I would probably say that it doesn't actually take away individual choice. So people are certainly, you can go.

Back for a second?

Yeah, absolutely. But I think it's shown that when the healthy choice is the easy choice, or that people change their practices. And I think that information, take menu labeling now, which is common, And that policy change, so giving people the information, I think the behavioral economics piece that you're talking about, those things, I think incremental ways forward in those areas, I think are important as well. My favorite studies where they took people.

And gave them a bowl of cereal, one bowl constantly refilled from the bottom, and the other one just was a fixed amount of cereal. And the ones that had the constantly refilling cereal just kept eating it.

It was like a trick bowl. That might be me because I actually love cereal. I'm gonna admit on your podcast That's okay.

We all have our weaknesses. Although I think, you know, I'm a serial killer. I hate cereal. I think it's one of the worst inventions of our society. It's 75% sugar.

Talk about added sugar.

Oh my God. Yeah, that's huge.

Yeah, absolutely.

Okay, so as a policymaker, now as a policy think tank advocate, you sort of mentioned a lot of these initiatives. You think it make a difference? I just keep pushing back against the idea of, you know, how do, how does the individual citizen sort of get their congressman to go? Because they don't have, you know, millions of dollars to go Lobby. Right. When I went to Washington, I paid my own ticket, I paid my own hotel. Washington is not cheap. I paid my own food. And they're like, who are you? Where are you from? And what are you doing? I'm like, because they never seen a individual be an advocate. And so, but there are ways, right? There are ways to get involved. And I think there's I think the Food Policy Action Network is, I think, a group that scores your congressmen and senators on their voting on food and ag policies. So there are ways to sort of affect it. But it's tough because you've got, for example, on the SNAP subject, you're probably aware of this, but when there's a hearing about SNAP to try to improve the nutrition quality in SNAP and talk about the soda reduction, maybe you were at the hearing, there were many of the committee members on the ad committee who basically said, it's all about personal responsibility, it's not more exercise, that's the real problem, it's not about the food. And when you look at who was funding their campaigns, it was soda companies. To the tune of literally, collectively millions of dollars. How do you fight that?

Yeah, well, I think it's, you know, first and foremost, helping Americans understand that there are things that government and policymakers can do to support them in these areas, that it's not just about personal responsibility. And so some of it is sort of education and empowerment there. Some of it is also the doctor-patient relationship, as you know, Dr. Hyman is a trusted one. I think, you know, ensuring that healthcare professionals can be that voice as well to support patients. Some of this is educating policy makers as well, and policy makers on their own understanding the importance of prevention. So in my book, for example, there are five sort of key takeaways for policy makers at the end in terms of what they can do to support Americans, the first, for example, to make prevention the number one priority for this or any administration coming in. the Health and Human Services Secretary saying, you know, there's a lot of mission essential functions, but prevention will be the number one priority. All of our agencies, whether it's the Centers for Disease Control and Prevention or the FDA or the National Institutes of Health, you know, figure out how prevention elevates at the top. Number two, health care professionals in value-based health care transformation, we're now going to measure you and hold you accountable not just for how well you manage diabetes or heart disease, but how well you prevent them in the first place. We're gonna hold you accountable not for how much you screen, just screen for obesity or tobacco.

Just do the test for blood sugar, but actually get them back.

Actually reduce it. And what that'll do is force the healthcare community to build the clinical community linkages to help support individuals. So that's sort of a second takeaway. A third takeaway is- these are all in the book. These are all in the book. Right, right. These are sort of the five overarching takeaways policymakers, which I think then can be helpful to Americans out there. The third is, in this country, if you're a drug, a pill, or a device, there is a pathway in this country for that intervention to be scaled. There is a Food and Drug Administration that assesses safety and efficacy, and once FDA approves that intervention, CMS, Medicare and Medicaid, decides whether it's reasonable and necessary for payment or for coverage. And then a lot of private payers follow what Medicare does.

Yeah, but if you're- Just to interrupt you there for a minute, the recent study that was published showing that stents and bypass and angioplasties don't work for the majority of patients that get them is not a new story. I read this article in different iterations in the past and it keeps getting repeated and the research gets more robust. And yet, Medicare and Medicaid pay for these services because they're a device and they're sort of in, but they won't pay for stuff that works like that. Lifestyle program that can reverse diabetes.

Right, right, right, right. On the treatment side. But if you're an evidence-based program, and either prevention or treatment, lifestyle focused, to your point, there is no pathway in this country like there is if you're a drug or a device. And yet there are so many evidence-based programs, like the one you just mentioned, the lifestyle treatment or prevention programs, whether it's falls prevention or chronic disease self-management programs. There are so many programs out there where thousands are benefiting, but millions need to be benefited. So in my book, I actually call for a parallel pathway. Just like you have FDA looking at the safety and efficacy of drugs or devices, whether it's CDC or the Administration on Aging, Congress ought to give them a regulatory authority to review a lot of these evidence-based community treatment or prevention programs. And if they meet the bar, then CMS would have to consider them as being reasonable and necessary for payment, just like they do for a drug.

So in other words, at Cleveland Clinic, we've got our program called Functioning for Life, where we take people in with chronic disease, we change their lifestyle, we change their diet, we actually, through social support, help them change their behavior. We're seeing extraordinary results. I mean, reversing diabetes, heart failure, all kinds of stuff, weight loss obviously. And yet, you know, it's not really reimbursed. That's right. And we're saving, we're saving so much money and we're not getting paid for what we do. We get paid, you know, 30 cents on the dollar and we're lucky if we make a hundred bucks on a patient and we see them or less, you know. And it doesn't even cover our costs of running our center. Yeah. But we're providing so much value in the system, which is benefiting Medicare, Medicaid and also private insurers.

And so the whole system is sort.

Of rigged to not incentivize to do the right right thing.

Yeah, absolutely.

And there's no money to study it. I was like, I'd love to get, I mean, there's literally billions of dollars spent on research in this country and almost nothing spent on nutrition or lifestyle research.

That's right. And therefore, a parallel pathway could help infuse resources to research as well as ensure that there's not a double standard for a lot of these interventions that are focused on lifestyle or occur outside the clinical clinical arena.

Amen to that. Now there's two other points.

Two others. The fourth is, look, we have about a $4 trillion budget in the federal government. This is prevention, public health. It's too important to underfund this. And there needs to be bipartisan support to finance evidence-based prevention and public health interventions. So it could be community-based prevention programs I talk about. several things that we did at Health and Human Services from the Recovery Act back in 2009. There are opportunities to finance the public health infrastructure, which is significantly underfunded in this country. A public health emergency fund, so the next Ebola or the Zika we face, we're not waiting on Congress to fight for months at a time before their resources. But targeted investments to lift up prevention and public health, that seems to be, that has to be a national priority. and I think in terms of bipartisanship, how do you crack that nut? There was an important commission on evidence-based policy making that Senator Patty Murray and former Speaker Paul Ryan actually led a couple of years ago and talked about sort of an evidence, the importance of evidence-based policy making. In that same vein, there ought to be bipartisanship around what are those priorities in the prevention and public health space that we actually need to invest more in.

Right, because the truth is, you know, Food industry and pharma are not investing in research around this.

That's right, that's right. And that leads me to sort of the fifth point, which is we need Dr. Hyman more research. I mean, we have evidence-based right now, but we need more research into prevention. Now, the National Institutes on Health estimates that 19% of their budget every year goes to prevention. Now, one could ask, is that the right number or not? I don't know.

Is that really true? 19% of the NIH budget goes to prevention?

19%. Now there is another study that I recently saw that if you look at the National Cancer Institute, only 5% of their budget goes to prevention. So whatever the number is, I think that these are all sort of low.

Well, let's just define prevention because is mammogram prevention, is colonoscopy prevention? No, it's early detection. True prevention is really dealing with the causes, the upstream causes that you talked about in your book.

Right, right. And so I would argue, and I argue in the book, that there ought to be a much more focused research emphasis on prevention that looks at not just sort of the biology of illnesses, but also the importance of behavioral change as well as policy as well as other areas. And so, and that will also actually help the Congressional Budget Office, irrespective of what happens with the 10-year budget window, the more research, the more evidence there, will help policymakers. So I think in all five of these areas, number one, leadership prioritizing prevention, number two, healthcare professionals focusing on prevention, not just management, number three, a parallel pathway for lifestyle interventions and evidence-based community prevention interventions, number four, public health resources, and number five, prevention research. All of these, they're all heavy lifts. Dr. Hummel, but I think that I wouldn't be writing a book if these weren't important. But these are absolutely important for policymakers on both sides of the aisle to understand the importance of these. And I think if there's movement on the policy side, the American public will see this also as a way to support themselves as they try to make sort of the healthy choice. But the American public is clamoring for assistance.

Yeah.

Behavioral change, is difficult given the environment which you have so beautifully described. And I think the best way to counter that environment is through policy change and empowered Americans speaking out.

Yeah, one of the things you mentioned in your book, in addition to sort of these points, is sort of targeting things that work but aren't paid for. So digital health, for example. You mentioned Omada Health, which I helped advise when they were starting out. And I said to them, look, the diabetes prevention was a good start, but it's based on a little bit antiquated nutritional data about low-fat diets, high carb diets for diabetics. But it worked because, and I met people who were in the program and they said, well, it worked because we came to groups because we had to write down everything we ate because we exercised together. Yeah. And the good dynamics. Yeah. Yeah. It wasn't so much the food, although it was healthier. Yeah. It wasn't the healthiest. And, and there's been more sort of advanced versions of that that have developed. Yeah. That are digital, for example, Berta Health, you probably heard about. Yeah. where they literally take in poorly controlled, like pretty overweight, poorly controlled diabetics, 60% reversal. Now, in traditional medicine, it's like zero. It's zero, right? Unless you get a gastric bypass. Yeah, that's right. And they had 60% reversal. They had 90% or more off of insulin or very low insulin doses. They had 12% weight loss, which is a massive amount. And weight loss studies, we get five, everybody's dancing around, happy and excited for a 5% weight loss. And they did it through a digital platform where there were coaches and support. There was remote monitoring for ketones, for weight, for blood sugar. And they published the data using a ketogenic intervention, which is the opposite of the DPP, which is basically high fat. And yet, this is not reimbursed. And the amount of savings in these patients is astronomical. how do we sort of get, because this sort of goes back to the conversation we're having earlier about prevention and treatment. So prevention is important. It's a population-based intervention. Not all the people you're going to do the intervention on are going to get the problem. In other words, not everybody who gets a colonoscopy was going to get colon cancer, right? But everybody who's already sick needs the intervention of lifestyle interventions because it's lifestyle is treatment not only as prevention. Right, right, right. But that's not reimbursed and yet it's probably the biggest bang for the buck in terms of our healthcare system. How do we get our government to start to understand that? And maybe it's what you talked about is funding more research that proves the model.

Right, right. Well, I think it's all the above, also having pathways. Again, as you said, there's no real pathway. Medicare, Medicaid don't really know what to do with a lot of these interventions that are not sort of the traditional medical model. As you know, in 1965 when Medicare was first created, it was essentially paid for the treatment of disease using, routine medical services. So it hasn't really caught up with today's day and age and what we know about the importance of lifestyle medicine either with prevention or treatment. So I think some of this is research, some of this are new pathways and the government regulatory pathways. Some of this is educating the public. It's really going to take, I think, all of the above to sort of change the status quo because there are a lot of opportunities out there. that are not being realized right now.

So you were in the middle of it all. Did you feel like there was movement when you were there? That people were trying to actually shift the policies in ways that actually were effective, or was it sort of spinning wheels? Yeah, yeah, no, I think-- Because people.

Go, Government's broken, it's not going to do anything.

What's the point? But you have a different view. Yeah, there are lots of things that.

I saw, I mean, with the Affordable Care Act, just say clinical preventive services. One part of that was now high-value clinical preventive services. there ought to be no cost sharing for them. And that makes sense from a value-based insurance design perspective. And that should increase the likelihood that Americans receive, you know, high value evidence-based clinical preventive services.

So meaning if people need to get screened for disease or a pap test or mammogram, they shouldn't have to pay for it.

And the private insurance shouldn't give them a copay and Medicare shouldn't give them a copay. That's absolutely right.

Cancer screenings or counseling interventions for tobacco.

Alcohol, immunizations, these things, can improve health.

We can't get a nutrition appointment reimbursed.

Well, right, right. I think we saw ways to go in some areas, but that's one example where we're trying to make it easier for people to access important clinical preventive services. In terms of community preventive services, I know that the diabetes prevention program maybe has antiquated sort of nutrition aspect of the intensive lifestyle piece there. But there, the team at Medicare and Medicaid, just getting the diabetes prevention program through took a lot of work. It required the authorities of a newly created center at Medicare and Medicaid called CMMI, which is a center for Medicare Medicaid Innovation. There was a test, essentially, of the diabetes prevention program. It was found to save money and reduce costs. That's the only way it got expanded. Sure. But that's why I call for a parallel pathway.

Otherwise, you're reliant on But the government has to fund this. It's not coming from industry, right?

Yeah, exactly. Exactly. So I think the government, and the reason why the government's so important is the private sector is critical, but there's only so much from a scale perspective that philanthropy or nonprofit organizations can do. The needs here are for millions, and we're only reaching thousands. And the only way to scale from thousands to millions There could be other ways, but there is a role for government and I think that's part of the premise of the book as well.

And the sort of community-based stuff is important because when you think about where disease happens or where health happens, it doesn't happen in the hospital or the clinic. You know, 80% of our health is determined by where we live and by our diet and lifestyle and our genes, things that have nothing to do with what you get when you go to the hospital to see the doctor, and yet 80% of our funding is for what happens with the doctor in hospital.

So it's completely backwards. Yeah, it is absolutely. I mean, we talk about the importance, for example, nutrition counseling. But if you get the best nutrition counseling, but then somebody walks out of that clinical setting, they see fast food establishments, they see no farmers markets, there are no Meals on Wheels programs, how do you expect them to... So the whole idea of clinical community linkages is to reinforce what happens, all the important efforts on the clinical side to reinforce them on the community side, otherwise they're not going to stick. So one example, a couple years ago I was out in the south side of Chicago and I visited a program called Community Rx. And essentially in this program, Community Rx?

Community is medicine.

Exactly. The Community Rx, the program mapped out social service providers and community-based organizations around the city, and then they took that information, linked it to the electronic health record, and linked it to particular conditions and diagnoses. So at the same time, whenever a patient came to a community health center, they always got a healthy Rx script based on their diagnosis, matching them up with appropriate community services in the community. So what they learned in the clinical setting was then they received essentially referrals to get supports in the community, to reinforce what they learned in the clinic. And that's just sort of one example of how we need to build these clinical community links.

Yeah, you know, the clinic we started a program with, because I'm very strong advocate of getting out of the hospital. And it's there when you need it. I mean, I had a heart rhythm problem this year and I had to have an ablation. I'm like, thank God. But most of the problems in these communities are not what's going on in the hospital and can't be solved there. So we went to a very underserved African-American community in Cleveland, near Cleveland Clinic, and we started a community program in a community center. It wasn't in a hospital, it was in their community health center. And no, it wasn't even a hospital, just a community center. And we developed a group program. I arranged for them to get meals, sort of fresh whole food meals. got them the right nutrients just as a sort of temporary solution. See what would happen if people had the support.

Right.

In their neighborhood, there was nowhere to get good food. Right. And within like six weeks, it's a 10 week program. We're gonna have a follow-on for a year. There were dramatic changes. I mean, people who lost 20 pounds in five weeks, they had dramatic drops in their blood sugar, their blood pressure. This one woman had a stroke, couldn't really talk or lift anything. Now was talking and actually was able to carry things with her arm. I was shocked. And it was so simple. And we taught them to cook. We did cooking classes together. They went shopping, they learned about food. We had talks with the nutritionists and the health coaches. And it was really powerful because they wanted to change. They just didn't know what or how and nobody showed them or nobody told them. And I think those kinds of things are where we need to be thinking about. This is not going to be solved in the hospital. We still need acute care medicine for sure. but the problems we have aren't solved in the hospitals.

Yeah, absolutely agree. I'll give you another example, Geisinger Health System in central Pennsylvania. Your podcast is called the Doctor's Pharmacy. They opened up their first food pharmacy a couple years ago, and they did a really good job matching the acuity of the individual with the intensity of the intervention. So they took poorly controlled diabetic patients who screened positive for food insecurity, and the intervention there was not just sort of diabetes self-management training and counseling, they actually provided the food. Two meals a day for 10 meals a week.

For the whole family.

For the whole family.

Right.

And what they found just in their pilot was that the average hemoglobin A1C, which is an indicator of severity of diabetes, fell from 9.6% to 7.5%. And why that matters is every 1% drop reduces mortality from diabetes and complications by 20% and saves $8,000 in healthcare costs.

And what's also important to realize is that two-point drop may not seem like a lot. But if a drug gets a half a point drop, it's a raging success, right?

There you go.

So it's four times as good as drug efficacy.

That's right.

That's right. Absolutely. So there's evidence based on why doesn't.

Medicare now pay for food pharmacies and pay for food for everybody? Yeah, well, I think we need to move in that direction. Again, it's the medical model that has been the focus of policymakers for so long. And as we build this evidence base, and in some areas it's substantial now, that different quote unquote, types of interventions can actually do more than the traditional interventions.

More than medical interventions.

More than medical interventions. That's where we need to focus because that's where we'll deliver not just the best improvements in health, but also the most significant health care cost savings.

So if you were an autocrat and you were in charge of America on policy and you were the Putin of health care, if you could too, I mean, that's not a bad analogy, but you could actually just take a wand and make the changes that you see are going to make the most difference. What would they be? You mentioned the five things already. Because those things are realistic. But if you really had things that were going to have the biggest impact, what would you do? Not just in terms of healthcare, but across our whole society in terms of making the changes that need to happen.

So I'd be laser focused on the risk factors driving chronic diseases in this country. as well as the social determinants of health. And there are organizations out there like Trust for America's Health who issued recommendations in this area. But I think it's really a package, Dr. Hyman, of policy changes. So on the chronic disease risk factor side of the equation, whether it's tobacco or poor diet, lack of physical activity, alcohol, there are a series of policy interventions there. Smoke-free laws are raising pricing on tobacco, reducing alcohol outlet density, increasing nutrition, physical activity access in schools, reducing the availability of unhealthy foods in different ways. There are a package of policy changes there. And then on the social determinants of health side, whether it's housing and affordable housing, housing first, whether it's education, Universal Pre-Kindergarten, whether it's income, paid family leave, earned income tax credit, there are a series of interventions that go beyond the four walls of the clinical setting, but tackle both the social determinants of health as well as the lifestyles, the risk factors driving chronic disease. And in this country, as you know, half of adults have chronic diseases.

60% now.

Yeah, 60% now. Half of that half have multiple chronic conditions, which was really my focus at Health and Human Services and virtually all the $3.6 trillion that we spend in this country go there. So I would be laser-like focused on the risk factors driving chronic disease and the interplay that the social determinants have and policies there. So a lot of this, again, is outside the four walls of the clinical setting.

I agree. I would add in there and I think, you know, it's going in the upstream conversation is, you know, what is driving the social determinants? What is driving the disease. For the most part, I would say it's our food system. And you have to change the way we grow food, what food we grow, how it's supported, all those upstream things. It's like we're just still down in the weeds if we don't actually change the food environment.

If you look at the subsidies going to that or agriculture sector, the marketing by the food industry, there are a lot of forces that whether they admit it or not, make it harder. Make it harder for Americans out there to make the healthy choice, the easy choice. And, you know, I don't think we want to demonize parts of our society, but we want to work with all sectors of our society to see how we can all push health forward. And I think that's in the best interest of our society.

Well, look, you know, we came down hard on tobacco because we were clear about its danger. But now obesity and food has overtaken tobacco as the leading cause of death. So, you know, I think we have to start to really think about that honestly.

Yeah. And I think the industry does as well. I mean, for the sake of their own future and their bottom line, they need to understand which products of theirs are leading to ill health and change their practice and culture as well. So, you know, and I think there are some, you know, in the industry who taken positive steps. And I think when that happens, we need to applaud them. But I think you're absolutely right as a whole. I think it's important where it's not possible to see that voluntary steps, I think government's got a role. It's got a really important role because ultimately that's why we have governments. I always say sort of health and education. Those are the two most important things. Health provides the foundation, education provides the acceleration. you know, as we pursue our goals in life. And if anywhere where a government needs to lean forward, it's got to be in those types of situations.

I agree. I think that's great. Well, thank you for your work.

Well, thank you.

Thank you for working for us in the government for so long trying to do the right thing. And now with the Bipartisan Policy Commission, which is, I think, one of the most important organizations out there bringing parties from all sides together to solve difficult problems across government. I think, you know, what I think is you need a big lobby arm. You need like a $100 million lobbying fund. So you can be out there telling these stories in ways that get lawmakers to pay attention. So thank you so much for your work and for your book, Prevention First: Policymaking for a Healthier America. It's a real contribution to our thinking about how do we do the right thing because if we keep going the way we're going, we're screwed. So thank you and check out the book on Amazon where we get books and your bookstore, Barnes & Noble's. and check out the work at the Bipartisan Policy Center. I love their stuff. It's a little nerdy, I'm a little geeky, but I love that stuff. You might too. And if you love this podcast, please share with your friends and family on social media. Leave a comment, we'd love to hear from you. Subscribe wherever you get your podcasts, and.

We'Ll see you next time on the Doctor's Pharmacy.

Thank you. Thank you for your leadership, Dr. Hamed. Thank you. Thank you. hi, everyone. It's Dr. Mark Hyman. So, two quick things. Number one, thanks so much for listening to this week's podcast. It really means a lot to me. If you love the podcast, I'd really appreciate you sharing with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark's Picks. Every week, I'm going to send out a list of a few things that I've been using to take my own health to the next level. this could be books, podcasts, research that I found, supplement recommendations, recipes, or even gadgets. I use a few of those. And if you'd like to get access to this free weekly list, all you have to do is visit drhyman.com/picks. That's drhyman.com/picks. I'll only email you once a week, I promise, and I'll never send you anything else besides my own recommendations. So just go to drhyman.com/picks. That's P-I-C-K-S to sign up. free today.