Tag Archives: Urban Institute

Public Health in Action – Health, Wealth, and UBI

einstein

Albert Einstein defined insanity as doing the same thing over and over and expecting different results.

As you may know, our country spends a lot of money on healthcare annually – over $3T, to be exact. You may also know that what we spend our healthcare dollars on isn’t exactly improving health outcomes. So, our hypothesis – spend more = better health – doesn’t hold up. So, what’s wrong?

First thing’s first: health and healthcare are not one in the same and should not be used interchangeably. Healthcare is a social determinant of health, which defined by Kaiser Family Foundation is a “structural determinant and condition in which people are born, grow, live, work and age.” Examples of social determinants of health include education, socioeconomic status, physical environment, employment, social support networks, and healthcare – seen in the first figure below.

SDOH2

Social determinants of health essentially contribute to an individual’s overall health in complex ways. And research provides their respective impact on health outcomes, specifically risk of premature death, in the following figure.

SDOH

But why do we spend so much annually on healthcare if research shows it’s only impacting up to 10% of health outcomes? Why aren’t we reallocating some of that toward addressing social and environmental factors like employment and housing?

Ask Einstein.

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Earlier this year, I came across a concept called Universal Basic Income (UBI) and followed up with more reading and research. I continue to wonder and speculate about its potential impact on individual and population health. Financial matters are an integral part of our daily lives – whether it’s paying bills, purchasing food, or filling a prescription, money is on our mind. It’s no wonder that income and wealth are linked to health and longevity, according to this brief from the Urban Institute

I’m excited to share a recent interview I had with Conrad Shaw, a former engineer, turned actor and co-founder of Bootstraps, a documentary series on a UBI trial they’ve developed.

Check it out!

Me: How did you end up doing the work that you’re currently doing?  Describe your journey to your current role as co-founder of Bootstraps.

Conrad Shaw: It was a long and winding road. I studied mechanical engineering in college, because I was pretty good at it and it represents a fairly safe career and a good education to head out into the world with. I liked it fine, and some of the work was rewarding, but I knew deep down that I was never passionate about it. The one class I really loved in college was Acting 101 in my senior year. I had always been a movie nerd, but this was my first experience with performing, and it brought me to life. I figured I should finish up my degree and get some experience on the resume in engineering, though, as a smart fallback plan and a way to keep my parents from panicking. A year and a half into working on missile systems and satellites for Lockheed Martin in Silicon Valley, I had had enough. Cubicle life was not for me, at least not yet. I gave my notice and moved to New York City to give acting a real go. I came in knowing nobody and struggled quite a lot to find flexible restaurant work, some engineering work, even a little day trading of stocks, and paid my way through acting school. Then I graduated and did all of the struggling that comes with building an acting career. I also wrote a couple of screenplays I’m still working to get developed, but I haven’t yet done anything you would have heard of, in case you were thinking of asking. Needless to say, starting an acting career is not a journey for the faint of heart.

It was meeting and falling in love with Deia Schlosberg – we’re now engaged – that sucked me into the world of documentary film-making. She had already established herself in the field, a supremely lucky break for me, and we were looking to work on a project together. I had just recently read an article that introduced me to the concept of universal basic income (UBI) and had become utterly fascinated. All my life, especially since being in New York, the issue of homelessness and poverty just didn’t quite make sense to me. There just had to be a smart way to handle it with a large governmental program, I always believed, and I’d be happy to pay extra in taxes for it to be so – assuming some day I was making an income that would even be worth taxing. But I never put too much thought into it, distracted by my own struggles, assuming somebody must be working on it. And if it hadn’t been done already or wasn’t in the works, it must be too large of a problem to solve – or so I assumed. We must not have enough resources for everyone to live well. But then along comes this idea of UBI. Well, holy crap, the issue wasn’t scarcity of resources after all; it was inefficiency, corruption, lazy thinking, and bad policy. Suddenly, I could no longer ignore the needless suffering going on around me; I couldn’t walk past a homeless person without a burning rage welling up inside me. How could I? I am part of this system, and so I am responsible for this human being’s suffering. What’s more, I’m especially culpable, because I now have an understanding of how we could fix it! But how could I help, I wondered, other than by sort of screaming into the wind on social media? It’s so hard to know what to do to actually make a difference, and so apathy threatens to numb out the rage.

In terms of the logistics, the simple mathematical elegance of the concept and implications of universality spoke to the engineer in me. I did some research and ran some back-of-the-napkin calculations on the realities of what our economy could handle, and really learned for the first time just how extreme our problem of economic inequality is in this country. Suffice to say we could fund a UBI multiple times over and still have bajillionaires roaming around. And the idea of having basic security while pursuing one’s ambitions spoke volumes to the struggling actor side of me. The kicker came when I was discussing it with a friend from the other side the political aisle, with whom I always disagree on everything, and we quickly were finding a lot of agreement on this radical new policy. I was hooked on the concept after about two weeks, and that’s around when Deia casually mentioned that it could be the subject of our next project together. The lightbulb went off at that moment, and we started working at it with all of our energy and haven’t stopped sprinting since.

Me: What inspires you on a daily basis, especially when things get hard?

CS: There are the little things in life, like acts of kindness, good art, cute kids, that are always sure bets for daily inspiration. Then there’s Deia of course. She’s a total badass – she’s all heart and kindness – and we certainly lean on each other and become better than the sum of our parts. I also read a lot about the problems we face and the solutions coming down the pipeline through the eyes of economists, futurists, thinkers, and policy makers who regularly blow my mind. But lately, too, there’s our project, Bootstraps, and what we’ve managed to cobble together so far. We’re running our own basic income trial in order to document and share the stories of regular Americans receiving basic incomes. It was and still is incredibly difficult to raise the funds both for a production and for a separate UBI trial, but we’ve had enough success at it that our trial now has 17 participants (soon to be 20) across 10 states. Letting them know they would be getting $1000/month in unconditional support for the next two years was the most rewarding and joyous thing I’ve ever experienced. And now, every day, we’re getting to see these beautiful people face life’s struggles with a little more confidence in their step and a bit more security in their hearts. We’ve seen a 56-year-old homeless man open his first checking account and save up for his first apartment. We’ve seen a prison inmate make the leap to push for his parole after delaying for 3 years out of fear that he’d fail on the outside. We’ve seen a family able to spend an entire year caring for their newborn in the hospital, able to take time from work to ensure that he continues to develop and have as normal a life as possible despite suffering a genetic condition. The list goes on. These people inspire Deia and I on a daily basis.

Me: Illustrate what problem this film series and UBI is attempting to fix.

CS: I could go deep into the weeds here, but the essence of basic income, as I see it, is shifting power to the people. It is the most efficient and elegant way to guarantee that everyone has a voice and can impact the way the world operates around them. It is a floor not only below which nobody can fall, but also one upon which everybody can stand and build. If everyone can vote with their wallets on what they care about, and if everyone can spare their time and attention on what is important to them without sacrificing their most basic security, then democracy, morality, and community flourish. We take a society preoccupied with accumulating as much as possible to hedge against catastrophe and protect themselves first and  foremost – a society designed to be selfish out of necessity – and evolve it into a society of interdependence and common strength in which every citizen feels part of the whole and cared for. Suddenly people can instead focus on what they can give back to society, how they want to contribute and to matter. Despite all the fearful rhetoric about looming job loss due to automation – which I do believe is a serious concern – UBI at its root is more importantly an issue of human rights, and of humanism itself. It’s a respect for the inherent value in every individual and a societal decision to include and invest in each person’s potential.

The goal of our film series, Bootstraps, is more specific within the UBI movement. We see a gaping hole in the conversation. To date, it is very technocratic and academic. We read daily about the threat of automation and growing support from Silicon Valley billionaires. We learn about ambitious UBI experiments happening in Canada, Oakland, Kenya, Finland, and more. However, political change doesn’t only happen because billionaires and professors, or even politicians, speak out for it, even if they do so beautifully. Things shift when the public rises up and demands that change. Not many people know that we almost had a basic income under Nixon in the 70s. We even had significant experiments of the concept back then, too. The parties in Congress were split on what level we should implement, though, and the people weren’t really kept in the loop so well, and the idea fizzled. We ended up with the crappy welfare system as we know it today. We won’t get the basic income we deserve and need unless it’s fully supported by a people’s movement, and the UBI movement is not yet bringing the people along. Most Americans don’t read thought pieces on economic policy, and certainly won’t read the white papers coming out of these current experiments. Nobody has time to research; we’re all trying to survive.

So, our aim with Bootstraps is to mainline the idea of UBI straight into people’s hearts and minds and create a major catalyst for a grassroots movement. We don’t want to do this with an advocacy piece, mind you. We’re not here to push UBI, but to spark awareness about, and discussion of, UBI. I happen to be an advocate on the side, because I’m pretty sold on the idea so far, as you may have noticed, but we’ve designed Bootstraps to be an honest experiment. And while the other experiments occurring are more quantitative, with large sample sizes and measuring for all kinds of statistical results, Bootstraps is meant to be more qualitative. Essentially, our goal is to show every American stories of fellow Americans who they would relate to, as well as some who they might judge negatively or suspiciously, and introduce a lens of UBI into those stories. Each of our 20 or so participants will receive their basic income for two years, and we will show what they do with it – the good and the bad. We don’t wish to teach people what we believe they should think, but rather to kickstart serious and widespread discussion on the potential merits and flaws of guaranteeing everyone a basic income. And we hope to stream these stories to millions of living rooms in every part of the country.

Me: What’s your vision for the film or movement in the next year, 5 years and 10 years? What do you need to get there? How can we help you?

CS: If the movement can keep growing at the pace it has been for the past few years, it would be incredible. The number one thing people can do to help is to get interested and to learn more. And don’t just listen to your news source of choice. Do some digging. The thing that’s special about UBI is it has serious support from all ideologies, and detractors. Find the different points of view and read them carefully. Let them land on you, and then sit with them. Discuss them with your friends and family, those with whom you agree and disagree. Try to imagine what kind of a system you would want to create to address the issues that UBI seeks to. This idea, I believe, might just prove to be a defining moment in history, a major legacy of our generation, so get engaged!

We will release the film in early 2020 in order to have maximum impact on the national discussion leading up to the presidential primaries. There is already one candidate, Andrew Yang, running with UBI explicitly as his main platform, and many other politicians toying with the idea of endorsing, so we need to do all we can in the meantime to apply pressure to them. My hope is that UBI will be a major issue discussed in earnest on stage in the 2020 presidential debates. I’ve talked to many who don’t anticipate it growing that fast, but these people haven’t been following UBI and interviewing people on the streets about it for the last year and a half as I have. This movement has legs, and the public is poised for a major change in the way we operate. Hell, we voted in Trump, didn’t we? If that’s not a giant red flag that revolution is nigh and possible, then I don’t know what is.

I don’t really have much of a 5 or 10 year plan on UBI. My thinking right now is generally grounded in that 2020 timeframe, because that’s when our project will release. We’ll just have to keep adapting to what circumstance brings moving forward. I’m sure there will be no lack of work to do.

In terms of how people can help with the film, they can get engaged with us, too! Go to our website and get on the newsletter; follow us on social media (@bootstrapsfilm); donate to the production or introduce us to major funders if they have that ability or those connections. They can share about us with their friends. We’ll be working between now and 2020 not only to create this film, but to bring the latest and best information on UBI to our followers, primarily through Facebook and the newsletter. We’ll also be sharing other ways people can help the movement as they come up.

Me: What are the current needs in NYC (or focus in on the city you live in) as they relate to social determinants of health (i.e SES, poverty, access to care, transportation, safety, etc.)?

CS: In general, my overarching philosophy revolves around opening up access and security to everyone, efficiently and universally, such that each can most easily contribute to their maximum potential. In New York City, same as everywhere else, there are several basics in life people need to be able to operate effectively. I think this applies to rural America and NYC similarly, the only difference being that NYC just has a bigger logistical scope to contend with. Along these lines, I would promote universal access to: 1) food and shelter, 2) healthcare, 3) transportation, 4) information, and 5) education, in that order of urgency, but there’s no reason I wouldn’t support doing them all at once.

Food and shelter would best be secured with UBI. In terms of providing affordable housing, I would love to see our awful system of shelters and soup kitchens perhaps replaced by something more along the lines of dormitory style living. What people need at minimum is the safety of a locking door, a place to keep their belongings and sleep at night every night. I would design buildings that provide these rooms, plus things like common areas, restrooms, cafeterias, electricity, wi-fi (this takes care of the information issue), and security staff with the goal of keeping costs below the level of UBI. The formerly homeless, the 20-somethings still working on finding their purpose, the bootstrapping artists and entrepreneurs, the natural disaster survivors, etc. could sustain themselves in dignity while pursuing their own roads to recovery, growth, prosperity, whatever, all the while fostering community and resilience among the residents.

Healthcare, I believe, would best be secured with single payer universal.

For public transportation, I imagine we should be able to find a way to subsidize completely through taxes. In NYC, anyone should be able to take a bus or a subway ride without first swiping. I don’t know the numbers behind this, but I imagine it would benefit society in general not to have people choosing between a trip to the doctor or the grocery store, or parents walking for miles to pick their kids up from school.

The costs of education would be mitigated to some degree by UBI already, but I’m certainly open to learning more about subsidized or free tuition for public school. I’m a strong proponent of fostering as educated and skilled a populace as possible.

Some people and pundits would put work opportunities at the top of that list. Many have started promoting things like a “Job Guarantee” program as an alternative to UBI and other tactics. I’m in support for work opportunity programs, sort of like a new ‘New Deal’ approach, as a method of helping people find purpose and ways to contribute in society. However, without a UBI floor first in place to guarantee basic security, a jobs program is not truly optional to the participants and therefore amounts to forced labor. Also, a UBI will allow many to find their own solutions to prosperity, by starting businesses, going back to school, etc. Without it, an attempt at a catch-all jobs program will end up another hopelessly overwhelmed bureaucratic quagmire. With a UBI in place, then sure, let’s invest in giving people more job opportunities doing important society-building work like infrastructure, home care, and more.

Lastly, in NYC politics as well as in all other localities and nationally, I think it’s essential that the voice of the people be empowered above that of any special interest. I would support not only overturning Citizen’s United, but restricting all campaigns to equal public funding only. Plus, I would support automatically registering every adult citizen to vote, making voting day a national holiday, and putting a serious effort into figuring out how to allow people to vote online. The debacle of 2016’s primaries left me among the millions who were thoroughly disillusioned with the idea that this country is actually a democracy we can still shape with our voices and votes. That needs to change once and for all.

If we invest in providing these sorts of universal access, the people of New York City will no longer sleep in shelters and on streets, will not wait endlessly for government to help them in their personal situations, will be empowered to take action in their communities, will be freed up to pay attention to and participate in politics, will be more resilient in the face of misfortune, and will no longer need to wonder how they’ll pay for their next meals. These are simple abilities that are currently not accessible to a large number of New Yorkers, and Americans in general, as I’ve witnessed over recent years.

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Public Health in Action – Anchored Upstream

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Public Health River Metaphor

A man was fishing in the river when he noticed someone was drowning. He pulled them out and attempted to resuscitate them. Shortly afterwards, he noticed another person in the river and saved them too. He then noticed another, and another and another. Soon he was exhausted and realized he would not be able save all of the drowning people.

He went further upstream to find out why all these people were falling into the river.

On arriving further upstream, he discovered a broken bridge was causing people to fall into the river and end up drowning where he had been fishing.  He decided he would fix the bridge to stop them falling in, instead of fishing them out after they were already drowning.

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There’s a radio ad campaign for the Powerball Lottery in my local area, Raleigh-Durham, North Carolina that has stood out to me more than the hundreds of others I hear on the radio. In the ad,’Wolfman’ (picture Michael J. Fox in the Teen Wolf movie) visits the barber shop for his regular hair cut. ‘Wolfman’ throws out a few ideas – maybe I should shave it all off? “Or maybe a mullet?” His barber asks why the sudden change from his usual cut. ‘Wolfman’ described that his life was so monotonous lately and he wanted to change things up a bit. The barber then responds by recommending that ‘Wolfman’ purchase a Powerball ticket because every jackpot is worth at least $40 million – a life-changing amount; a change that  coincidentally ‘Wolfman’ was looking for. A disclaimer followed in the final seconds stating the odds of winning a Powerball jackpot, which was a measly 1/292 million. Ads, like this one, that tap into our well of emotions leave us particularly susceptible to any product that marketers are hawking, despite the impossible odds or practical necessity in one’s life.

While 1/292 million are nearly impossible odds, 1/4 seems almost certain in comparison. A recent article from the Atlantic highlighted results from Urban Institute’s study on medical debt. 23.8% of adults under 65 in the US has medical debt. Southern states, like Mississippi and Arkansas, have higher rates of medical debt – both over 35%. Furthermore, insurance coverage had a minimal positive effect: 23% of adults with health insurance still had medical debt compared to 31% of uninsured. As mentioned in the article, this has been a common criticism of the Affordable Care Act, aka Obamacare: that expanding health insurance does little to reduce high costs of health care for individuals (out-of-pocket costs) as well as the healthcare system as a whole.

Health policy in most recent years have been focused primarily on health insurance and affordable access to healthcare services. In the river metaphor above, focusing on health insurance would be akin to pulling people out of the river while they were drowning – providing them healthcare when they were sick, rather than figuring out how to prevent, or at least greatly reduce the risk of, illness. In public health and health care lingo this is what’s referred to as “looking upstream.”

In my interview below, Dr. James Leone, professor at Bridgewater State University, describes his career in “looking upstream.” Other upstream heroes of mine include:

Dr. Rishi Manchanda

Dr. Camara Jones

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Me: How did you end up doing the work that you’re currently doing?  Describe your journey to your current role as professor at Bridgewater State University.  Describe why you’re passionate about Improving men’s health…why others should care about the health disparities between genders.

James Leone: My journey into public health education and higher education was a bit random/arbitrary. I began in clinical practice serving as a certified athletic trainer (ATC) where I worked in various settings including: professional with the New England Patriots, clinical outreach at high school, collegiate and physical therapy clinics. I also worked with coordinating rehabilitation clinics and strength and conditioning services in a variety of settings. Not too long into my clinical practice, I received an offer to teach sports medicine/athletic training at Southern Illinois University Carbondale, which was a new challenge for me professionally. I continued to teach and clinically practice, but my love of education rose to the top of my priorities, so I pursued a PhD in public health education. I saw value in what I could contribute on an individual level with people, however, my brain has always been geared towards the “bigger picture” – I guess you can say I embrace an upstream mentality/approach. This was my entry into health promotion and public health studies. I made my way up to Bridgewater State University (BSU) after serving on faculty at Southern Illinois University Carbondale, Northeastern University, and The George Washington University (GWU). Additionally, I currently serve as an adjunct professor at Northeastern University where I have taught courses in athletic training, physical therapy, physician assistant studies, and recently in the master of public health program.

As previously mentioned I have embraced a more “upstreamist” approach in my world and professional view. That said, I realized that male health always seemed to be lacking whether from personal experience or reviewing study after study and large data sets. I always have championed efforts to advocate for groups, be it my athletes or gender (in this case). Also, in 2007 I was approached by my former Chairperson at GWU to offer a class in men’s health, which I quickly embraced since my thought process was already in-tune with this topic. I quickly realized that evidence was lacking in terms of “why” men live sicker and die sooner than women. Also, there were few academic resources (i.e. books) from which to facilitate the topic. I set out consuming as much as I could to develop my course and my knowledge in this area of research. This journey led me to propose a textbook on male health (published in 2012) as well as develop two courses on male health (one at GWU and the other at BSU, presently). I am currently pursuing opportunities to develop male health curricula further so that beyond greater awareness of the topic and issues, we can move dialogue into action and advocacy by training public health professionals and providers on gender-specific needs of men and boys.

So, why do I care about male health topics? I have always been an advocate for people, ethics, and basic human rights. Poor health outcomes in males challenges these aforementioned principles, negatively impacting overall population health. From the public health perspective, we are morally and professionally obligated to help right these wrongs so as to create a more equitable society aimed at a “true public health for all.” I believe Sir Geoffrey Vickers captured it best in his quote, “public health consists of “a successive re-defining of the unacceptable.” I believe gender disparities, particularly those affecting men have been “unacceptable” and warrant our full and undivided attention at present times.

Me: What inspires you on a daily basis, especially when things get hard?

JL: My commitment is based on my ethics and morals, which guide my actions. My intolerance for average often guides my “drive” to improve most things in my personal life and professional practice. Knowing that I do work that directly corresponds to people’s health and experiences is more than enriching for me on a daily basis. When times get rough I often remain mindful of the transient nature of life and experiences – the viewpoint “nothing is guaranteed in life” often helps me to keep my life and work perspectives in check most days.

Me: I saw your presentation at this year’s American Public Health Association (APHA) conference on men’s health as a national security concern.  Can you describe your perspective on this issue?

JL: I was in a graduate school lecture discussing public health initiatives and Harry Truman’s 1946 speech was referenced in the talk. As part of that talk, Truman commented on the nature of the military and investing in the health of the youth to strengthen the defense system of the U.S. Of course, at the time, the vast majority of the military were younger men whose overall health and qualifications for military service were being called into question. The latter point got me thinking as to what it would be today; likely, things have gotten worse with rising overweight and obesity issues nationally. This perspective motivated my presentation at APHA in November. Overall, I think this is an incredibly important issue for two main reasons: 1. Of course we want to a strong system of defense if called upon, and 2. And perhaps most importantly, poor men’s health brings to light the overall issues in male health in the U.S. When we are able to gain the attention of the Department of Justice and Department of Defense, we might actually see Congress move on some of the issues in men’s health that we have been advocating for over the past few decades.

Me: What made you decide to be involved in the men’s health movement and the American Public Health Association Men’s Health Caucus (MHC)?

JL: I saw the APHA MHC as a strong platform from which to pool my energies and resources on advancing male health. I value like-minded people, but also, I am challenged by various ways of thinking and working towards solutions in these groups. I have learned that even though there is a shared value and perspective, we all have something unique to contribute to the conversation over men’s health. The men’s health movement attracts me simply because we as a society must look upstream to the issues that we generalize and deal with downstream. We have grown too normalized with poor men’s health and the forces that drive it. I think working with Men’s Health Network, MHC, and APHA can embolden an area that has gone largely unnoticed even at the detriment of society.

Me: What are the current needs in the Boston metro area (or focus in on the city you live in) as they relate to social determinants of health (i.e SES, poverty, access to care, transportation, safety, etc.)?

JL: I consider Boston and the surrounding areas as “lucky” because we have so much access to health, healthcare, education, and most of the social determinants that can positively affect population health. However, when we look below the generalized population data, we still see a consistent and stark contrast in the health of the privileged and the socially marginalized as with most other major cities. Boston struggles to meet the needs of harder to reach populations and men just like most other major cities in the U.S. We do have some excellent and progressive programming such as the Men’s Health Center (Whittier Street) in Roxbury and the men’s health program through Cambridge, however, the salient question is always: are we meeting the needs of the most vulnerable at the right moments so as to promote long-term individual and population health – I guess time and statistics will tell that story.