[00:00.00]Much of the national focus on improving health care has centered on the expansion of coverage that's starting to take effect. 
[00:07.85]But a report out today says it's time for the country to pay more attention to the socioeconomic conditions that play a role in health outcomes, especially for lower-income Americans.
[00:18.71]The recommendations, issued by a nonpartisan commission created by the Robert Wood Johnson Foundation, call for new investments like pre-k education for children under 5.
[00:30.94]David Williams is a professor at Harvard's School of Public Health. He was a staff director for the commission as well.
[00:36.56]And, for the record, the foundation is one of our sponsors for health coverage.
[00:40.84]Professor Williams, it's good to have you with us.
[00:43.09]It's good to be with you.
[00:43.64]So what is the rationale for thinking that doing something about socioeconomic conditions is going to be connected to a health improvement?
[00:52.95]Well, first, the larger context is, as a nation, we have a huge problem. We spend more money on medical care than any other country in the world.
[01:02.15]According to the World Bank, half of the money spent on medical care in the world annually is spent in the United States. Yet we rank among -- 
[01:10.02]at the bottom of the industrialized world on health and we are losing ground over time. So we have a crisis. 
[01:16.64]And the problem is not just a problem of the low-income individuals and the poor.
[01:22.76]Even the best-off Americans are not currently achieving a level of health that is possible. 
[01:29.59]And more medical care spending will not solve it. 
[01:32.78]We now need to look at what are the drivers of health in the first place.
[01:37.51]Our health care system is wonderful. We have great facilities. We have the best-trained medical work force in the world, 
[01:43.28]but to a large degree, medical care is a repair shop that takes care of us once we get sick, and it doesn't determine whether we get sick or not in the first place.
[01:53.33]So, what is an example of something that can be done to improve someone's what we call socioeconomic status, 
[02:00.47]whether it's education or something else, that then leads to an improvement in health?
[02:03.95]So, let's talk about early childhood development.
[02:06.64]What we know is that the foundations of health in adulthood are laid in childhood. 
[02:12.78]And the opportunities and the experiences that children have even before they go to school shape their risk of chronic disease 30, 40 years later, 
[02:24.19]so that everything that we can do to prepare those children and give them the optimal health and optimal developmental opportunities in the preschool area, 
[02:34.24]then they're ready for school, and they have high levels of education, and they will have better health for the rest of their life.
[02:40.01]But can you give us an example of something they would learn in school that would then lead to a better health outcome?
[02:46.10]Certainly, more health education and more physical fitness in school are good, but that is not where I'm going.
[02:54.91]We're going on preparing those kids for learning. So, for example, a child exposed to toxic stress -- 
[03:01.48]and toxic stress are examples of being taken care of by a caregiver who is chronically depressed, growing up in chronic poverty, being a victim of abuse -- 
[03:12.78]that child will have more problems in success in school, but will also have more health problems as an adult.
[03:21.71]Studies show that we can actually measure the alteration of brain structure in those preschool kids linked to their exposure to toxic stress.
[03:31.17]At the same time, I was reading today that, of course, there is disagreement among experts about whether universal pre-K education, 
[03:38.45]which is one the things I think your task force is calling for, is good for all children.
[03:45.18]How do you look at the arguments that are out there about this?
[03:48.86]I think every child needs the opportunity for healthy development.
[03:55.82]For many children, they may get that in the home. And they don't have to go to a preschool setting. 
[04:01.49]So we are not necessarily calling for preschool -- universal preschool for all. 
[04:07.07]We are calling for universal preschool for those who are in environments where they need that healthy environment to do well.
[04:15.05]And that certainly characterizes many of our lower socioeconomic populations.
[04:19.07]Looking at -- looking again at some of your recommendations, it's a pretty ambitious agenda. How do you pay for it?
[04:25.13]That is a really good question.
[04:27.13]Given our expenditure on medical care, this money is not -- there isn't a shortage of money in this country. 
[04:37.93]The question is, how do we spend our money and what are our priorities? 
[04:41.26]But the good news is, there are promising models all across the country right now with creative public-private participations, like in the state of Minnesota, 
[04:51.97]where the business community and the state has come together to provide scholarships so that all poor kids can get a preschool education.
[04:59.06]Or there's an example from Texas where the state raised the sales tax by one-eighth of a penny, and that money is allocated for preschool education. 
[05:08.37]So there are wonderful examples.
[05:09.62]So, you are saying the evidence is already out there that this works?
[05:12.86]Let me tell you how powerful the evidence is.
[05:16.24]The best evidence comes from a study done in Ypsilanti, Michigan, more than 50 years ago, the Perry Preschool study, 
[05:22.86]where kids were randomly, by the flip of a coin, received preschool or didn't receive preschool. 
[05:28.09]They have now been followed for 40 years. 
[05:30.49]Those kids that got the preschool, 40 years later, higher levels of education, higher levels of income, higher levels of home ownership, 
[05:37.11]higher levels of marriage, less involvement with the criminal justice system, less involvement with the social welfare system.
[05:44.23]And for every dollar invested, there is a $17 return to society from that preschool program. 
[05:50.75]That is stunning. That is amazing economic development that we can achieve.
[05:56.32]So, just very quickly, finally, is this something you have to persuade the White House and the Congress to go along with to make it happen?
[06:02.10]I think there is a lot of interest in pre-K education across the political spectrum in the United States now, 
[06:11.21]because the evidence is so strong that there is such enormous benefit for our society.
[06:15.45]All right, Professor David Williams of Harvard, we thank you very much.
[06:19.83]Thank you.