What Americans agree on when it comes to health Rebecca Onie
Today, we are a country divided,
or at least that’s what we’re told.
We are torn apart
by immigration, education, guns
and health care.
Health care is ugly and it is loud,
so loud that it threatens
to drown out everything else.
(Voice-over) Protesters: Health care
is a human right! Fight, fight, fight!
Protesters: Hey hey! Ho ho!
Obamacare has got to go!
Rebecca Onie: But what if
underneath all the noise,
we’re not divided?
What if the things that we don’t ask about
are the things that we most agree upon?
It turns out that when we ask
the right questions,
the answers are startling,
because we agree, not on health care,
but on something more important:
we agree on health.
For 20 years, I’ve been obsessed
with one question:
What do we, what do all of us need
in order to be healthy?
As a college student in 1995,
I spent months talking to physicians
at a chaotic hospital in Boston,
asking them, “What’s the one thing
your patients most need to be healthy?”
They shared the same story
again and again,
one that I’ve heard hundreds
of variations of since.
They say, “Every day I see a patient
with an asthma exacerbation,
and I prescribe a controller medication.
But I know she is living
in a mold-infested apartment.
Or I see a kid with an ear infection,
and I prescribe antibiotics,
but I know there is no food at home.
And I don’t ask about those issues,
because there’s nothing I can do.”
Now, it seemed that it shouldn’t
be so complicated
to design a doctor’s visit around
what people actually need to be healthy.
So I created Health Leads,
an organization enabling thousands
of physicians and other caregivers
to ask their patients,
“What do you need to be healthy?”
and then prescribe those things –
fruits and vegetables, heat in the winter,
electricity to refrigerate
their medication –
and we then navigated
patients to those resources
in their communities.
The model works.
A Mass General Hospital study found that
navigating patients to essential resources
is associated with improvements
in blood pressure and cholesterol levels
similar to introducing a new drug,
but without all the side effects.
So two decades later, what’s changed?
It’s now widely recognized
that just 20 percent of health outcomes
are tied to medical care,
whereas up to 70 percent
are tied to healthy behaviors
and what’s called the social
determinants of health –
basically, everything that happens to us
for that vast majority of time
when we’re not in the doctor’s office
or the hospital.
Health care executives
now routinely remind us
that our zip code matters more
than our genetic code.
And one health care publication
even recently had the audacity
to describe the social
determinants of health
as “the feel-good buzzword of the year.”
Now, there’s been some action, too.
Over the past decade, six major
health care providers and insurers
have committed over 600 million dollars
to affordable housing,
recognizing that it reduces
infant mortality
and increases life expectancy.
But let’s be honest.
Is our 3.5 trillion dollar
health care system
fundamentally designed to create health?
Absolutely not.
Take access to healthy food.
Not long ago, a teenage boy shows up
at a hospital in Baltimore,
losing weight.
Just as his doctors are huddled up
figuring out which metabolic panels
and blood tests to run,
one of my colleagues asks out loud,
“Do you think he might be hungry?”
It turned out that this kid
had been kicked out of his housing
and literally hadn’t had a meal in weeks.
He said he was “… so relieved
that somebody finally asked me.”
Somehow, we’ve created
a health care system
where asking a patient “Are you hungry?”
is so far outside the bounds
of what counts as health care
that we mostly fail or forget
to ask altogether;
where doctors lament a hospital’s
“no third sandwich policy,”
meaning that if you’re
a hungry patient in the ER,
you can have only two free sandwiches,
but as many MRIs as the doctor orders;
where, in 2016 in the state of Texas,
they spent 1.2 billion dollars
on the medical costs of malnutrition
instead of on access to healthy food;
where a Centers for Medicare
and Medicaid Services program
stratifies hungry patients,
so that some get access to food
and some get information about food,
with the justification that
doing nothing for hungry patients
is standard and usual care
in this country.
And that’s just food.
The same is true
for housing, electricity …
The bottom line is,
health care may be changing,
but not by enough
and certainly not fast enough.
We ask the wrong questions
of our doctors, of our patients,
but also of our citizens.
We ask about and argue about health care,
but how do voters think about health?
No one could tell us
the answer to that question,
so we launched a new initiative
and hired a polling firm
to ask voters across the country:
What do you need to be healthy?
What was so striking about this
was that no one has any clue
what we are talking about in health care.
Voters do not think
the social determinants of health
is a feel-good phrase.
They actually hate it.
“What uneducated person
came up with that language?”
one of the voters said.
Or my favorite was the guy who said,
“You’re killing me.”
But when you strip away
all the ridiculousness
of our language in health care,
we know exactly what creates health.
So take Charlotte, North Carolina.
We had two focus groups,
one of African American Democratic women
and one of white Republican women.
And we asked them,
“If you had a hundred dollars,
how would you spend it
to buy health in your community?
Turns out, they agree
nearly to the last percentage point.
First, they agree that health care
only sort of impacts health.
So they choose to spend
the majority of their dollars
outside of hospitals and clinics.
And second, they agree
on what creates health,
spending 19 percent on affordable housing
and about 25 percent
on access to healthy food.
So I am sure you are thinking,
“This has got to be a fluke.”
But it’s not.
White and Latino male
swing voters in Seattle,
white and African American
Democratic voters in Cleveland,
white male Republicans in Dallas,
low-income white Democrats
in Hendersonville, North Carolina:
their answers are strikingly similar,
with all of them choosing
to spend more money
on healthy food and safe housing
than they would on hospitals
and health centers.
When you ask the right questions,
it becomes pretty clear:
we may be fractured
on health care in this country,
but we are unified on health.
The thing that I’ve been
struggling with is why.
Why do we agree on health?
We agree on health
because it is common sense.
We all know that the things
we need to get healthy –
medicine and medical care –
are not the things we need to be healthy,
to not get sick in the first place.
But we also agree because
of common experience.
In a study of 5,000 patients,
24 percent of the patients
with commercial health insurance –
meaning, they had a job –
still ran out of food or struggled
to find housing or transportation
or other essential resources.
Twenty-four percent.
And we saw the same thing
in our focus groups.
Nearly every voter knew
what it meant to struggle,
either themselves or their families
or their neighbors.
One of those white Republican
women in Charlotte was a waitress
struggling to stay awake
with an enormous Big Gulp soda.
She just looked exhausted.
And she was.
She told us that she worked two jobs
but still could not afford
a membership to the Y,
but it was OK that she couldn’t go
to the gym, she said,
because she also could not afford gas
and walked 10 miles to and from work
every single day.
Listening to her, I felt
this familiar panic rise in me,
the residue of my own childhood.
When I was 10 years old,
my father lay on the living room floor
in the grips of one
of his many depressions.
As I crouched next to him, he told me
that he wanted to kill himself.
My father lived,
but he struggled to work.
And my family survived,
but we teetered,
down one paycheck,
relying on my mom’s schoolteacher salary.
Even as a little kid, I knew
we lived in the shadow
of financial and emotional collapse.
This is really hard to say,
because it’s taken me 25 years
to be honest with myself
that this is why I do this work:
knowing that my father
needed health care to recover,
but to be healthy, my family
needed something else,
we needed a decent income;
and knowing, as so many do more than I,
that panic when the basics
threaten to slip away.
To the voters in our focus groups,
the solutions were straightforward.
As one of those white Republican
women in Charlotte said,
“Instead of putting all this money
into health care,
put it into affordable housing.
You know, like, take it
and distribute it differently.”
It turns out that when you have
the right language
and you ask the right questions,
the answers become remarkably clear
and unanimous.
What we know is that,
despite all the noise,
the plan for health care in this country
is that there is no plan.
But we have something more powerful
than any politician’s bill,
any candidate’s platform,
any think tank’s policy statement.
We have our common sense
and our common experience.
So I ask, if you are
a health care executive:
Do you know how many
of your patients run out of food
or struggle to pay the rent
at the end of the month?
Is that data on your scorecard,
shaping your business and your bonuses?
If you are a politician:
Will you continue to fight
on the scorched earth of health care,
or will you act on what your voters,
what Democratic
and Republican voters alike,
already know,
which is that good wages,
healthy food and safe housing
are health?
And for the rest of us,
for the citizens of this country:
Will we demand accountability
to what we know to be true,
which is that our common sense,
our common experience,
makes us the experts
in what it takes to be healthy?
This moment, as it turns out,
is not about changing minds.
It is about something more powerful.
It is about changing the questions we ask
and quieting the noise
to hear each other’s answers.
It is about the radical possibility
that we the patients,
we the physicians, we the caregivers,
we the health care executives
and yes, even we the people,
that we agree.
And it is now time –
in fact, long overdue –
for us to marshal the courage
to hear those answers
and to act upon them.
Thank you.
(Applause)