Integrating Health Promotion Into National Health Policy

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For the first time in our lifetimes, the President of the United States and Congress are committed to integrating health promotion concepts into national health policy.  Equally exciting, the actions each of us take in the next few months to advocate for these efforts have the potential to transform our field in terms of the quality of the programs we offer, the numbers of people we are able to reach and help, and the career opportunities in our futures.  I will attempt to give you my guess on the Why, What, and When of all this, and describe your role in making this happen.
 
Why?
The science linking lifestyle to health and medical cost has been solid for a decade or more.  Why does the leadership of our nation finally understand what we have all known for years?  Part of it is luck…bad luck.  The economic crisis has made it very clear that our nation’s government, employers, and people can no longer afford the price we pay for medical care.  Another factor is the visibility of the obesity epidemic. Obesity is not a silent or invisible killer like hypertension; we can literally see this epidemic grow before our eyes.  The deciding factor was, of course, when President Barack H. Obama decided that solving the medical cost crisis was a necessary part of solving the economic crisis.  He could have just as easily concluded that we could not afford to solve this until the economy recovered.  So how did President Obama and Congress connect the dots?  How did they see the connection between lifestyle and chronic disease and medical costs?  I think the answer is the brilliant way Dr. Ken Thorpe, and The Partnership to Fight Chronic Disease¹ framed this problem with the core message that three lifestyle behaviors (tobacco use, inactivity, and poor nutrition) cause 75% of chronic disease (including 80% of heart disease, stroke, and diabetes as well as 40% of cancers) and that 75% of all medical spending, including 96% of Medicare and 83% of Medicaid spending, is for patients with chronic disease.  Many of us presented similar data in compelling ways, but they nailed it.  The Partnership to Fight Chronic Disease also developed a broad coalition to carry this message forward, and they used their contacts to educate all the presidential candidates early in the election process.  Another key player was Jeff Levi, the executive director of the Trust for America’s Health².  This organization pulled together large volumes of data at the local and national levels to show why prevention pays.  They also rallied the health advocacy groups to speak with a single voice during the scramble for economic stimulus dollars that resulted in $1 billion being devoted to “prevention,” the National Institutes of Health (NIH) getting a $10 billion budget bonus and other new funds for related areas, such as $1.1 billion comparative effectiveness research. Another key player was Steve Byrd, CEO of Safeway, who went door to door through the halls of Congress to explain in very tangible terms the impact of medical costs on business viability and to illustrate how employees can be engaged to improve health and reduce costs.  From where I sit and from listening to Congressional staff members, these three people were game changers, the new leaders that pushed us over the top. Of course, there were hundreds of other people and dozens of other groups involved. The Robert Wood Johnson Foundation, which pledged $500 million dollars to fight childhood obesity, has been a core institutional leader in moving this field forward for decades.  The Robert Wood Johnson Foundation has made it possible for scientists to conduct the research and for advocacy groups to frame and broadcast the compelling message that made all of this possible.  Nevertheless, I focused attention on the three game changers because I believe it is important, instructive, to reflect on what made the difference.
 
What?
Before we hand out too many congratulations, we better make sure real progress is being made in health promotion funding.  Huge wins have already been confirmed, including the $10 billion budget bonus for NIH, and an additional $1 billion for prevention…but let’s see how much of that money goes to health promotion efforts that change behaviors versus other causes that are worthy, like immunizations and screenings, but are not health promotion. Another big win was the passage of State Child Health Insurance Program (S-CHIP) which will pay for medical coverage for children of low income families and will be funded by a 61¢ increase in the federal tobacco tax.  Legislation has already passed in the House of Representatives on April 2 to give the U.S. Federal Drug Administration (FDA), the authority to regulate tobacco.  This legislation was introduced in the Senate on May 5 and is expected to be voted upon in June. 
 
Of course the bills closest to my heart are the Health Promotion Funding Integrated Research, Synthesis and Training (FIRST) Act (S1001, HR2354), and the Healthy Workforce Act (S803, HR 1897).  Health Promotion Advocates³, a not for profit organization that I chair, worked closely with members of Congress to develop these bills and we are continuing to work very hard to build support to pass them.  The Healthy Workforce Act provides a tax credit to pay for half the cost of a comprehensive workplace health promotion programs and is projected to stimulate $3 billion in new annual investments for workplace health promotion, create 40,000 new health promotion jobs, and engage 28 million people in 75,000 companies in organized health promotion efforts for the first time.  Health Promotion FIRST provides a road map on how to build health promotion concepts into every aspect of federal policy and stimulate basic and applied research that will improve the effectiveness of our programs.
 
All of this legislation will have a huge impact on our field, but, in surfing terms, the big wave is still out there and is almost in sight.  In the past three months, I visited with nearly 80 Congressional offices to build support for the two health promotion bills.  I have focused on the offices of members of the Senate Health, Education, Labor and Pensions (HELP) Committee, the Senate Finance Committee, the House Energy and Commerce Committee, and the House Ways and Means Committee.  These committees have jurisdiction over the above bills. Those four committees plus the House Education and Labor Committee have jurisdiction over all health care reform legislation. They are working hard to craft major health care reform legislation. Discussions of health care reform legislation have been framed by The CALL TO ACTION HEALTH REFORM 2009⁴, released by Senator Max Baucus, chairman of the Senate Finance Committee.  His priorities are (1) universal access to care,  (2), high quality care, and (3) affordability.  Health promotion is also a core element of his plan, although Senator Baucus and most members of Congress use the terms “prevention” or “wellness.”  The word “prevention” is used 30 times and the word “wellness” 20 times in his report.  The excerpt below⁵ illustrates the extent to which Senator Baucus really seems to embrace this concept:

“Prevention must become a cornerstone of the health care system rather than an after thought.  This shift requires a fundamental change in the way individuals perceive and access the system as well as the way care is delivered.  The system must support clinical preventive services and community-based wellness approaches at the Federal, state, and local levels.  With a national culture of wellness, chronic disease and obesity will be better managed and, more importantly, reduced.”

Other health care reform proposals include wellness.  For example, Senator Ron Wyden’s Healthy Americans Act⁶ calls for the shifting of health insurance coverage from employers to individuals, requiring employers to provide a salary increase to employees equivalent to the cost of health insurance, and requiring health insurance plans to provide comprehensive health promotion programs.  Another emerging proposal would allow 50% of individual health insurance premiums to be tied to health behaviors.  There are dozens of health care reform proposals, and plenty of partisan positioning and squabbling, but one consistent message I have heard from every single Congressional office is that “prevention” will be a core element of any proposal that comes out of the Senate and the House of Representatives. WOW.  The excellent science base we have developed over the past three decades, the compelling arguments we have learned to craft, and more importantly, the economic and health crisis the world is facing, have pushed health promotion from obscurity to prominence.
 
When
The pace at which this is moving is remarkable.  I am writing this on May 8, 2009.  Health Promotion FIRST was introduced in the Senate yesterday.  Healthy Workforce Act was introduced April 2. The fate of both health promotion bills and much of the health care reform legislation may be largely determined by the time this is published on July 1.   The committees of jurisdiction in the House of Representatives were planning to produce and pass one unified health care reform bill by all three committees by the end of May.  At that point, they need to shift their attention to other issues.  For example, the Energy and Commerce Committee needs to produce a comprehensive energy bill during the balance of the summer. They will not meet the May deadline, but they are likely to finish before the summer is over. Any health issue not confirmed at committee level by the time these committees finish their work is unlikely to be considered again until 2010.  The House has also committed to having health care reform legislation passed by the entire House before the August 1, 2009 recess.  The Senate seems to be just a few weeks behind that schedule.  The Senate Finance and HELP Committees are likely to finalize their legislation in June at the committee level, and the entire Senate is expected to approve it August 1st or by the end of September.  They expect to resolve any differences between the Senate and House versions of the bill by October so the president can sign a bill into law before winter.  A similar, slightly more aggressive schedule, will probably be followed in 2010 for health reform issues that are not resolved in 2009.   Given this schedule, Health Promotion Advocates has focused efforts to date on building support among the 41 members of the Senate and 80 members of the House who have jurisdiction over our bills.  If our bills are included in the legislation that comes out of committee, we will reach out to the remaining 414 members of the Senate and House in the summer.  If our bills do not survive the committee approval process, we will focus back on committees so we can make a stronger showing in 2010.
 
Your role.
Each of us has an opportunity, a unique, maybe a once in a lifetime opportunity, to shape national policy in a way that can have a profound impact on the health of our nation, and that can transform the career opportunities in our own futures.  Does that sound like something worthy of your time?  I hope so.  If it does, what should you do?  The first step is to go to the Web site of Health Promotion Advocates (http://healthpromotionadvocates.org) to read the summaries of the legislation, and decide if you support the legislation we are advocating.  If you do support it, sign up as a grassroots advocate.  We ask grassroots advocates to contact their two Senators and their representative several times a year, to ask for support of this legislation.  This takes about 15 minutes each time, maybe one hour in the year.  We provide simple instructions, template letters, and tell you when to act.  One letter from one person does not make much of a difference, but thousands of letters do make a difference. If you want to make a bigger impact, you can do this by establishing regular contact with one staff member in the offices of each of your Senators and your Representative, and making a commitment to keep talking to them until they understand why health promotion is important and they agree to support our bills.  This might take 5 hours in a year.  Once you start doing this, it becomes very easy. Congressional staff members are very talented young people, most of whom really have a gift of listening and working with constituents….and they are looking for good ideas to support.  If we can establish relationships in the offices of each of the 100 Senators and 435 Representatives, we are likely to get the support we need to pass our legislation.  This is important and meaningful work.  I have enjoyed every second of it.  I hope you do too.

References

1. The Partnership to Fight Chronic Disease. http://www.fightchronicdisease.org. Accessed May 7, 2009.
2. Trust for America’s Health. http://healthyamericans.org. Accessed May 7, 2009.
3. Health Promotion Advocates website. http://healthpromotionadvocates.org. Accessed May 7, 2009.
4. CALL TO ACTION HEALTH REFORM 2009, http://finance.senate.gov/healthreform2009/home.html. Accessed May 7, 2009.
5. Ibid, page 28.
6. Healthy Americans Act,
   http://wyden.senate.gov/issues/Legislation/Healthy_Americans_Act.cfm. Accessed May 7, 2009.