Why Our Current Healthcare System Keeps Us Sick And How To Fix It

Coming up on this episode of the Doctor's Pharmacy.

We have a $3.6 trillion healthcare system and frankly, we can't make as much money on prevention as you can on treatment. So the incentives are not as much there.

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Episode of the Doctor's Pharmacy. Hi, this is Lauren Vien, one of the producers of the Doctor's Pharmacy podcast. The US is home to the best hospitals, most highly trained doctors, and people come from all over the world to get medical treatment here. Yet we're lagging behind almost every other country in health metrics, including life expectancy and infant mortality. That's because we're not being set up for success. The policies and systems we rely on for health care aren't supporting prevention, education, and accessibility for all our communities. In today's episode, we feature three conversations from the Doctor's Pharmacy on why public policy is a key component of disease prevention. Dr. Hyman speaks with Dr. Anand Parekh on the challenge to get policymakers to appreciate prevention, with former Senator Bill Frist.

On the importance of grassroots bipartisan efforts.

To generate change, and with Dr. Dariush Mozaffarian on the need for government policies and why we can't solely rely on big food to change. Let's jump in.

We all agree that prevention is important, but why has it not been that policymakers 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. 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 determinant 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. Those dollars in prevention might be a slush fund. And 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. 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, 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. So 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 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-- yeah.

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, you know, 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, you know, paying for a car, but it didn't work. Like you're not paying for the outcome. And so value-based care is a new way of thinking that's incentivizing healthcare systems and doctors to be accountable for the outcomes of their patient's 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 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 they don't realize the power of prevention, or we haven't realized, or 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 there are not community supports, if there are 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 sort of dichotomy between the idea of personal responsibility and sort of the nanny state, the environment we live in, how do we change the toxic environment? And I think, you know, 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. 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? And 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, 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 that's just to find prevention because.

It'S a mammogram prevention, is a 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, 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 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 heavy lifts. 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. 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 these points, is 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. Right, right. 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 group 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 that are digital, for example, Virta Health, you probably heard about, 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 amazing.

It's zero, right? Unless you get a gastric bypass. 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 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 it's the amount of savings in these patients is astronomical. So how do we sort of get, because this sort of goes back to the conversation we were 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.

But that's not reimbursed, and yet it's probably the biggest bang for the buck in terms of our healthcare system. And 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 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 sort of 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 in 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.

Hey, everybody, it's Dr. Mark here.

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Well, I think, and remember, I did that for 20 years in medicine, 12 years in politics and policy, but for the last 12 years, I used the private sector. And the example, the food that I gave, the example that I gave to you really comes out of the importance of the private sector and investments that are made that are cutting edge that ultimately define policy. I also work from the policy end. So even though I'm no longer majority leader of the Senate, you mentioned it. I'm on the board of the Robert Wood Johnson Foundation, where we talk about the health of the community, the non-medical determinants of health being much more important than the health care. That the food and our behavior and where we live and how we live is much more important than Bill Frist, the heart transplant surgeon, you know, doing dramatic things. That's where the drama is. very important, don't want to diminish it, but the sort of 60% of the impact is in the dimensions that we were talking about. And that means we have to go to policy. People say, why did you leave medicine and go to the United States Senate? What drove you to do it? Did you lose your mind? And I guess I did lose my mind. But one of the reasons is to be able to participate in the system that we're talking about. and that is ultimately public policy matters. Today, a lot of people dismiss government, dismiss institutions, but at the end of the day, the public policy matters. And you've written about it, you know, we've talked about nutrition and agricultural policy, the Bipartisan Policy Center always, which is a center in Washington, D.C. Bipartisan Tom Daschle and I run the health component. We stay on the issues of supplemental nutrition on agricultural policy, We're on that because it does affect health care and the health, the burdens of disease and the sort of quality of lives we're going to live. So it really starts from the private sector all the way up to the public sector. And you don't have to be a politician to participate in the public sector.

Yeah, you don't. And so, you know, the key things that have to get changed, when you write about them, for example, in the bipartisan policy work, you know, SNAP, food labels, you know, reforms to Medicare, reimbursement around food is medicine, which you're talking about. How challenging do you think it is to get some of these things done? Because, for example, with SNAP, you know, the Leveraging Nutrition was a great report that was put out by the Bipartisan Policy Center, which outlined some of the things that need to be done, like sort of limiting access to, for example, sugar-sweetened beverages, which the Dietary Guidelines say we we shouldn't eat, but the SNAP benefits provide $7 billion a year for soda consumption. And so it's like schizophrenic. It's like the right hand doesn't know what the left hand of the government is doing. And there are people who are for it. There's people who are against it. For example, the hunger groups oppose any restrictions. And how do you thread that needle? Because I think it's such an important program, for example, for feeding the hungry and food insecurity, but it also has secondary negative consequences of actually increasing poor health in that community and increasing the need for Medicaid and Medicare to pay for those patients who eat those foods who get sick. So it's really a kind of a rabbit hole. You don't want to go down.

It is, and again, you've written so much about it, but the Food Stamp Program of the 1960s, a program that you've written about, was mainly, can people afford the food? And let's just get them food. Let's just get them calories and some protein, but let's get them calories. And then in the 70s, when sort of I was coming through in medical school, we first began to say, well, that's not going to be enough, and we really need to start looking to sort of better nutrition. But it took another 15 years to a healthier food and not just any food. But it took another 15 years really, and the SNAP actually became SNAP, the Supplemental Nutrition Program, after I left the Senate. But the fact that nutrition was put in the title, that was good. But then it took another five or six years before the people say, what does nutrition really mean? And I think the SNAP, the Bipartisan Policy Center report that you mentioned basically said three things. Instead of taking the big policy issue and just arguing for it, it said, let's take three things. Number one, that food is medicine and healthy food has to be an objective of SNAP. Not the, that wasn't the objective back in the 60s. So do that, number one. Number two, sugary beverages. We know from science, you've known for a long time. But for the last eight years, we know that it's probably the number one killer out there today in terms of when you look at metabolic disorder. That's just so prominent and I'm exaggerating a little bit and oversimplifying. But we made that number two. And then number three, in that just one report, and that one report goes to the 450 sort of policy makers out there, the United States Congress, we made the healthy reading in terms of fruits, and vegetables and to lower making them both affordable but also in the SNAP program itself. So we focused on all that. We took it. Now, that's not because of that report, but obviously the Obama administration came in, made huge progress. We have, based on the science, and that's been evaluated, you know, the health, the metabolic conditions, we're probably 40% healthier, some reports say, than we did with the old SNAP program. And now you have President Trump coming in trying to roll that back.

Yeah.

And that rollback, now the only thing that's gonna stop that, again, as you said, all the lobbying is out there against it, is gonna be the science. If we're 40% healthier, we're 40% more productive at work, there's 40% less absenteeism, the GDP, the economy is growing, the jobs are being created, and it's that sort of reasoning that ultimately we need to push through, continue to push through. Again, you've written this whole story, but things like the Bipartisan Policy Center and other foundations need to echo that directly into the policy centers.

Yeah, I think that's right. I mean, I think, you know, I'm always curious about, you know, policy ideas becoming then policy and then becoming implemented. And it seems like there's a lot of steps there that things can go wrong. How do you navigate that?

Well, that's hard to be because it's a fragmented system. We have our executive branch, which can sort of be out there, voice and can do a lot through regulations. We have our legislative branch where all the money is and people forget that. And the House of Representatives is where all the sort of money starts and therefore ultimately has to be translated. But then even after the law is passed, it goes back to the execution and those are different people. The only thing I can say is it comes back in this region, I'm talking to you now and you're talking to me and we've got, you know, hundreds of thousands of listeners. it comes back to the American people and how educated, how knowledgeable they are that they can translate that up through their mayors, to their school boards, to their city boards, through the state, and ultimately it gets through the system itself. And that's why democracy is a tough, tough system of government to implement and execute because it takes so long to get through it. But again, the HIV/AIDS is a great example for your for our listeners to listen to because it was killing 3 million people a year, not 60,000 a year, 3 million people a year globally. Huge stigma around it, impossible to do. And by coming together, Democrats and Republicans in a global and appreciation of the global environment, just like nutrition is and metabolic disorder, it's a global issue, by coming together over a period of two years, We were totally able to reverse what up until that time, the previous 20 years since the early 1980s, had been set over in the corner and stigmatized. And now there are 20 million people alive because of that legislation. So policy can work. So we got to stick with it.

It reminds me of what Winston Churchill said, which is, Democracy is the worst form of government except for all the others.

Yeah. Yeah.

And I think, you know, you're kind of a unicorn, because you thread the needle between a heart surgeon, which is the sort of epitome of acute care rescue medicine, and public health, which has been a large focus of your work, and particularly with the Robert Wood Johnson Foundation. And like you said, you were there operating on the downstream consequences of all this stuff, and you're like, wait a minute, maybe we better figure out a way to not get these people on my operating table. And a lot of the work you're doing now in Nashville with Nashville Health and the Robert Wood Johnson Foundation is focused on population health and how the social determinants, which are food and your housing and your economic opportunities, all the things that we don't think are that important, which may make up to 80% of the difference in your health and your actual health quality of life and productivity. What do you see is required for the government to really shift to say, wait a minute, we're focusing on the wrong end of the stick here. Yes, we need to, you know, maintain our best healthcare system in the world and the high quality of acute care medicine. But if we're really going to solve the health disparities, the economic impact of chronic disease, the fact that six out of 10 Americans suffer from a chronic disease, four out of 10 have two, and in a few years, 83 million will have three or more chronic diseases, and, you know, this obese metabolic health, you know, only being 12% of the population, 88% are not healthy. How do we start to shift our focus and share some of the work you're doing there because it's so important and it's such a different framework for how we solve these problems than just more access to care and better financing and better efficiencies. It's flipping the whole problem on its head.

Yeah, it is. And I'll tell you what, just from the political standpoint and again, It's nice to put politics aside, but politics are important in our democracy and where we are today. But the language that we use is critical. And the study of language and the storytelling, if we want to move and establish movements. And for the HIVAIDS end of things, one of the things that we did was focus on young people and people like Jesse Helms, sort of an arch conservative, who had written an article in the New York Times about how evil and immoral HIV/AIDS is and therefore we should not support any sort of helping people. That changed over about two or three months as we focused on things like a drug called Naltrexone, but you know, and that for just 50 cents you can give that to somebody and that would reverse 10 million orphans out there to growing over time. And when Jesse Helms heard that, you know, there's a really sort of cost effective way to protect babies and future babies and orphans and people, all of a sudden he said he became our biggest advocate and he pulled in a huge constituency and evangelicals came on board, and the right people on the right, people from the left. Family planning, another huge global issue that I've been involved with, is an issue that, you know, Republicans will turn to abortion issues and Democrats will turn to abortion issues and try to politicize it in all ways. But if you instead of you say family planning, you say the healthy timing and spacing of babies.

I don't even mention it, but you.

Just say that all of a sudden people come to the room and I think we can do a better job. Instead of, you know, saying eat healthy or eat your vegetables, it all really do frame it. And I'll just close with saying what does speak. and the Affordable Care Act became so unpopular because it focused just on access, which is important, but it didn't focus on cost. It didn't focus on money. To the individual person, their prices were going up and they weren't getting any more benefits. So I think the more we can translate things into cost to effectiveness to well-being, and we know that a healthier we know for my heart transplant. My heart transplants, they would do well long term if nutritionally and metabolically they were strong. So yeah, I did a heart transplant. I wanted to live 50 years and it came back to nutrition and a healthier lifestyle coming in. So I think if we do translate nutrition policy, not just good, bad, eat healthier, but translate it into a healthier person as a more productive person and greater well-being and it means more productivity at work. does mean a growing of economy, means fewer absentee days, the economy growing, individual well-being increased, which translates into national effects in the economy. And the Affordable Care Act missed it this time around. I think if we get the right language and we do end up couching it into growth, personal growth, product of economic growth, productivity, that the case can be made, will be made, will be listened to.

That's true. And the thing that you talked about in terms of medically tailored meals is such a great example of an out-of-the-box intervention that works better than anything else. And you see that with the homeless population, providing them housing, literally paying for their apartments, reduces health care costs dramatically and is actually an economic benefit. Or I was speaking to the former head of population health at Cleveland Clinic where I worked, and he said, you know, if we provided housing and food for young mothers, we would dramatically reduce preterm births and neonatal costs, which are literally in the billions and billions of dollars. And yet our healthcare system isn't set up to provide food or housing or any of the things that actually make the most difference. That's what's so striking to me.

Yeah, and I think the things that, as people listen to us, they say, well, again, you're talking about Washington, DC and policy and all that stuff, and it's so far away. But it really isn't. When I left the Senate, the first thing I did is come back to Nashville, Tennessee, where I grew up, Vanderbilt and family and all. And Nashville, ironically, it's sort of a Silicon Valley of health services. All the hospital chains, disease management chains, psychiatric hospital chains are based there on a per capita basis, much bigger than New York or Boston or Washington in terms of the reach. But ironically, in the Davidson County where all these home offices are, the population health measures, and it could be metabolic disorders, diabetes, obesity, how long somebody lives, infant mortality, are higher there than other sort of brother-sister cities around the country of comparable size. And so we started a local initiative called Nashville Health, not appointed by the mayor or the governor. Those are good, but they tend to go away when they go away. but a collaborative of 120 nonprofits, the academic institution partnering with government, addressing these local issues. And because it's not healthcare, it's health, and as you said, 80% of that are things like food and housing and access to the internet. That's where our focus is. And we're making measurable change in the local community. And I throw that out there because whoever is listening to us, you know, look around. Do you have a collaborative like that? addressing these issues at that ground level. And that's where this great movement can be of educating mayors and educating governors and educating Congress people starting in one's own community.

That's true. We were at a friend's house, Jimmy Haslam, and his brother was the governor of Tennessee. And we were chatting and he said, you know, a third of our Tennessee budget is Medicaid, which is predominantly because of populations who are affected by these social determinants. And they're desperate to find solutions. But I don't think they're hearing the right ideas. I don't think they're hearing the right information. And I think, you know, the fact that, you know, you're out there talking about this and that there's these models like National Health, I think hopefully will spur governors and mayors and others to actually start to act on this because this is where we have to move. I think, you know, in healthcare right now, there's this movement towards population health. Cleveland Clinic just stood up a new program called 4C Cleveland Clinic Community Care to try to actually act in this space and they started a Food is Medicine program. So you see these global leaders like Cleveland Clinic leaning into this space, but I still find it so incremental and I am like, wait, you know, It's like, I feel like I've got a big truck full of water and I'm in the desert and on the other side of this glass wall, everybody's dying of thirst and it's so not that hard. And yet, it's so frustrating. So I think you're right, I think it's a grassroots efforts and on the local levels being focused on this. And it's also educating policymakers. And that's really why I wrote my book, Food Fix, is why I started the Food Fix campaign to try to create a coordinated effort, like you're talking about, for the 2,000 people in Washington that actually need to be educated to understand these things. Because, you know, I don't believe there's anybody that wakes up in the morning and says, you know, I just want to keep people sick in America. And I, you know, I want to, you know, maintain the status quo. I mean, people, whether you're a big CEO of a food company or you're a politician, everybody wants better for themselves, for their families, for their country. It's just that we don't have the roadmap to get there. And I think this is the kind of stuff that actually has to be at the forefront of whoever is in the next administration in the aftermath of COVID-19 because in just in terms of pandemic preparedness, how do we deal even the next pandemic that's going to come unless we make a more resilient health care system, a more resilient population? And I think, you know, I think you've worked so hard to do that. So how would you, if you were president today, what would you be like leading the charge on to get us going in the right direction around this incredible burden of health disparities and chronic disease and social determinants?

Yeah, it's a great question. First of all, go back and- I would vote for you actually.

I'm a Democrat, but I would vote for you.

Thank you, but you're not gonna have the chance to.

Come on. why aren't the good people running? I just don't understand.

You know, it is interesting that people say, how are you spending your time? And first of all, as you know, I do a podcast and that podcast is really interesting. It's called a Second Opinion. But I'm talking to people just like you are. And it's really interesting. My particular podcast looks at this intersection of health and healing, the life that you and I live as physicians, intersected with policy, the sort of things we talk about today. And the third big bubble is innovation, the creativity innovation. So we bring people on and not to be advertising it too much, but the interesting thing is that when we gravitate back to that intersection of policy number one, number two, health and healing, number three, innovation, just at that intersection there, it comes back to exactly what we're talking about, these non-medical determinants overall that will lower cost, improve outcomes, have greater wellbeing productivity for the nation coming and then you end up starting with shelter and you start with housing and you start with access to access and consumption of healthy foods and nutrition and then you gravitate back out to do that.

You're one of the few scientists, physicians who've come to the insight that we can't just treat patients in the office and tell them what to eat, that we have to fix the food environment, that healthcare fixed. It's not just about better care coordination or better efficiencies or improving payment systems or prevention in some vague way, but it has to do with changing the context in which we eat, the foods that we have access to, and the policies that promote the consumption of more and more of the bad stuff. And we're sort of incentivizing the wrong things. So, one, how did you kind of have the aha? And two, Let's talk about this because it seems like one in five dollars is for healthcare and about 80% of that is for chronic disease. And most of that is from diet. That if we go upstream, unless we go upstream, we're not going to fix the problem.

Yeah, I just want to highlight and repeat what you said. One in five dollars in the entire US economy is spent on healthcare. One in four dollars in the entire federal budget is spent on Medicare and Medicaid.

And that's projected to go up exponentially.

In the next 10 years. This is swallowing the economics of our country. It's swallowing our government budgets. It's swallowing competitiveness of business. It's pretty shocking if you think about food, how big of a part of our lives it is, how big of a part of the economy it is. I can't think of any other part of our economy, any other products that we interact with every day, where safety is left up to the consumer. Imagine if you went to toy stores and...

I love this analogy.

Just imagine you went to toy stores and everybody knew there was lots of toys that were unsafe for the kids. There were lots of toys that were okay, not a little bit unsafe, but not fully safe. And there were some toys that were really safe. Or you walked into a building or you went to buy a house and some houses met earthquake standards and fire standards and electrical standards and plumbing standards. Others didn't at all, not even close. And some houses were kind of in between, some things were met or other things were not met. Or teachers in schools, some teachers, you know, were safe, you know, and were good.

That's for sure.

The teachers and others were known. Everyone knew the teachers were dangerous for the children in different ways. Yeah. We would never leave it up to, you know, the individual family or the individual person to deal with that mess, right? We would say this is outrageous, right? We want safe toys. save cars, save homes, some minimum standards, right? And yet in food, it's the only system where we sort of say, well, it's up to the individual person. We need education, we need labeling, we need dietary guidelines. You know, we just need to leave it up to the person and just not do anything else. And I think, you know, again, that's to me kind of the, you know, kind of the craziest thing about our policy approach so far is that it's all up to the individual consumer. And so, of course, we need to keep choice and there's a range of foods that people should be able to choose from, but all of them should be reasonably safe. Yeah, all of them.

Well, the challenge with that is that the food industry has polluted the science with studies that confound the truth, that challenge notions that they're unsafe. You know, American Beverage Association funds studies that soda doesn't cause obesity and kind of muddies the waters. And so the argument is, well, who's going to be the, you know, the, the judge and determine whether or not this is safe or not safe. Right. Some people think, well, Twinkie's fine if you eat it once a week, but maybe not.

Well, yeah, I get asked about, you know, what my thoughts on the role of the food industry a lot, and it's, it's like everything else, it's complicated. It's not straightforward. So, so first, I have to say that the food industry has followed and continues to follow a lot of the, the really harmful and unwelcome playbook of tobacco, where it's about deception, denial, attacking the scientists, hardball lobbying, softball buying of influence, a lot of the same tactics. But I think at the end of the day, the analogy to tobacco only goes so far. And many of those examples are actually around soda and big soda. There are still present for other foods, but it's really about big soda. I think the analogy with the big with tobacco only goes so far for a few reasons. You know, first the food company is incredibly diverse and heterogeneous. There's there's thousands of companies with thousands of products compared to tobacco.

Yeah.

You know, second, I think that with tobacco, it's a fight to the death. Whereas with food, we need the food industry. We need their scale, we need their expertise, we need their technology, we need their distribution systems. And when I say big food, I mean from agribusiness to large supermarket, international supermarkets, to restaurants, to manufacturers. People think of the manufacturers, but there's four pieces to big food. And I think, sure. And I think, you know, maybe most importantly, we shouldn't forget is the food industry mostly for the last 50 years did what we as public health experts and scientists told them to do. And now in the last 20 years, it hasn't been that long as we've really gotten to new science we're saying, wait a minute, you know, while you did what we asked you to do, slow down and, and change and refresh. And this is where the problem is that some food companies are slowly trying to do the right thing and trying to pick that up mostly because they're being pushed by their losses and sales. Yeah. Some because they believe in doing the right thing. Others are fighting and, and drug, you know, digging in, digging in every step of the way. So there's a lot of heterogeneity. But, but I think what's interesting is.

That You know, it's interesting, there was a guy who was at the Milken Conference who was the head of a big food company. He was like, I feel like a frightened dinosaur.

Yeah, yeah. All the people I speak to and have heard from, they see that the food revolution is coming. There's absolutely, the food in 10 years is not going to look like the food it does now. And so, I think what keeps me up at night is not that there's not going to be change, there's going to be change, but that the change isn't going to be informed by and so, you know, we need innovation in the food system. We need investment in the food system, but going from Doritos to Cool Ranch Doritos is not innovation. Going from gummy bears to non-GMO gummy bears is not innovation. We need real innovation.

We can make an Oreo 90 calories instead of 100 calories. Exactly.

Six trillion calories out of the food supply. There's a major food company who wanted to reduce the calories in their ice cream, so they added air.

Yeah.

Right? So that per cup there'd be fewer calories, right? But adding air to food is not gonna improve its health, right? So I think that, you know, that's the kind of thing that I worry about.

Calories are the same, sure.

Yeah.

Yeah.

So we need to, but the public, I think the biggest thing the public is demanding from their food right now is trust. And big food is not trusted. And that's a wake-up call. and that's good that that's a wake-up call. And so I think that we don't want to demonize the entire food industry. There's, there's a lot of, of folks trying to do the right thing. A lot of graduates from our school at Tufts in the industry trying to do the, help them do the right thing. But we also want to work with industry and also work against industry when we need to give them carrots, give them sticks, help them and sell healthier, more equitable, more sustainable food.

And I think that's happening. I think I see these big companies like Nestle and Pepsi just struggling to reinvent themselves. But it's tough because they've got, I talked to the head of Nestle and he's like, yeah, we have lean cuisine, which is mostly carbs because it's low fat and because we call it lean, the FDA says we can't change the composition of it, so we can't make it healthier even though we want to. It's an $800 million business. I get it. These are like big issues for them.

And this is where, Mark, government has a key role, right? Because if you leave it up to every individual food company to try to fight the system, they're going to go under. If they innovate and the other companies don't, they'll go under. So this is where government has really a role to play to even out the playing field and help these food companies do the right thing.

So let's talk about what those positives are, because there's a lot of things we've written about. and I want to get into some of them. You talked about your best buy policy changes that are going to be not one thing, but a series of things that attack multiple sectors where there's issues, whether it's policy schools, whether it's quality issues, whether it's, you know, labeling, whether it's research, all these things are, are needed in concert to actually shift the whole dynamic from what we have now. But one of the articles wrote was called the real cost of food. can taxes and subsidies improve public health and JAMA a few years ago? And one of the challenges that, you know, we sort of don't want a nanny state, but in essence, we are creating a nanny state in reverse because we're being a nanny to the big food companies by subsidizing commodities that are wheat, corn, and soy that are almost 60% of our calories. And the people who consume the most of them are the sick and of course we then fund food stamps, which is predominantly, I think it's 70 plus percent of it goes to junk food and seven billion, almost 10% goes just to soda. So we've created a system where we're having price supports for the bad food but not for the good food. You talk about flipping that upside down.

Well, so you said a lot there, there's a lot of points there. And, you know, just what's really interesting and again, sort of wonderful from a point of view of wanting to study this is that just like there's no single magic bullet to eating and nutrition science shows us that you can't just pick one piece of the diet and fix it and everything's fine. The same is true for policy. There's no going to be no magic bullet. There's a range of solutions that are needed. I think that taxes and subsidies are pretty crucial and I'll talk about that in a minute. But I would go back to your comment about subsidies. There's been this sort of popular myth that's, you know, kind of urban legend that's spread through the media that somehow there's subsidies to commodities that's making the prices cheaper. And I just want to really say clearly that's totally false. That all US policy for commodities keeps the prices high. The reason, you know, what farmer in the US wants their prices low, right? They all want their prices as high. And so sugar is a great example. People say, well, there are subsidies, you know, and first, most of the subsidies have turned to crop insurance. Crop insurance gives farmers insurance so that if they have a really bad season because of, you know, drought or something, they don't go under. And so most subsidies now are actually crop insurance for those commodities, not direct cash, you know, subsidies. That's still a form of a subsidy, but it's not direct. But corn is a great example. But we actually keep the price of sugar high in this country because natural Brazilian sugar is much cheaper than corn syrup, much, much cheaper sugar from Brazilian farms than US corn farmers.

It's interesting because I talked to the vice chair of Pepsi, he's like, Mark, I said, why use high fructose corn.

Syrup in your drinks? He says, because the government makes it too cheap for us not to. Well, they make it cheaper than natural sugar by putting tariffs on the Brazilian cane sugar to protect corn farms.

Right.

Right.

So if you took away all the price supports, which actually keep the price high, corn farmers would go out of business, but the market would be flooded with cheap sugar from other countries. So that's just one example of this kind of conventional notion somehow. I don't know, I don't know Michael Pollan, someone wrote about this and it's just entered the- But does it allow.

For the production of more and more of the food? In other words, they pay for them to produce food, even if they for example, in bad soils or in ditches, and then they fail and they pay this money. I mean, I've heard all these stories.

The great majority of commodity crops in our country aren't eaten by humans. So the great majority of commodity crops in our country go to livestock or go to energy.

So it's- I thought that's what Nixon's policies on Earl Butz were designed to do, which is to drive the prices of milk and meat down because they were consuming these commodity crops, and he was worried about the prices going too high and not getting elected, and he got Earl Butz to change the policies. I thought that's what the whole thing was about.

I would have to go and look at that history. I don't know that history. I know about Earl Butz and his kind of green revolution, but the farm bill and kind of the subsidy approach has been oversimplified. There's actually a lot of things in the newer farm bills to promote specialty crops that are called specialty crops like fruits and vegetables. to start to promote them, a better approach would be to go to the retail level, right? A better approach would be to go directly to the consumer. And I think we should do that because right now the price we pay for foods doesn't reflect the true societal cost of the food and health care and lost productivity and suffering.

All the externalities.

All the externalities.

Even how we grow the food, how it affects soils and water and climate.

Absolutely. And so it's really not a punitive or approach or a favoritism approach, it's just bringing true market prices to food, right? Food should reflect the true market cost and benefit to people. And so if we taxed most foods, most packaged and processed foods with a flat tax, 10%, 20%, 30%, whatever we could do, and then we used all of that money crucially, we used all of that money to heavily subsidize at the retail level, at the consumer purchase level, or at the farm cost level if you invest in farmer training, new equipment, other things. Then you would use all that money to invest in and reduce the price of minimally processed healthy foods like fruits and vegetables and nuts and seeds and plant oils and fish and yogurt and things like that. You would turn the prices up, you know, upside down, or at least more normal, right? Where you couldn't buy a soda, you know, 36 ounce soda for 99 cents anymore. And you wouldn't have to pay 50 cents or 70 cents for an apple. You'd pay 25 cents, 20 cents for an apple. You'd pay a dollar for a serving of salmon, right? You'd pay $1.30 for soda instead. Yeah. That would change all the incentives for farmers, for retailers, for restaurants. for manufacturers and for the consumer. And so, you know, what's happened over.

The last 40 years is the price of soda has gone down 40% and the price of fruits and vegetables have gone up 40%.

Well, fruits and vegetables in season are still quite affordable. The FDA, excuse me, the USDA did a nice analysis of that. So fruits and vegetables in season are quite affordable, but there's a lot of fruits and vegetables out of season now and those are, of course, are really expensive. 'cause they're getting shipped around the world. So that's another challenge. But I think that price is clearly one tool that the government needs to use to help address healthier food. And it sounds sort of pie in the sky like this will never happen, but there's now at least a dozen countries around the world that have passed soda taxes. Mexico's passed a junk food tax. Yeah. Unfortunately, none of that money is being used to my knowledge, for subsidizing healthy foods. And so that makes the taxes only regressive for in terms of finances for the poor, although it's progressive for health for the poor, it's progressive for finances. We should use that, the revenue from those taxes to create incentives and systems for making healthy food less expensive while helping farmers, right? We don't want to just make the food less expensive by putting farmers out of business. So I think that that's, you know, price is just an absolutely crucial tool. And we've learned from tobacco, for example, how important price is.

So what are your best buy policies if you were willing to sort of be in charge for a little bit and could just do what you wanted? And so it was a thing. You're in North Korea, just make a decision or whatever you want to do.

Yeah, well, I, I, yeah, there's a lot of challenges in North Korea, for sure, that maybe food wouldn't be the first thing I'd address, but it would be up there. So I think that, you know, There's probably six or seven categories of policies that I think are really crucial. One is fiscal economic incentives. So like we talked about direct to consumer incentives or taxes, industry incentives, fiscal incentives, give them incentives for marketing and advertising and developing of healthy foods and give them disincentives for the opposite.

No, but we shouldn't give them a tax break for spending billions of dollars advertising junk food to kids.

Yeah, that's actually been proposed in Congress that hasn't gained steam or gotten out committee, but it's been proposed to take away the tax breaks that companies now get for marketing junk food, right? Fiscal incentives through SNAP, the food stamps program. Fiscal incentives is one category. Two other categories are crucial is to change the environments in schools and work sites. Their kids spend much of their day in schools, adults spend much of their day at work sites. There's a lot of ways, wellness programming, environmental standards, Schools and work sites, places where you, and hospitals, you know, places where you can only really get healthy food, food that tastes good and is healthy and is good.

Well, our school lunch policy now doesn't exactly do that, right? Pizza is a vegetable and french fries are a vegetable.

Well, the 2010 Healthy Hunger Free Kids Act was actually a pretty enormous advance. And so school lunch is much, much better than it was before that. There are still holes, but it's actually probably one of the best policies, food policies we have nationally is school lunch.

50% of schools, you go in and get brand name food on different days. Monday it's McDonald's day, Tuesday it's Burger King, Wednesday it's Domino's. That's 50% of schools and 80% have contracts with soda companies. Well, soda is not allowed in public schools anymore.

No, but also sports drinks, which are extremely high in sugar. No, no, soda is not allowed in schools. Soda is not competitive. including sports drinks, competitive foods, they're smart snack standards, and they're not, they're pretty much out. There's no sugar sweetened beverages in schools. Yeah, that's pretty much 100% juice is okay, but sugar sweetened beverages are out of schools with healthy hunger free kids. Pretty landmark actually. There are again some holes, but it's pretty landmark, but more can be done, I agree. So I think schools, work sites, fiscal incentives, those are three categories. Health care reform, there's a lot to do in health care, and we can. That's a whole nother podcast. But, you know, getting food in the electronic health record, the number one cause of health isn't tracked in the electronic health record. That tells you everything. Right, right. Right.

First, you got to train the doctors and.

Yeah. Fruit and vegetable prescriptions, medical education, medically tailored meals, changing quality guidelines, changing reimbursement guidelines.

There's a lot to do in Healthcare reform. Research and Innovation is. Just before you jump on there, just to show you how powerful that is what you just said, that if you, if you get food prescriptions, the impact can be fabulous. Why would the government want to pay for food? It seems like a waste of money. They people have to eat anyway. But Geisinger did a study where they actually took very treatment resistant type two diabetics who were poorly controlled, the most food insecure. They were costing an average of 248, 000 a year, and they gave them 2, 400 of food. and some support, social support and help to use the food and learn what they're doing. And they reduce their cost to 48, 080 cost reduction while improving dramatically the health of the people. And so it's a no-brainer but, you know, you can't get Medicare to cover a fruit and vegetable prescription.

Well, so, yeah, you're describing medically tailored meals. And, and what you say is really crucial about five percent of the population costs about 50% of healthcare costs, all the patients with really complex chronic diseases, kidney disease, cancer, heart failure, AIDS, a range of really severe conditions. And several interventional studies now have shown that if you actually give those people food, give them three meals a day, which costs about $20 a day, it's much, much cheaper. You save money because they don't go to the hospital, they don't get admitted, they don't go to the emergency room. And because of that, things are changing so quickly, Mark, because of that, California has just launched a $6 million pilot to do medically tailored meals in eight counties in California this year. And if it works and they see the same results, they're gonna extend it to all of California. So change is coming.

Change is a coming.

Change is a coming. And so healthcare is a fourth bucket, another fifth bucket, which I think is crucial for policy, is research and innovation. A lot we know, but there's so much left to learn. There's so much left to learn about how foods affect our brains, our microbiomes, the differences between different processing methods that we've talked about.

I mean, we could go on and on and on. We don't focus on, you wrote that we spend about a billion and a half on nutrition research and about 60.

Billion on drug and other research. So it's like- yeah, the numbers are really telling. The federal government itself estimated that all of its nutrition research is about $1.5 billion a year. And that sounds like a lot, but again, all of the country's drug industry research, pharmaceutical research, is about $60 billion a year. Advertising on candy in the US is about $5 billion a year compared to $1.5 billion on nutrition research. Advertising on candy is $5 billion a year, and just purchasing of candy is $50 billion a year in the US. And so that $1.5 billion is just nothing compared to the true issue is going on.

I heard some scary thing. We spend more on animal pet care and food than we do on education for our kids.

I have not seen that, but that really would be sad if that were true. Amazing. So we really need research and innovation. I think we need a new National Institute of Nutrition at the NIH. The NIH has a National Cancer Institute, a National Heart, blood institute, all these institutes focus on diseases. We need a National Institute of Nutrition. It's the National Institute of Health. Food is the biggest challenge to health. Let's create a new National Institute of Nutrition. And again, that sounds impossible, but the National Cancer Institute was added to NIH, you know, not that long ago, because of just the concerted acts of a few people going to Congress and saying, hey, we need a war on cancer. We need a war on bad food and a victory for healthy food. We need a National Institute nutrition. We need public private partnerships and guardrails so industry can fund nutrition research. I think industry has a role to fund nutrition research but we really have to figure out how to do that transparently and carefully.

I mean, it's tough. You got 40% of the Academy of Nutrition Dietetics, which is our dietetic group in America, being funded by the food industry.

It's a challenge. Again, the food industry is a hard.

Healthy cereal with seven teaspoons of sugar. sugar.

You know, that makes you want to.

Quit the American Heart Association.

It's challenging. It's challenging. I mean, I mean, the food industry has expertise that we need, and they also have negative influence that we don't need. And so how can we use the expertise and, and minimize the, the negative? So, and then I can think the.

Last area, you know, create transparency around.

And have transparency around food in general. And I think the last policy area, we talked about economic incentives, schools work sites, research and innovation, the healthcare system. The last area is sort of quality standards. There are some basic things. The same way we have quality standards for toys or for cars or for houses, we need some minimum quality standards. And the easiest places to start are additives. So we need some quality standards. Basically, the government's saying you shouldn't have too much of these things in food. It's just a minimum standard. We already have done that for trans fat. That's a huge win for the US.

50 years.

Yeah, it took a long time, but we've done it. We need to do that for salt and for sugar additives. And then we need marketing restrictions on marketing of unhealthy foods to young kids. I hope you enjoyed today's episode. One of the best ways you can.

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