How to Improve the Health and Well-Being of the United States and the World by 2025 for Only 3.1 Trillion Dollars¹ a Year

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What if early in his first term as president of the United States, Barack Obama announced that a core strategy in his health care reform plan was to push the United States from a system dominated by treatment of disease to a more balanced approach that also focused on enhancing health and quality of life. He challenged his Cabinet by saying that their individual performance would be judged, and the future funding of their organizations would be determined, by their ability to use the resources and authority of their departments to improve health in addition to the core goal of their department.
 
Agriculture. The most immediate effects were seen in the Department of Agriculture. The mission of the department shifted from maximizing agri-business profits to supporting an agricultural industry that could provide nutritious, affordable, accessible food to all Americans. Farm subsidies shifted to reflect the nutritional value of foods. Annual subsidies dropped for meat and dairy products (from $52 billion to $1 billion) and sugars and oils (from $8 billion to $1 billion). These savings were used to increase subsidies for fruit and vegetables ($265 million to $27 billion), grains for human consumption ($9 billion to $27 billion), and plant based proteins ($1 billion to $15 billion).² By 2012, the price of a vegetable sandwich on whole grain bread plus a fruit smoothie dropped to less than half the price of a hamburger with fries and a soft drink from triple the cost in 2008. The growth of local farms provided an economic spark to small rural towns and the emergence of community gardens stimulated a rebirth of decaying urban centers. The destruction of the rain forests in Brazil stopped by 2016 because there was no longer a need for expansive ranges for cattle grazing. Global greenhouse gas emissions dropped 18% by 2020³ because meat consumption dropped in all developed nations.
 
Transportation and Interior. The Department of Transportation announced that no matching funds to build roads would be provided to communities unless they developed comprehensive strategies to integrate physical activity into daily living. This was confirmed in law with the passage of the 2009 Transportation Bill. By 2015, pedestrian and bike friendly communities were the norm. By 2020, it was rare to see a community that did not have mixed zoning codes that stimulated the growth of homes, businesses, parks, entertainment, and schools within the same neighborhood.⁴ The concept of a street that was not complete with sidewalks and safe bicycle lanes became a distant memory.⁵ Kids walking to the neighborhood school again became the norm^[6] and the presence of people on the streets reinvigorated neighborhoods and pushed crime rates to historic lows. The Department of the Interior collaborated with the Conservation Fund and the US Conference of Mayors through the National Forum on Children and Nature to redevelop 1000 urban parks.⁷ The average American walked an additional one mile every day, which in turn resulted in 8 pounds of weight loss or gain avoided every single year.⁸ The prevalence of overweight dropped from 70% in 2009 to 15% in 2020.

Education, Commerce, Labor and Housing and Urban Development. The Department of Education adopted the definition of optimal health espoused by the American Journal of Health Promotion (a balance of physical, social, spiritual, emotional, and social health) as a framework to help schools develop curriculum that embraced students as whole beings.⁹ Daily gym classes became a requirement for all elementary students and comprehensive school sports programs were restored in most school systems by 2012. The time pressure to fit everything in the curriculum was relieved by 60% of schools shifting to a 12-month calendar by 2016.¹⁰ Part time job opportunities were built into the school day through collaborative arrangements with the Departments of Commerce and Labor. Federal subsidies were strongest for programs that supported society’s greatest needs including providing companionship for frail elderly, tutoring students in low income neighborhoods, and serving in the Urban Redevelopment Corps, a collaboration between Habitat for Humanity and the Department of Housing and Urban Development that rebuilt 200 urban decaying neighborhoods by 2015 and 1,000 by 2020. The Manchester/Bidwell¹¹ model of training adults in the skills they need to perform jobs that are available in the community were replicated in all 71 cities with populations of 250,000 or more by 2024.
 
Medical Care, Health Insurance, State Government and Workplace Health Promotion. Leaders from medical care, health insurance employer and state government communities collaborated as well. Most of the health care organizations and physicians in the nation adopted a wellness focused electronic medical record by 2020 after the Cleveland Clinic donated its programming algorithms to the public domain in 2009. Built around the 3 A’s and an R Counseling Model (Asking about smoking, physical activity, and eating habits; providing brief Advice on the importance of making changes to improve the patient’s current health problem ; Assessing readiness to change; and Referring to skilled behavior change experts). By 2020, physicians referred patients to health promotion programs 115 million times, representing a referral from 14% of the office visits.¹² Many of these referrals were to workplace programs that had been stimulated by Senator Thomas Harkin’s Healthy Workforce Act, which provided tax credits to employers who offered workers comprehensive health promotion programs.¹³ Program success rates have climbed dramatically because health promotion evolved from an art to a true science through the passage of Senator Richard G. Lugar’s Health Promotion FIRST (Funding Integrated Research Synthesis and Training) Act,¹³ which provided a more solid planning and science base for the field and the Health Enhancement Research Organization Scorecard,¹⁴ which has helped employers understand the program components and funding levels required to improve health, reduce medical costs, and enhance productivity. Employer and health plan collaboratives started funding these programs when they discovered medical cost savings exceeded program costs.¹⁵ Adult smoking rates reached 1.5% by 2020; 327 million years of life were saved by this drop in rates.¹⁶ The first step was a $2.00 federal tax on cigarettes implemented in 2009. This reduced smoking rates among high school seniors to 15% and motivated 75% of adult smokers to try to quit each year. Free treatment combining behavior and drug therapy was available universally and quit rates jumped from 5% to 30%. Treatment costs were $68 billion during this 12-year span, but these costs were fully covered by the $246 billion Tobacco Master Settlement Agreement.¹⁷ The percent of these funds devoted to tobacco prevention and treatment increased from 3% to 40% in 2010, when Ohio Governor Strickland was run out of office for his leadership role in decimating Ohio tobacco prevention efforts.¹⁸ After that date, health advocates challenged each candidate for governor to state their support for tobacco prevention efforts. Collectively, these changes resulted in elimination of 90% of the cases of diabetes, 80% of heart disease, and up 60% of cancers in the United States¹⁹
 
Global Efforts through Defense and State. The Departments of State and Defense decided that health and education diplomacy would become the core outreach strategy for the United States. Troop withdrawals from Iraq were completed by December 31, 2011, saving the US government $10 billion every month. This entire sum was devoted to global health issues. Providing access to safe drinking water for the world’s population was the first priority. Within 77 days, $25 billion dollars was saved. This was sufficient to fund construction of self supporting water systems that provided clean water to the one billion people who never before had access to clean water.²⁰ This reduced illness in the developing world by 80%.²¹ The remaining funds were devoted to meeting the Millennium Development goals²².  By 2015,  93% of the entire cost of this effort in poor nations was covered by the savings.²³ This cut in half the proportion of people in the world suffering from hunger, allowed every child in the world to complete a full course of primary schooling, reduced child mortality by two-thirds, reduced the number of mothers who die in child birth by two thirds, halted the growth and began to reverse the spread of HIV/AIDS and malaria globally, and cut in half the proportion of people who do not have access to basic sanitation. In 2015, the favorability rating of the United States rose to a record high of 85% for the nations of Africa, Asia, South America, the Middle East, and Eastern Europe.
 
Global Agenda Council on Chronic Disease and Malnutrition of the World Economic Forum
 
Note:  This essay is one of a series of essays written by the members of the Global Agenda Council on Chronic Disease and Malnutrition of the World Economic Forum.  Council members were challenged to write scenarios of how the world might change if bold actions were taken now to attack chronic disease and malnutrition.  Essays by other members of Council can be found at the following website: http://www.weforum.org/en/events/ArchivedEvents/InauguralSummitontheGlobalAgenda/CouncilReports/HealthCouncil/index.htm. The World Economic Forum is an independent international organization committed to improving the state of the world by engaging industry leaders in partnerships to shape global, regional and industry agendas.  Its members include the leaders of 1000 of the largest companies in the world, and the heads of state of most nations of the world.

Michael P. O'Donnell, PhD, MBA, MPH

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