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January 28, 2019
View from Here
Christopher F. Koller
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I teach a public health course on the US health system. As the grizzled realist in the room, I remind my bright-eyed “public healthers” that being right is not the same as being effective. That while an ounce of prevention really is worth a pound of cure, it is not enough to hector the rest of us constantly. And that to make prevention efforts work, they have to understand where all the money is in health care and how it got there.
I find myself doing the reverse, however, on a current health care topic. Are we really serious about reducing the “deaths of despair” that are rising in our country and appear to be driving a mortifying reduction in US life expectancy for the second time in three years? If yes—then all the resources we can muster to address the epidemic of opioid deaths that has captured headlines and the attention of politicians will be ineffective unless paired with the economic and social equivalent of public health prevention, of the kind promoted by a prominent US social economist.
Last year, researchers at the Commonwealth Fund used their annual state scorecard to explore further the changes in the rates of death for suicide, drugs, and alcohol, first identified collectively as deaths of despair by Anne Case and Angus Deaton. Their main findings were that
Efforts to treat the drug overdose epidemic have accelerated at the federal, state, and local level. The Feds have made significant additional financial resources available and state and local policymakers are learning effective strategies for reducing drug supply (with law enforcement efforts), preventing addiction (with mental health service access), and providing treatment (peer group counseling and medication-assisted treatment). As is to be expected, the levels of comprehensiveness and effectiveness of these efforts vary significantly among jurisdictions, as demonstrated by different rates of increase—or, in some cases, even decline, in recent years.
Regardless of the attention given to the opioid epidemic, we should not let that distract health policymakers from the deeper message of Case’s and Deaton’s deaths of despair. Imagine a 25% increase over 10 years in deaths per capita from breast cancer or obesity. A “war” on the condition would be declared. Congress would conduct hearings and allocate vast resources for research. Advocates would organize. Culprits would be sought and identified. Such was the case 30 years ago with AIDS.
Yet a similar increase in suicides and alcohol-related fatalities elicits no such uproar. Perhaps it is because opioids are a clearer foe and we can draw a bead on obvious perpetrators—the shameless peddlers of prescription painkillers.
More likely it is because despair cannot be attributed to a virus—a biochemical foe that can be identified, researched, and attacked. Instead the causes are social. Our researchers are not NIH clinicians but journalists, social scientists, and neighbors, like Sam Quinones (Dreamland), Arlie Russell Hochschild (Strangers in their Own Land), and J.D. Vance (Hillbilly Elegy). Their conclusions are partial and messy. The pathogens can’t be definitively identified under a microscope: a lack of jobs, a failure of the political system, a failure of parenting to instill virtue.
Of course, for health providers, care must be administered to these victims, even if there is no equivalent to an antiretroviral therapy for despair. But prevention of these cases lies far outside the realm of health care—for all but the most expansive public health advocates.
Instead we must turn to the realm of the “dismal science”—economics. In her new book, The Forgotten Americans, veteran social economist and former Clinton administration official Isabel Sawhill focuses her attention on the population most susceptible to deaths of despair. Defining her target as white, non-college graduates with an income below the US median, and the problem as the loss of economic mobility for this population, Sawhill asks what can be done to help them become more engaged (and less despairing) members of their communities.
Recognizing that her challenge is cultural, not clinical, Sawhill proposes that any public policy to address the lack of economic mobility in this group promotes three core values—the dignity of work, the centrality of the family, and the importance of education. Her specific policy recommendations are what she describes as “radically centrist”—a GI bill for career and technical education, universal national public service, refundable credits for low-wage workers paid for by higher estate taxes, tax policies that promote greater worker ownership and profit sharing, and changes in Social Security that promote the three core values and acknowledge the realities of longer lifespans.
Sawhill’s proposals attempt to address the conditions under which these “forgotten Americans” live—the social determinants of health that drive them into the country’s emergency rooms and pharmacies and drive up our health care spending. She acknowledges that enactment of these proposals would require public sector agency—effective (if limited) actions by the very institutions of government in which people have diminishing confidence. Their enactment also expects individual agency—recognizing one’s duties as a citizen, parent, and worker.
One can debate the merits and feasibility of these proposals. They certainly are socially challenging, and perhaps they may be politically unattainable or economically unsound. But unless we are content to continue engaging in the endless triage of victims of despair—figuratively and literally administering naloxone over and over again—we must pay attention to the issues that Sawhill is addressing. If anyone recognizes this truth it should be those of us who work in health care. We repeatedly treat (and pay for) these victims of despair. We know the need for prevention. We understand that both individual behaviors and social circumstances matter. We know that bad luck happens and mercy is necessary. And that doing repeatedly what does not work is Einstein’s definition of insanity.
A 50% increase in deaths from suicide, drugs, and alcohol constitutes a crisis. It is only the most graphic representation of a culture that is not providing hope and dignity to all its citizens. Better health care alone will not fix this—my “public healthers” are right. To be effective, as Sawhill proposes, we also have to work to change the economic and social rules.
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