Health care reform in the United States:

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• Health care reform in the United States
• Why bike lanes are part of the solution
• Jean S. Fraser
• Presentation to Shape Up Coalition
• April 9, 2008

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Figure 1. International Comparison of Spending on
Health,19802004
Average spending on healthper capita (US PPP)
Total expenditures on healthas percent of GDP
Data OECD Health Data 2005 and 2006.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006.
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Costs driven by numerous factors

• Increasing medical labor costs
• Hospital consolidations
• Cost-shifting by providers due to unreimbursed
  services for uninsured
• Patient demand driven by ads and Internet
• Creation of new medical technology/drugs
• More people need more treatment because Americans
  are less active than ever before

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Two approaches I am most passionate about in
health care reform 1. cover everyone 2.
change our environment to make physical
activity a part of everyday life
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Cover everyone

• Good for individuals
• Good for business
• Eliminates cost-shifting
• Creates incentive to make population-based
  changes to decrease costs

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Changing the environment to make physical
activity part of every day life is also critical

• We must address the epidemic of weight gain and
  lack of physical exercise and their attendant
  problems
• We must do this on a society-wide basis, not on
  an individual basis

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Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 20
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Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
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Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
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With lack of exercise and increasing weight come
numerous health problems that degrade our quality
of live and cost a lot of money to treat

• Hypertension
• Diabetes
• Cardiovascular disease
• Asthma
• Joint/back problems, including arthritis, that
  disable a person
• Depression

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Some examples of the consequences of lack of
exercise and being overweight

• Four times rate of physical disabilities if
  severely obese
• Arthritis now occurs in 37 of people ages 44-64
• Epidemic of diabetes, including among children
• Obesity boosts annual medical spending per adult
  by 37.

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There are two major causes Our food system and
our built environment

• Larger portions of cheap, high-calorie,
  low-density food Super Size Me!
• Work on the Farm Bill!
• Changes in how we get around
• 1960 10 Americans walked to work
• 2000 3
• 1970 66 of kids walked/biked to school
• 2000 16
• 5 of Americans get recommended 30 minutes of
  moderate exercise every day

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What is the solution?

• A reduction in population-level prevalence
  of obesity requires changes in the environmental
  conditions (i.e., opportunities for activity
  such as walking trails and bike routes) that
  support widespread changes in . activity
  habits.Roussos and Fawcett, 2000, p. 375

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Telling people to get more recreational exercise
will not work for vast majority of people

• 1 barrier to exercise lack of time
• Other barriers include
• Perceived/real physical inability to exercise
• Lack of motivation
• Lack of social support structure
• Lack of financial resources
• It is not possible to eliminate these barriers on
  individual basis

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We need to start treating this epidemic as a
societal problem, not a personal one

• Public health past successes were based on
  eliminating causes, not changing individual
  behavior
• Sanitation systems
• Clean water systems
• Similarly, we need to make exercise nearly
  unavoidable
• We must make active transportation -- walking and
  biking -- a better alternative to driving a car
  so that people get their exercise while doing
  something useful to them

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If you build it, they will come.

• 1975 2001, Germany increased by 50 trips made
  by bike by increasing gas tax and improving
  biking conditions.
• Walking increases with age in Netherlands and
  Germany cycling falls off only slightly.
• European cities accomplished these behavioral
  changes through tax changes and how they built
  their cities
• Wide, well-lit sidewalks on both sides of streets
• Designating bicycling streets which permit cars
  but give cyclists right of way
• Traffic calming in residential areas
• Increased taxes on auto purchase/use
• Reducing/increasing cost of parking

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If you build it, they will come, even in San
Francisco.

• Installing Howard Street bike lanes increased
  commute-time bikers by 300.
• One of every three San Franciscans say they would
  ride if there were more bike lanes and safer
  streets.

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Excellent public transit is a CRITICAL element of
active transportation strategy because

• Every transit trip starts and ends with a walk or
  a bike ride
• Public transit is used by walkers and bikers as
  complementary mode of transportation people can
  forego car ownership if public transit is
  excellent
• Unless we develop reliable, attractive
  alternatives to car use, our roads and our
  politics will be dominated by cars

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What is each City dept doing to make
walking/biking a better alternative than driving?

• MTA
• Office of Economic Development
• Rec Park
• DPW
• DPH
• SFUSD
• SF Env

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Planning is one of most important City
departments for active transportation

• Level of service reform for CEQA
• Right now CEQA review solely focuses on whether
  project will slow number of cars traveling thru
  intersections
• Planning new neighborhoods
• Eastern Neighborhoods need to be mixed-use, with
  neighborhood shopping, calmed streets, bike lanes
  and excellent public transit
• Parking minimums/maximums
• Parking should be unbundled from residences

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Active transportation gives greatest benefits to
the most vulnerable

• Low-income people
• Transportation costs are much larger percentage
  of income
• Often do not own cars
• Communities of color
• Higher rates of overweight/obesity in some
  communities of color
• Sedentary people
• People who have not exercised in past get
  greatest increase in health benefits from even
  small increases in activity

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Active transportation gives greatest benefits to
the most vulnerable

• Elderly and disabled
• Functional limitations and subsequent loss of
  independence delayed with physical activity
• For those who cannot drive, supporting safe
  walking and neighborhood stores increases their
  physical safety and decreases their isolation
• Children
• If children cannot walk/ride to school/around
  their community, they have no way to get exercise
  other than structured settings which require
  adult assistance, money and time

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So what should you and I do now?

• Public health folks and other concerned citizens
  need to tell planners, transportation experts,
  politicians what to do, though not how to do it
• Tell them our cities need to be built so that
  virtually everyone walks or bikes 30 minutes a day

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Beware the black holes of negativity

• People wont give up their cars
• Polls show people would like to give up their
  cars but the alternatives have to be viable,
  attractive
• Oil prices give us an opening
• We dont have the money
• Much cheaper to build/maintain bike facilities
  than car facilities
• Large potential sources of revenue in increasing
  costs of driving
• Its all a matter of priorities

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Beware the black holes of negativity

• The political will does not exist
• 90 San Franciscans consider biking legitimate
  way to get around City
• 75 San Franciscans want better biking conditions
• It takes too long
• If it took 30 years to accomplish this, would
  that be worth the wait? It took us over 30 years
  to get to where we are today.

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The effort is worth it.

• Decrease health care costs
• Improvement among 10 of people in CA with
  obesity could save 13 billion in 5 years.
• Improve air quality (and reduce global warming)
• Decrease asthma and other air quality-related
  problems
• Increase life expectancy
• First generation for whom life expectancy may be
  shorter than preceding generation unless we do
  something about it
• Make us happier
• Three million American children have significant
  depression symptoms. Best way to treat
  depression is exercise and social connectedness.

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We now realize that how we design the built
environment may hold tremendous potential for
addressing many of the nations greatest current
public health concerns, including obesity,
cardiovascular disease, diabetes, asthma, injury,
depression, violence and social inequities.

• Richard Jackson, M.D., former California Public
  Health Officer