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MS. STEAD SELLERS: Hello, and welcome to Washington Post Live. I’m Frances Stead Sellers, a senior writer here at The Post.

Today we're going to take another step towards explaining America by looking at the troubling statistics around life expectancy and also the state of America's health care system with two experts. I'm joined today by Michelle Williams, dean of the Harvard Chan School of Public Health, and Dr. Asaf Bitton, who directs the Ariadne Labs which focuses on health systems innovation.

A very warm welcome to you both, Dr. Williams and Dr. Bitton.

DR. WILLIAMS: Thank you, Frances.

DR. BITTON: Thank you so much.

MS. STEAD SELLERS: Dr. Williams, if I may start with you. I've been struck, these numbers about life expectancy have hit international headlines now. There was a huge story out from the Financial Times, for example. To what extent are these numbers surprising to you? They're certainly shocking.

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DR. WILLIAMS: I would say I'm not surprised, but I would say the numbers are shocking. I think the numbers tell us something that we've known for a long time, and that is we know that young people in America or younger people in America are dying at rates that are higher than our counterparts in the EU, for example, or in the OECD states.

We know, as you saw in the opening film, that we have among the highest, if not the highest, maternal mortality rates and infant mortality rates of our other upper-income countries.

We also know that when young people die, when infant mortality, which is so much higher in the United States than other developed countries, that is going to have an outsized impact on life expectancy.

I think the emphasis on life expectancy is important. It's an incredible indicator of health of a population, but it only tells part of the story. What the life expectancy numbers don't tell us is the massive amount of preventable morbidity that also exists in our ecosystem.

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MS. STEAD SELLERS: So, Dr. Bitton, if you could pick up on this. Here we are in a country with the best hospitals probably in the world, the best schools of public health or certainly among them in the world, huge amounts of philanthropy backing technology and other innovations. How do you square this paradox between what Dr. Williams was telling us and all the advantages America has?

DR. BITTON: Well, as both a primary care physician and public health professional, my mind goes actually to a somewhat rarely talked about law, which is called EMTALA. It's a law from the '80s that basically says a pretty wonderful thing. It says that if you are in need of medical care and you have a medical emergency, that it is the responsibility of hospital to treat you. And so that responsibility is sacrosanct and for everyone.

But when you start to think about it, what it also means is that up until the moment that you collapse from a heart attack, a stroke, from a gunshot wound, or a seizure, the responsibility that our society has literally written into the law and a social fabric is actually contingent. It's contingent on whether you have health insurance. It's contingent on where you live. It's contingent on who you are, your race, ethnicity, your access to--or lack of access to different structures in the societal system and the health care system. And so it's that contingency that doesn't allow everyone to not only have access to preventative care but really all the upstream factors that Dean Williams just talked about, clean air, clean water, a place to live, good education, good food, the ability to make good choices for your health. And so it's our contingency up until the moment that someone literally collapses in front of us. Then we have a commitment to each other to intervene and to throw the best of what we have, which is we have a wonderful sick care system that takes care of very sick people, but a very inadequate health care system.

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MS. STEAD SELLERS: But one of the bizarre things--and tell me if I'm wrong, Dr. Williams. One of the bizarre things about these numbers is that even being college-educated and insured in the United States doesn't put you at an advantage over equivalent people in other developed countries. Where does that come from?

DR. WILLIAMS: You know, I think it comes from that imbalance that Asaf was just speaking to. If the emphasis is placed on taking care after health is lost, we have missed the opportunity to support, nurture and, enable health--healthfulness and health. So I would say that what is missing and what drives these quixotic numbers are that we are out of balance in terms of how we think about health and wellness.

We think about the high tech supporting that acute care part of the spectrum, which is taking care of someone after health is lost, as opposed to investing in what is considered the high touch that is providing for screening and evaluation to early detect and prevent chronic diseases, that is providing that social safety net that many of our counterparts in the OECD countries provide. So I think where we are different is that we emphasize rescue care, acute care at the expense of investing in supporting and enabling health promotion and disease prevention. That lack of balance is best illustrated in a very stunning truth about our country. While we are leaders in medical and health innovation, we are also at the bottom of the curve when it comes to having primary care doctors who are critical and essential for health, health care, health and wellness, and disease prevention. We have not invested in the end of the spectrum where health and wellness is prioritized and invested in. We only spend, in the last--in 2021, only 4.4 percent of health care dollars were contributed to public health. That is way out of balance compared to what we would really need to support and enable disease prevention and health promotion.

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For example, I'll give you one more example. We can prevent, almost eliminate, deaths from cervical cancer, but because we don't have universal health care, because we do not afford women who need it very basic cervical cancer screening and breast cancer screening, we see people showing up for rescue care when we could have prevented these conditions by screening and prevention programs.

MS. STEAD SELLERS: This is fascinating, and I want to just ask one more big-picture question before we get into some of the finer details. Larry Summers, the former Treasury secretary, tweeted recently that these numbers about life expectancy were terrifying, and let me read to you a little of what he wrote. He said, "They're the most disturbing set of data on America that I've encountered in a long time," and he'd likened these sort of demographic trends to the trends he saw before the fall of the Soviet Union.

So, Dr. Bitton, to what extent do you see sort of life expectancy numbers as a harbinger of economic downtrends or even economic collapse?

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DR. BITTON: Well, they may be a harbinger. I think they're also a signal of acute distress in a society.

I mean, I remember when I was at the school, as a public health student, learning about, you know, post-Soviet Russia as one of the first developed economies to have acute falls in life expectancy and what an unusual thing that was compared to increases in life expectancy that have generally been seen across the globe as economies develop.

Well, it's a harbinger of something really serious because, as you mentioned earlier on, these are not--the fallen life expectancy begins before people are born. That means that it starts with unconscionably high rates of maternal mortality and infant mortality in the U.S. that dwarf any comparator developed country and continue through unbelievable rates of youth mortality. I mean, 1 in 25 five-year-olds doesn't make it to their 40th birthday. That's one out of every average-size kindergarten class--kindergartner in a classroom is not going to live to be 40 for a variety of reasons that mainly have to do with injuries, violence, homicide, suicide, overdose, and lack of access to basic care.

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So I think that we should be right to be focusing on this, to be quite scared about it, but also to ask ourselves a critical question: What kind of cohesive formulation of the problem that can orient itself across the spectrum of political and social belief can we muster in a time of great social lack of cohesion in order to face this problem? It cannot be faced by policy prescriptions on one side of the aisle or the other.

MS. STEAD SELLERS: So we can look at the system. We can look at the lack of access to primary care, but there are other issues, risk factors like obesity. Dr. Williams, where does America's obesity, its approach to food, factor into all of this? What's happening with our diet?

DR. WILLIAMS: That's a great question, and I will tell you that our diet--the problem of obesity begins not only with individual behavior but our systems, our policies that allow for, you know, highly processed foods to replace more healthful foods that are admittedly harder to maintain in certain communities because, you know, fresh fruits and vegetables are highly perishable. And food deserts begin to emerge in places where small shopkeepers and communities can't afford to carry fresh fruits and vegetables.

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Our problem with food and diet is not about the individual as much as about it's our ecosystem of policies and practices around how food is produced, distributed, and managed.

We in the United States have an obesity rate of close to 40 percent--36 percent, which is double the rate that you'd find in peer-developed countries. But we also have places where there is massive amount of food insecurity. So we have--you know, it's a tale of two extremes. We have more food than we would need to feed the population in a healthful way, but we have policies and practices, legacies of inequality, legacies of poor urban planning for how food is maintained in communities so that fresh fruits and vegetables can be a first choice.

What would be required to fix this would be an intentionality, a system-wide approach to ensuring that healthful foods and vegetables are available across the board that meets the needs of individuals across the life span. It's not just a public health problem. It is a problem that would require policy adjustments as well as the engagement of the private sector in securing and appropriating fresh fruits and vegetables in communities where there might not necessarily be such an easy line between profit and revenue generation.

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MS. STEAD SELLERS: And are you seeing any communities, cities, states that are putting a particular focus on making those kinds of policy changes?

DR. WILLIAMS: There are really nice examples that I'm aware of in California. You know, I'm remembering how the leadership of Kaiser Permanente in Northern California actually tried to solve the problem and successfully solved the problem by using their purchasing power to procure fresh fruits and vegetables in excess of the health system's needs so that small mom-and-pop shops in communities could actually purchase, at a discount rate, fresh fruits and vegetables, that allowed them to provide their clients access to fresh fruits and vegetables without their running afoul of the economic balance for keeping their shops open.

I think there are lots of examples like that, that engage the private sector, the public sector, involved in trying to address a problem around accessing fruits and vegetables that are appropriate.

You know, there is a movement of fruit--of food as medicine, where people are rethinking the approach to how healthy diets can actually be at the root of promoting health and wellness.

MS. STEAD SELLERS: This is so interesting because you chose Kaiser Permanente, which, of course, is an HMO system, and I'm wondering, Dr. Bitton, whether many of these problems stem from a structural way that we arrange health care in this country.

DR. BITTON: Well, they certainly relate immensely to that structural way. You know, we talked earlier about the sick care system. We have a sort of technology and procedural bias that winds its way into the way we pay for medicine and way--and the ways that we don't pay for the things that Dean Williams just spoke about.

You know, as a primary care provider, I'm lucky if I get to see my patients, you know, maybe, you know, for 30 to 60 minutes a year in person, and, you know, the rest of the 99.99 percent of the year, those are choices and mechanisms that people need encouragement to be made. But here's what we know about the U.S. health care system and what works and what doesn't. We know that parts of the U.S. and globally that invest in primary care, invest in long-term healing relationships between teams of clinicians embedded and trusted in communities to walk with their patients as they encounter both acute, chronic, preventive, and end-of-life issues. We know that investments in those primary care systems routinely result in both improved outcomes and improved equity. This is from a National Academies of Sciences, Engineering, and Medicine report in 2021.

So all other parts of the health care system, you can invest in them, but they will not routinely improve equity, improve life expectancy, improve outcomes. And so the question is, why do we only spend 3 to 5 percent of our health care dollar? The $4 trillion that we spend every year on mostly a sick care system once you've had the collapse or had the wound or had the heart attack, why can't we change the mechanisms of incentive structures that go both from state and federal payers, commercial payers, purchasers, and other actors in the system to make it easier to do the right thing, make it easier to provide that usual source of care, that first contact to access, that person who knows and trusts, and that you trust in them for your chronic disease, preventive needs, and coordination of care?

We have a choice, and that's a choice that can be made either legislatively. It can be made within payers. It can be made by health care provider systems. Do they want to invest upstream in health, or do they want to continue the business of sick care?

MS. STEAD SELLERS: So, Dr. Williams, you have raised the issue of race, and I'd love for you to help me understand the extent to which it is coupled with other socioeconomic issues and the impact of structural racism in the health care system.

DR. WILLIAMS: Sure. Let's go back to looking at the life expectancy--

MS. STEAD SELLERS: Yeah.

DR. WILLIAMS: --statistics. We know that within, you know, a distance of about six miles in--right here in Massachusetts that we can go from Roxbury to Brookline and we can see that there is a life expectancy difference--Roxbury, a largely Black and brown community; Brookline, a largely White and upper-income community. We know that within the distance of about nine miles, we will see more than nine years difference in life expectancy.

Now, what's driving that? We have to remember that when we think about life expectancy, we're really asking ourselves fundamentally, what is it that's causing younger people to die? Because a death of a young person impacts the life expectancy numbers more disproportionately.

When you think about maternal mortality, reproductive age women, admittedly, young women are dying. Black women are dying at a rate that's three times higher than their White counterpart.

Infants. Infants, Black and brown, Black infants, in particular, are dying at a rate of three to four times more than their White counterparts. So you are looking at two causes of death, infant mortality because of premature delivery, let's say, and because of lack of quality prenatal care or lack of access to quality prenatal care, driving a number of higher rates of death for and Black women.

When you look at the concentration of gun-related violence and gun-related suicides, you see emerging in our statistics that poor, low-income children are at higher risk of suicides now than their counterparts who are in upper-income brackets and are White, and we're seeing that these causes of premature death disproportionately affecting low-income and Black people. The intersectionality of poverty and of race has never been as strong as we have seen it in the causes of maternal mortality in a very, very long time. We are seeing this, which is essentially a legacy of inequality that has grown over the last decade or so.

MS. STEAD SELLERS: So these structural issues are in some ways peculiarly American, but, Dr. Bitton, when you look around the world, there are examples of countries where life expectancy is going up. Portugal is a very interesting example, not a rich country, though it's had some recent investment. Where do you see people doing things right, and are there easy lessons that the U.S. could import from those places?

DR. BITTON: The good thing, if we choose to look, is that there are a lot of lessons from around the world. They aren't recipes. This is not a cookbook, but they do offer directional thought and opportunity and possibility in these seemingly intractable problems.

You mentioned Portugal. It's a wonderful example in the sense that if you start to look at OECD countries with a population over 5 million, Portugal, about 50, 60 years ago, was on the bottom of this list, and the U.S. was near the top, the difference being between seven to eight years of life expectancy. As of the end of the last decade, that's flipped in the sense that Portugal now has a higher life expectancy than the U.S.

Another great example within our own hemisphere is Costa Rica, a middle-income country, that spend--that has the per capita GDP about $12,000 and spends only about $800 a year on health care and public health. But what Costa Rica has managed to do is remarkable. They have managed to have a--build a health care system that's integrated with their public health system and actually increase life expectancy to the point that it's actually higher than the U.S. while spending about the 10th that we spend.

And how did they do it? Well, four really core things. The first thing that they did that we could do and we can make that commitment tomorrow if we had the cohesion and the will to do it is to grant everybody, even undocumented migrants from the surrounding countries, access to universal basic health care. So everybody has access to health care through an insurance scheme.

And the second thing that happens is that everyone has access to a primary health care team that visits them once a year at their home or in a clinic, that understands and does preventive screening and offers them connection to the rest of the health care system.

The third thing that you do once you impanel, which means that you've reached everybody in your population, whether they live in a city or live in an extremely rural environment, is that you start to integrate the offerings between health care and public health. You don't keep them with this false dichotomy as if they don't touch on each other. And I think that's a major lesson from covid.

The lack of integration of public health and health care infrastructures in midst of a pandemic, let alone in the midst of all of the causes of falling life expectancy, make it more likely that we'll continue to stay in these silos and not do things together.

The fourth thing that they do is that they collect data on how the system is operating for everyone, and instead of punishing the areas that aren't doing so well, they actually increase their investments in the poor or most unequal areas.

And so I think that countries like Costa Rica, countries like Portugal, starting with offering basic health coverage and health insurance to everyone but then by integrating their public health and health care infrastructure have made huge strides that we could learn from.

DR. WILLIAMS: Frances, if I can--

MS. STEAD SELLERS: Yes. I have a question.

DR. WILLIAMS: If I can add to this, those four things really, in my mind, represent the values that these countries have placed on making sure that health is a right for all of their citizens. Those four points brought together, as articulated by Asaf, indicate something in my mind that we in the U.S. don't tend to do. We tend to celebrate breakthroughs at the expense of really doing the kind of intensive follow-through that is needed to completely leverage the know-how, the knowledge, the innovation, the extraordinary scientific talents that we have. We don't invest enough in bringing those four threads together and following through in a meaningful way so that the most vulnerable members of our population, as well as those who have resources, are afforded the right of good quality care that preserves, protects, and promotes their health in health care prevention population ways and then also ensuring that acute health care is available to everyone when they need it. Follow-through is critical.

MS. STEAD SELLERS: Yeah, follow-through is critical, and yet let's talk about the political realities of this country. We had a massive battle over the Affordable Care Act. During covid, certainly at a state level, lawmakers pushed back against public health authorities. So I'd like to hear from both of you. Where do you see the path forward here? Because the ideas sound wonderful. Implementing them sound very, very difficult. So, Dr. Williams, maybe you could start and then Dr. Bitton, take on these political issues.

DR. WILLIAMS: You know, I think where we start is the recognition that our--the current system, as we have it in the U.S., is costing all of us, that providing population health and primary health care to all who need it should not be seen as charity. It should be seen as a strategic pillar of economic investment and social resilience in our country.

If we can get our leaders to appreciate that health care, access to universal health care has a moral--we have a moral imperative to do that and we also gain as a nation an economic social stability that comes from doing this, we will have, hopefully, a stronger will and commitment to providing that integrative population health and health care.

It's also going to require our taking a real hard look at the economic incentives, the financial incentives that drive and keep the status quo. We really have to change the narrative and flip the way we think about health and wellness, where the things that bring real value to society by keeping a population healthy, active, and engaged, stemming premature and preventable mortality, documenting that that is better for a more robust society and a robust economy.

You mentioned Larry Summers bringing this forward. I mean, Larry is bringing forward the economic argument for why it's important to invest in population health and primary health.

MS. STEAD SELLERS: Any more to add, Dr. Bitton? I mean, I'm thinking even back to Friday's decision over abortion, which many people would argue were ideologically driven, the science in that, rather than based on evidence-based medicine. What--where's the leverage here? Where's the point where we get expertise leading the way in what you both describe are very key issues for the health of the country?

DR. BITTON: Well, I think of two things really to add on to Dean Williams, and I agree with what she said. I think they're issues of pressures that we cannot ignore and traction that we must start to gain. So the pressures that we cannot ignore really are those that are economic. You laid them out. I mean, if we have one 1 out of 25 kids not surviving to age 40, if we have a falling life expectancy, the competitiveness, the economic engine that as unequal as it is across the U.S. has managed to make us continue to be the wealthiest country on the world and able to spend $4 trillion on a system that's--a health care system that's not giving it what it should back to society. Those pressures become more and more acute. It's a harbinger, but it's also here and now. We spend 20 percent of our GDP on health care, and it's only going up and up. And yet we're having falling life expectancy.

That equation doesn't continue forever and ever. Those pressures become real. We won't--we have a working-age population that's not healthy enough to really sustain us into this next decade. So we have that looming.

And then the other part is traction, and it starts with local. It starts with understanding that the issue of life expectancy, whether people want to politicize it or not, has to do with your neighbors. It has to do with your family, has to do with your community. If you see that 1 in 25 kindergartners isn't going to survive to age 40, if you see that working-age people are dying and becoming disabled prematurely, that has no political strife to it.

And so you say, well, then what's the next part? The next thing that I say from observing and traveling the world and doing research on effective health and social systems, is that these systems do not have a political strife. They are--some of them, most free market systems, have guaranteed universal health coverage, as have systems that like to do more on the state side. And so if everyone basically has discovered that it's a good idea to invest in health, then to my earliest point that we started off with, let's make--not make this a contingent issue. Investing in people's health shouldn't be contingent until the moment that they drop in front of us and we take them to the ED. It should be something that we start to do upstream because it's smart for them, it's the right thing to do for the economy and the country, and it's the right thing to do for our families and our neighbors.

MS. STEAD SELLERS: Thank you.

Investing in health, it's a strong message to end on, and I thank you both. Dr. Asaf Bitton and Dr. Michelle Williams, thank you so much for joining us here on Washington Post Live.

DR. WILLIAMS: Thank you, Frances.

DR. BITTON: Thank you.

MS. STEAD SELLERS: That’s all we have time for today. What a fascinating conversation. You know where to find more great conversations on Washington Post Live at WashingtonPostLive.com. So check it out. Thank you for joining us. I’m Frances Stead Sellers.

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