ISSUE REPORT for a Healthier America 2016 POLICY PRIORITIES FOR THE NEXT A ADMINISTRATION AND CONGRESS OCTOBER 2016 Acknowledgments Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. This report is supported by grants from the Robert Wood Johnson Foundation, W.K. Kellogg Foundation, The California Endowment and The Kresge Foundation. TFAH thanks the foundations for their generous support. The opinions in this report are those of the authors and do not necessarily reflect the views of the supporters. TFAH BOARD OF DIRECTORS TFAH STAFF Gail C. Christopher, DN Richard Hamburg, MPA President of the Board, TFAH Interim President and CEO Vice President for Policy and Senior Advisor Anne De Biasi, MHA WK Kellogg Foundation Director of Policy Development Cynthia M. Harris, PhD, DABT Latoya Gibson Vice President of the Board, TFAH Office Manager Director and Professor Institute of Public Health, Florida A&M University Tiffany Henry Financial, Human Resources and Compliance Theodore Spencer Manager Secretary of the Board, TFAH Senior Advocate, Climate Center Tim Hughes Natural Resources Defense Council External Relations and Outreach Associate Robert T. Harris, MD Vinu Ilakkuvan, MPH Treasurer of the Board, TFAH Health Policy and Communications Manager Medical Director Albert Lang North Carolina Medicaid Support Services CSC, Inc. Senior Communications Manager David Fleming, MD Dara Alpert Lieberman, MPP Vice President Senior Government Relations Manager PATH Alejandra Martín, MPH Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Health Policy Research Manager Executive Director Hogg Foundation for Mental Health at the Kevin McIntyre University of Texas at Austin Government Relations Associate C. Kent McGuire, PhD Genny Olson, MPH President and CEO Health Policy Fellow Southern Education Foundation Jack Rayburn, MPH Eduardo Sanchez, MD, MPH Senior Government Relations Manager Chief Medical Officer for Prevention American Heart Association Rebecca Salay Director of Government Relations Laura M. Segal, MA Director of Public Affairs REPORT AUTHORS Dara Alpert Lieberman, MPP REPORT CONTRIBUTOR Senior Government Relations Manager Laura M. Segal, MA Alejandra Martín, MPH Director of Public Affairs Genny Olson, MPH Health Policy Research Manager Health Policy Fellow Anne De Biasi, MHA Director of Policy Development Vinu Ilakkuvan, MPH Health Policy and Communications Manager 2 TFAH • healthyamericans.org Blueprint for TABLE OF CONTENTS Table of Contents l I ntermediaries and Example . . . . . . . . . . . 29 l A ccountable Communities for Health and Vision for a Healthier America . . . . . . . . . . . 5 The Problem and Need for Action . . . . . . . . . 6 l Examples . . . . . . . . . . . . . . . . . . . . . . . . 30 N eeds Assessments and Measuring Success and Example . . . . . . . . . . . . . . . . . . . . . . 32 a Healthier America Guiding Principles for Improving Health . . . . 7 2. Financial Management . . . . . . . . . . . . . . . . 33 Introduction . . . . . . . . . . . . . . . . . . . . 10 l C ertification for Financial Management of l P rescription Drug and Heroin Crises . . . . . 10 Local Health Improvement Partnerships . . 35 l F uture Health of America’s Children . . . . . 10 3. overnment Leadership and Multi-Sector G l I nfectious Disease, Disaster and Bioterrorism Collaboration: Examples of Strategies for Readiness . . . . . . . . . . . . . . . . . . . . . . . 11 Coordinating and Leveraging the Use of l E nvironmental Justice . . . . . . . . . . . . . . . 11 Health and Social Service Funds . . . . . . . . 36 l R educing Substance Misuse . . . . . . . . . . 11 l E xamples of State Level Systems l P reventing Chronic Diseases . . . . . . . . . . 11 Coordinating and Leveraging the Use of Health and Social Service Funds . . . . . . . . 41 l S peeding Detection and Control of Infectious Disease Outbreaks . . . . . . . . . . . . . . . . . 12 4. ealth Sector Partners: Public Health H l R educing Environmental Threats . . . . . . . . 12 Agencies, Providers, Insurers, Hospitals and l ddressing Social Needs that Impact Health 12 A Community Health Centers . . . . . . . . . . . . . 42 l upport in Early Childhood . . . . . . . . . . . 13 S l P ublic Health: Chief Health Strategists and l riority Recommendations in the Blueprint . 14 Examples . . . . . . . . . . . . . . . . . . . . . . . . 42 P l dditional Public Health Policy l H ealthcare Providers and Insurers and A Examples . . . . . . . . . . . . . . . . . . . . . . . . 44 Recommendation Initiatives . . . . . . . . . . . . . l M edicaid and Examples . . . . . . . . . . . . . . 46 l A ccountable Health Communities . . . . . . . 47 SECTION 1: Prioritizing Wide-Scale Implementation of the Most Effective l H ospitals and Examples . . . . . . . . . . . . . . 48 Approaches for Improving Health in l C ommunity Health Centers/Federally Qualified Health Centers and Examples . . . . . . . . . . 49 Communities Around the Country. . . . . 15 5. nnovative and Social Impact Funding I A. olicy Priorities for Supporting Health P Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Improvement Efforts Around the Country 19 l C ommunity Development Financial Institutions l S upporting Local Health Improvement and Example . . . . . . . . . . . . . . . . . . . . . . 50 Partnerships to Address Community Priorities 19 l N ew Market Tax Credits and Example . . . . 51 l I mplementing Evidence-Based, High Health l C ommunity Development Corporations . . . 53 Impact Strategies and Creating Academic/ Expert Health Improvement Institutes in Every l P ay-for-Performance and Social Impact Bonds Sate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 and Example . . . . . . . . . . . . . . . . . . . . . . 54 l F ully Funding the Prevention and Public Health l W ellness Trusts and Example . . . . . . . . . . 56 Fund and Other Community-Based Health 6. Examples of Organizations and Efforts Improvement Efforts . . . . . . . . . . . . . . . . 19 Advancing Place-Based Health Improvement l I ncrease Strategic Aligning of Policies, Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Programs, and Other Factors to Improve Health l T he California Endowment: Building Healthy and Other Factors that Influence Health – With Communities . . . . . . . . . . . . . . . . . . . . . . 60 a Focus on Improving Outcomes . . . . . . . . . 20 l I ncentivize Increased Support for Community- C. reating an Expert Institute Network to C Based Health Improvement Efforts via Serve Communities in Every State . . . . . 61 Nonprofit Hospital Community Benefit l E xamples of Academic and Expert Programs . . . . . . . . . . . . . . . . . . . . . . . . 21 Assistance Models . . . . . . . . . . . . . . . . . 62 l I ncrease Innovative Social Investments . . . 22 D. Improving and Scaling Efforts to Address l P rovide Support to Medicare, Medicaid, and Unmet Social Needs that Impact Health 64 Private Healthcare Insurers and Providers to Expand the Use of Health Improvement 1. otential Savings from Health and Social P Strategies and Services . . . . . . . . . . . . . . 22 Service Coordinator Systems: Addressing Unmet Social Needs of High-Cost Individuals . . . . . . 66 B. Place-based Strategy: Local Health – or A OCTOBER 2016 l “ Linked” Programs Yielding 10 percent to 20 Well-being – Improvement Partnerships . 24 percent Savings . . . . . . . . . . . . . . . . . . . 69 l K ey Local Health – Well-being – Partners l H ealthcare Spending and Potential Savings . 70 Include: Public Health “Chief Health l L evering Social Determinants of Health . . 75 Strategist” Partners; Health Partners; Multi-sector Partners; Innovative, Social E. caling High-Impact Community-Based and S Impact Investors; Government Partners; and Clinical-Community Health Improvement Community Partners . . . . . . . . . . . . . . . . 24 Strategies . . . . . . . . . . . . . . . . . . . . . . . 76 1. Lead Partner . . . . . . . . . . . . . . . . . . . . . . . . 27 l E xamples for Resources for Community-Based l I ntegrators and Example . . . . . . . . . . . . . 28 Health Improvement Programs . . . . . . . . . 76 Table of Contents (continued) l C ommunity Guide to Prevention Services . . 76 l I ncentivize and Support Medical Countermeasure Research, Development, l C DC’s Health Impact in 5 Years (HI-5) . . . . 77 Stockpiling, and Distribution . . . . . . . . . . 102 l T he 6|18 Initiative: Accelerating Evidence into Action . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 l M aintaining a Robust, Well-Trained Public Health Workforce . . . . . . . . . . . . . . . . . . 104 l E xample High-Impact 6|18 Initiative Strategy: Diabetes Prevention Program . . . . . . . . . . 79 l R ebooting and Developing a New Strategy for Hospital and Healthcare Emergency l E xamples of High-Impact 6|18 Initiative Strategy: Preparedness – Surge Capacity for Major Child Asthma Prevention Programs . . . . . . . . 82 Emergencies; Healthcare Associated F. Improving Use of Preventive Services . . . 83 Infections; and Integrated Public Health and Healthcare Response . . . . . . . . . . . . . . . 106 SECTION 2: A PUBLIC HEALTH AND l S upporting Community Resilience – for HEALTHCARE SYSTEM PREPARED FOR Communities to Better Cope and Recover from Emergencies – With Better Behavioral EMERGENCIES . . . . . . . . . . . . . . . . . . 85 Health Infrastructure and Capacity . . . . . 109 l K ey Priorities for Achieving a More Prepared l E xample: Save the Children: Get Ready Get System . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Safe . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 l R eforming Baseline Abilities to Diagnose, Detect and Control Health Crises: SECTION 3: PRIORITIZING MAJOR Foundational Capabilities . . . . . . . . . . . . 89 HEALTH TOPICS. . . . . . . . . . . . . . . . 111 l S table, Sufficient Funding for Ongoing Emergency Preparedness – and Funding a Permanent Public l H ealthy Early Childhoods . . . . . . . . . . . . 113 Health Emergency Fund to Support Immediate l S upport Healthy Students and Healthy and “Surge” Needs During an Emergency . . . 92 Schools . . . . . . . . . . . . . . . . . . . . . . . . 116 l O utbreaks: Protecting American’s from l P romote Healthier Aging for Seniors . . . . 120 Infectious Disease . . . . . . . . . . . . . . . . . . 94 l S top the Prescription Painkiller Misuse and l N ational Health Security Preparedness Index 95 Heroin Epidemics . . . . . . . . . . . . . . . . . 123 l I mproved Federal Leadership Before, During l P revent Obesity, Improve Nutrition and and After Disasters . . . . . . . . . . . . . . . . . 96 Increase Physical Activity . . . . . . . . . . . . 123 l A National Blueprint for Biodefense: l E liminate Tobacco Use . . . . . . . . . . . . . . 127 Leadership and Major Reform Needed to l P rioritize Prevention in the Cancer Optimize Efforts . . . . . . . . . . . . . . . . . . . . 96 Moonshot Initiative . . . . . . . . . . . . . . . . 129 l R eport of the Independent Panel on the U.S. l E nd the HIV/AIDS Epidemic . . . . . . . . . . 131 Department of Health and Human Services l S top Superbugs and Antibiotic Resistance . 133 (HHS) Ebola Response . . . . . . . . . . . . . . . 96 l upport Environmental Health and Justice . 135 S l B uilding an Ongoing, Focused Strategy l ddress the Health Impact of Climate A to Support Scientific and Technological Upgrades, Including Wide Implementation Change and Extreme Weather . . . . . . . . . 137 of Faster Diagnostics, Biosurveillance and l A chieve Health Equity . . . . . . . . . . . . . . . 141 Medical Countermeasures . . . . . . . . . . . . 97 l R everse Rising Death Rates Among l U pgrading to Modern Molecular Technologies 97 Middle-Aged White Adults . . . . . . . . . . . . 144 l M odernizing to Real-Time, Interoperable l P romote Positive Mental Health . . . . . . . 147 Disease Surveillance . . . . . . . . . . . . . . . 100 4 TFAH • healthyamericans.org Blueprint for VISION STATEMENT Vision for a Healthier America a Healthier America All Americans should have the opportunity to be as healthy as they can be. Every community should be safe from threats to its health. All individuals and families should have a high level of services that protect, promote and preserve their health, regardless of who they are or where they live. To realize these goals, the incoming Experts have identified top strategies and Administration and Congress should approaches for ways the public health and make improving health a top priority. health systems can work better — which is There is nothing more valuable to the important, but far from sufficient. Where nation than the health and vitality of we live, learn, work and play can have a the American people. bigger impact on health than medical care alone. Working together, the public There has never been a better health, healthcare and social service opportunity to shift the paradigm systems can achieve a much stronger from a system that treats people after collective impact. Moving forward, we they become sick to a true health must build partnerships and leverage system, focused on keeping people assets across the health system, mental OCTOBER 2016 healthier in the first place, while and behavioral health systems, social and also lowering healthcare costs and public services, the private sector and increasing productivity. communities to work together toward the common aim of a Healthier America. The Problem and Need for Action Communities across the country face serious, ongoing health problems — a majority of which are preventable, including by prioritizing stronger population health efforts. Some big challenges include: l hronic Diseases: Approximately half C addicted to heroin.7 Prescription homes and neighborhoods,10 and (117 million) of U.S. adults have at painkillers have resulted in more than global public health officials have least one chronic health condition — 14,000 deaths in 2014, and deaths stressed the need to address the ranging from cancer to diabetes to heart from heroin more than tripled from health impacts of climate change and disease, but a majority of these could be 2010 to 2014.8 There is a need for extreme weather events. prevented.1 More than 85 percent of an integrated and balanced strategy l njury and Violence: One person dies I healthcare spending is for individuals to fight chronic pain and addiction. from an injury or violence every three with more than one chronic condition.2 Substance misuse and suicides are minutes in the United States, and contributing to higher death rates l besity: More than one-third of O injuries are the leading cause of death among middle-aged White Americans. adults and 17 percent of children for children and for all Americans are obese, putting them at increased l nfectious Diseases and Health I between the ages of 1 and 44.11 risk for a range of health problems.3 Security Threats: Millions of l ental Health: Mental illness affects M Seventy percent of nonprofit hospitals’ Americans become unnecessarily one in five adults and is the fourth assessments ranked obesity as the sick or die each year from infectious biggest driver of medical expenses and number one health concern in their diseases, which cost the country more the top medical cost for children.12, 13, 14 community.4 than $120 billion each year.9 The ongoing HIV/AIDS epidemic; the l dverse Childhood Experiences: More A l obacco Use: Tobacco use remains the T emergence of the Zika virus, Ebola, than half of U.S. children — across leading cause of preventable death each MERS-CoV, periodic foodborne disease the economic spectrum — experience year in the United States — responsible outbreaks and threats of bioterrorism; an adverse event, such as physical or for more than 480,000 deaths and $170 and the resurgence of hepatitis C, sexual abuse or substance use in the billion in preventable healthcare costs. measles and whooping cough household — and half of children are More than 16 million Americans are underscore the need for more constant in low-income families, putting them living with a tobacco-caused disease.5 vigilance against ongoing threats. at increased risk for living in unsafe l rescription Drug, Heroin and P conditions and prolonged stress, l ead and Other Environmental L Other Substance Misuse: Currently, often called “toxic stress,” which can Threats: The contaminated water around 21 million (8.1 percent of) contribute to a range of physical and emergency in Flint, Michigan and Americans struggle with a substance mental health conditions.15, 16, 17, 18 other locations serves as a clarion use disorder.6 More than 2 million call to renew our commitment to l isability: One in five Americans D people have a prescription painkiller addressing the nation’s environmental has some kind of disability. The dependence, which has contributed health challenges. The Surgeon annual healthcare expenditures to a related rise in heroin use — General has identified a series of associated with disability are with nearly half a million Americans priorities for healthier air, water, estimated at $400 billion. Obesity Rates in the United States Prescription painkillers have Mental Illness Affects One in Five Adults resulted in more than 14,000 More than one-third of adults are obese deaths in 2014, and deaths from heroin more than tripled 17 percent of children are obese from 2010 to 2014. 6 TFAH • healthyamericans.org Guiding Principles for Improving Health Achieving a healthier America requires a national commitment to: l rioritize Health Care vs. Sick Care: P Effective, evidence-based health improvement strategies can lower healthcare costs and improve the vitality of neighborhoods — but have never been widely implemented. For instance, evidence-based community prevention programs to increase physical activity, improve nutrition and prevent smoking could save the country more than $16 billion annually within five years — a $5.60 return for every $1 spent. Strategic community-clinic based programs can show strong results, such as the Diabetes Prevention Program (DPP) which has cut disease rates by more than 50 percent. The Stanford Chronic Disease Self-Management Programs saved more than $300 per patient per year — if scaled to 10 bring key partners and assets from percent of Americans with chronic the community to work together to diseases could yield around $6.6 tackle those concerns. Effectively billion annually in savings.19, 20, 21 The addressing health problems requires shift to a value-based approach to sustained engagement — through health provides new opportunities multisector collaborations of key and incentives to make staying healthy leaders and institutions — with a higher priority — and to bring healthcare providers and payers, high-impact programs into action. A public health, social services, private strong focus should be placed on early businesses, philanthropies, schools childhood policies and programs — and community groups — who have a which can have the highest impact vested interest in improving the health for setting the course for lifelong and vitality of a community. Different health — as well as continued support sectors bring different strengths and through different life stages. expertise — and a diversification of l etter Meet Local Priorities: Health B resources — to help achieve a stronger improvement strategies must be collective impact. Local collaboratives flexible enough for local communities should have access to and support to be able to prioritize their shared from a network of leading local, goals — addressing prescription drug state and national experts to identify, misuse to obesity to adverse childhood implement, evaluate and continuously experiences and toxic stress — and improve efforts. TFAH • healthyamericans.org 7 l upport for Health and Well-being S l Modern Public Health System that A access and functional needs. While Beyond the Doctor’s Office: Collective is Prepared for Emergencies and emergencies and new threats are impact strategies provide increased Ongoing Priorities: Every community inevitable, the current system does not ability to determine how to align and around the country should have a have built-in capacity to respond to leverage the shared goals and resources baseline, modern public health system new or surge needs. Instead, arising of communities — along with federal, capable of responding to emerging emergencies disrupt attention and funds state and local investments — to and ongoing threats — ranging from from ongoing pressing priorities — and improve health and related factors emerging infectious disease outbreaks create cycles of relying on a series of that impact health more efficiently and bioterrorism to ongoing concerns emergency supplemental spending and effectively. For instance, working like obesity and diabetes — and that bills — instead of building a stronger together, cross-sector partnerships can serve as a Chief Health Strategist baseline system with increased flexibility. can better address key issues, such as and advisor to the community for l upport Better Health in Every S affordable housing, quality education, using the best available evidence to Community: Too often where people income, transportation, the availability inform strategies and programs to live determines how healthy they of affordable nutritious food, safe achieve better health. Federal, state are. Disease rates and funding vary places to be physically activity and and local public health systems should dramatically from neighborhood-to- healthy conditions in neighborhoods. be modernized to focus on a set of neighborhood, zip-code-to-zip-code, There is also an increased need “foundational” capabilities, including city-to-city, county-to-county and state- and opportunity to better integrate the ability to quickly diagnose, detect to-state. Strategies must work to achieve healthcare, behavioral health and and control epidemics, recognizing health equity and improve the health public health services with other the needs of the entire population, of all Americans, regardless of race, available social services. including children, individuals with ethnicity and socioeconomic status. disabilities and other persons with 8 TFAH • healthyamericans.org Sharing a Vision for a Healthier America AcademyHealth • Academy of Nutrition and Dietetics • Advocates for Better Children’s Diets • Alaska Public Health Association • Allen Temple Neighborhood Development Inc. • Allergy & Asthma Network • Alliance for the Prudent Use of Antibiotics • American Academy of Pediatrics • American Association of Colleges of Pharmacy • American Association of Occupational Health Nurses • American Cancer Society Cancer Action Network • American College of Preventive Medicine • American Council on Exercise • American Heart Association • American Lung Association • American Planning Association • American Public Health Association • American School Health Association • Antibiotic Resistance Action Center, Milken Institute School of Public Health, the George Washington University • Association of Accredited Public Health Programs (AAPHP) • Association of American Veterinary Medical Colleges • Association of Maternal & Child Health Programs • Association of Public Health Laboratories • Association of Schools and Programs of Public Health • Association of State and Territorial Health Officials • Association of State Public Health Nutritionists (ASPHN) • Asthma and Allergy Foundation of America • BCCH- Bonner County Coalition for Health • Big Cities Health Coalition • Boston Alliance for Community Health • Boston Public Health Commission • Boulder County Public Health • Campaign for Tobacco-Free Kids • Center for Science in the Public Interest • ChangeLab Solutions • Children’s Environmental Health Network • Children’s Mental Health Network • Coalition for Health Funding • Community Anti-Drug Coalitions of America (CADCA) • Creatinghealthycommuniies.org • Delaware Academy of Medicine / Delaware Public Health Association • Directors of Health Promotion and Education (DHPE) • Doctors for America • Dorchester County Health Department • Eat Smart Move More South Carolina • Ehrens Consulting • Emory Centers for Training and Technical Assistance • Family Resource Network • Fizika Group • FLIPANY (Florida Introduces Physical Activity and Nutrition to Youth) • Florida Public Health Association • Foundation for Healthy Generations • Fund for Public Health in New York City • Greater Philadelphia Business Coalition on Health • Green & Healthy Homes Initiative • Hawaii Public Health Association • Health Care Foundation of Greater Kansas City • Healthcare Leadership Council • Healthcare Ready • Health Care Without Harm • Health Promotion Advocates • Health Resources in Action • Healthy Homes Coalition of West Michigan • Healthy Schools Campaign • Healthy Teen Network • Hispanic Health Initiatives, Inc. • Idaho Public Health Association • Illinois Public Health Association • Illinois Public Health Institute • Indiana State Council of the Emergency Nurses Association Chapter 401 • Institute for Health and Productivity Studies • Institute of Social Medicine & Community Health • International Health, Racquet & Sportsclub Association • Iowa Public Health Association • IT’S TIME TEXAS • Jasper Newton County Public Health District • Johnson County Department of Health & Environment • Joy-Southfield Community Development Corporation • JPS Health Network • Kansas Association of Local Health Departments • Kickapoo Tribe in Kansas • Lawrence-Douglas County Health Department • LifeLong Medical Care • Logan County Health Department • Louisiana Public Health Institute • Lutheran Services in America • Madison Area Bus Advocates • Maine Public Health Association • Meade County Health Department • Mennin Consulting • Michael O. D. Brown We Love Our Sons & Daughters Foundation • Minnesota Public Health Association • MYZONE • National Alliance of State & Territorial AIDS Directors • National Association of Chronic Disease Directors • National Association of Counties • National Association of County and City Health Officials (NACCHO) • National Association of Pediatric Nurse Practitioners • National Association of School Nurses • National Athletic Trainers’ Association • National Center for Weight and Wellness • National Coalition for Promoting Physical Activity • National Coalition on Health Care • National Environmental Health Association • National Forum for Heart Disease & Stroke Prevention • National Foundation for Infectious Diseases • National Health Foundation • National Housing Conference • National Indian Health Board • National Network of Public Health Institutes • National Recreation and Park Association • National WIC Association • Nemours Children’s Health System • Nevada Public Health Association • New Jersey Public Health Association • NIRSA: Leaders in Collegiate Recreation • North Dakota Public Health Association • Ohio Public Health Association • Orange County Food Access Coalition • Oregon Public Health Association • Partnership for a Healthy Lincoln • Pawnee County Health Department • PinneyAssociates • Prevention Institute • Public Health Advocates • Public Health Association of New York City (PHANYC) • Public Health Foundation • Public Health Institute • Rails-to-Trails Conservancy • Regional Asthma Management and Prevention (RAMP) • Research!America • Respiratory Health Association • RiverStone Health • Safe Routes to School National Partnership • School-Based Health Alliance • SHAPE America - Society of Health and Physical Educators • Snohomish Health District • Society for Public Health Education • Society of Behavioral Medicine • Society of Infectious Diseases Pharmacists • Society of State Leaders of Health and Physical Educators • Southern California Public Health Association • Spokane Regional Health District • Stand2Learn • Stanton County Health Department • Tacoma-Pierce County Health Department • Texas Action for Healthy Kids • The Bronx Health REACH • The Food Trust • The National REACH Coalition • The Root Cause Coalition • The Society for Healthcare Epidemiology of America • Trust for America’s Health • Truth Initiative • UNC Gillings School of Global Public Health • Universal Health Care Action Network of Ohio • Vermont Public Health Association • Washington State Public Health Association • Wisconsin Institute for Healthy Aging • WomenHeart: the National Coalition for Women with Heart Disease • YMCA of the USA TFAH • healthyamericans.org 9 I NT RO D UC TION Blueprint for INTRODUCTION Introduction a Healthier The United States faces a series of major health crises. America Unfortunately, however, for decades, the health system has been set up to treat people after they are sick rather than keeping them well in the first place. The health system has largely been benefit from the most effective health driven by paying for treatment and improvement strategies. doctor’s care — and not focusing on The stakes could not be higher. overall health — yielding more of a sick- care system than a healthcare system. l rescription Drug and Heroin Crises: P Deaths from prescription painkillers Despite the $3 trillion spent annually have quadrupled in the past 15 years, on health, it has not translated into and more than 2.1 million people misuse “buying” better health for the country.22 these drugs. The epidemic costs the To date, there has never been a country more than $55 billion a year concerted or long-term strategy to in healthcare, workplace and criminal improve health in the United States. justice spending.23, 24, 25, 26 This has also But a different approach is possible. contributed to a major rise in heroin use. Much of the pain, suffering and cost Fatal heroin overdoses have more than of many health problems could be tripled since 2010 and nearly half prevented or mitigated — with a greater a million people are addicted to focus on trying to stop problems before heroin.27, 28, 29 Heroin use among young they happen. This new approach would White adults (18- to-25-year-olds) has improve quality of life for millions of more than doubled in the past decade, Americans — while reducing disease with large concentrations in some rates and healthcare costs. communities and states, including Indiana, Kentucky and New Jersey.30, 31 Experts have identified a growing set of Substance misuse is contributing to lower high-impact, evidence-based strategies — life expectancies — and higher death but there has not been a significant effort rates — among middle-aged Whites.32 to widely implement and sustain them. l uture Health of America’s Children: F In this Blueprint for a Healthier If things continue on their current America, the Trust for America’s Health track, one in three children will develop (TFAH) presents key strategies for diabetes and four out of 10 will develop improving the health of Americans. heart disease in their lifetime.33, 34 This There has never been a better is preventable and not inevitable. opportunity to align the objectives and Today’s children are not as healthy as OCTOBER 2016 resources of public health, healthcare, they could be or should be — one in social services and community four, between the ages of 17 to 24, are improvement efforts to advance the goal not even considered healthy enough of improved health. to join the military.35 Without stronger local health improvement programs, Over the next four years, the they are being resigned to serious health country should prioritize ensuring problems that could have been avoided. communities around the country can l nfectious Disease, Disaster and I l educing Substance Misuse: Five of the R Bioterrorism Readiness: Fifteen years strongest school-based substance use after the September 11, 2001 and prevention strategies have returns on anthrax tragedies and 10 years after investment (ROI) ranging from $3.8:1 Hurricane Katrina, the country is to $34:1 — and have demonstrated still not as ready as it could or should results in reducing misuse of a range be for major health emergencies — of drugs, alcohol and tobacco along whether they are manmade attacks with other risky behaviors — while like aerosolized anthrax or emerging improving school achievement and infectious diseases like the Zika virus future career attainment.40, 41, 42, 43 or a major new pandemic. While l reventing Chronic Diseases: An P emergencies and new threats are investment of $10 per person per year Over Five Years the Return For Every inevitable, the system does not have in proven evidenced-based community $1 invested is $5.60 built-in capacity to respond to new prevention programs that increase or surge needs. Instead, arising physical activity, improve nutrition emergencies disrupt attention and funds and prevent smoking and other from ongoing pressing priorities — and tobacco use could save the country create cycles of relying on a series of more than $16 billion annually emergency supplemental appropriations within five years — a return of $5.60 — instead of building a stronger for every $1 invested.44 In addition, baseline system with increased flexibility. the National Diabetes Prevention New diseases can have a significant Program and strategies that link economic impact. Seasonal flu alone clinical and community resources costs the country $87 billion annually.36 have shown significant results — DPP l nvironmental Justice: The E has reduced diabetes incidence by 58 contaminated water in Flint, Michigan percent in persons with prediabetes and other locations serves as a call and Stanford’s Chronic Disease Self- to renew our nation’s environmental Management Programs net more than health policies. Around 434,000 $300 per patient in savings — and children in the United States have if scaled to 10 percent of Americans lead poisoning — the most common with chronic diseases, could yield an source is from exposure to paint in estimated $6.6 billion in healthcare older homes or apartment buildings savings annually.45, 46, 47 among children in low-income families l peeding Detection and Control S — putting them at high risk for of Infectious Disease Outbreaks: serious developmental, behavioral and New scientific and technological cognitive delays.37 Millions of families breakthroughs — like genomics live in neighborhoods that adversely and real-time, interoperable disease impact their health and do not offer outbreak tracking — are ready for the same degree of protection from use and could dramatically speed the environmental and health hazards as ability to identify and respond to crises. those only a few zip codes away.38, 39 However, these breakthroughs will only But strategies do exist to address the make a difference if they are scaled problems — but have not been broadly up and complemented with workforce taken to scale across the country. For training and reforms to address the gaps example: in the basic underlying health system. TFAH • healthyamericans.org 11 l educing Environmental Threats: R l upport in Early Childhood: Investing S Targeted strategies can significantly in good health and well-being for reduce the impact of adverse young children can yield lifelong environmental problems on health. For benefits. For instance, quality early instance, the Centers for Disease Control childhood education can provide and Prevention (CDC), state and local a 7 percent to 10 percent annual initiatives have reduced lead poisoning return on investment based on higher by 70 percent since 1990 — and lead school and career achievement and abatement programs have shown a return reduced costs in remedial education, of $17 to $221 for every $1 invested.48 health and criminal justice system expenditures.50, 51 The Supplemental l ddressing Social Needs that Impact A Nutrition Program for Women, Health: An new analysis by TFAH and Infants and Children (WIC) has Healthsperien estimates that investing in found that each $1 spent leads to Health and Social Service Coordinator a reduction in healthcare costs of Systems that address gaps between $1.77 to $3.13 in the two months after medical care and effective social service birth (between a 2:1 to 3:1 ROI).52 In programs with a range of strategic and addition, infants born into low-income targeted interventions — through a families receiving rental assistance “navigator-plus-support” approach — were 43 percent less likely to have could yield between $15 billion and hospitalizations from serious illnesses $72 billion in healthcare savings a year compared to infants in low-income within 10 years, depending on how families not receiving any rental broadly these programs are supported assistance.53 And nurse family home (i.e., potentially reaching between 12 visits for high-risk families with young percent and 25 percent of low-income children has shown a return of $5.70 Americans — between 13 million and 28 for every $1 invested.54 million people).49 EXAMPLES OF RETURN ON INVESTMENTS FOR PREVENTION EFFORTS Five Strongest Community-based School-based Nutrition, Activity 3.80:1 Lead Abatement 17:1 to Substance Misuse and Tobacco 5.60:1 Prevention to 34:1 Prevention Programs 221:1 Programs Programs Community Health Supportive Worker Navigator, Early Childhood Housing Programs 2:1 Referral and Case 2:1 Education 4:1 to for High-Need to 6:1 Management to 4:1 Programs 12:155 Patients Programs WIC Program Child Asthma Nurse Home 1.46:1 Savings in 2:1 Prevention Visiting for 5.70:1 Programs to 7:1 Healthcare Costs to 3:1 High Risk Infants for Infants 12 TFAH • healthyamericans.org Blueprint for a Healthier America The Blueprint identifies key policies around the country — to benefit and lives, in their workplaces, schools, and strategies to move the country improve the health of more Americans. neighborhoods and homes. toward a more value-based approach to Value-based healthcare is helping to It requires a more strategic approach — improving health. support a shift from sick care once building a mutually beneficial integration Communities around the country have diseases have developed to helping keep of public health and healthcare as well been developing successful efforts — people healthy in the first place — by attending to how different factors impact resulting in better health and quality creating new incentives and an increased health including economics, education, of life for millions of Americans and emphasis on improving health. There housing, transportation and other reducing healthcare costs. And, experts is a strong emphasis on delivering sectors. This approach also focuses on have identified high-impact policy levels quality care and reducing healthcare making the most effective use of existing and models that could be used to help costs — but improving “population resources and assets, supporting the top scale the most effective programs. health” is also one of the top priorities priority goals of communities across the of the Triple Aim.56, 57 Improving country, and leveraging opportunities to The goal is to take the most effective, health also requires addressing factors align resources to help achieve shared high-impact strategies and scale them that influence health in people’s daily goals of improving health and well-being. PRIORITY RECOMMENDATIONS IN THE BLUEPRINT INCLUDE: l W ide-Scale Implementation of the “Navigator-Plus-Support” Model for l S upport Healthy Students and Most Effective Evidence-based Health Integrating Health and Social Services Healthy Schools Improvement Strategies l H ealthier Aging for Seniors l M odernize the Public Health System l F ully support the Prevention and to Be Prepared for Emergencies and l S top the Prescription Painkiller Public Health Fund Ongoing Threats Misuse and Heroin Epidemics l S upport Place-based, Multisector l S upport Stable, Sufficient Funding for l P revent Obesity, Improve Nutrition Local Health Improvement Partner- Emergency Preparedness — to Main- and Increase Physical Activity ships to Address Top Health Priorities tain Basic Readiness and a Public l E liminate Tobacco Use in Communities Around the Country Health Emergency Fund to Ramp Up l P rioritize Prevention in the Cancer l D evelop State Expert Research and when a Crisis Strikes Moonshot Initiative Technical Assistance Networks l I mprove and Modernize Basic Public l E nd the HIV/AIDS Epidemic l S upport Greater Coordination of Fed- Health Capabilities in Communities eral Grant Programs Across Sectors Around the Country — Via l S top Superbugs and Antibiotic for Better Efficiency and Outcomes Foundational Capabilities and Resistance l N onprofit Hospitals to Use State-of-the-Art Technology l S upport Environmental Health and Community Benefit Programs to l C reate a Special Assistant to the Justice Support Community-based Health President for Health Security and Im- l A ddress the Health Impact of Climate Improvement Efforts prove Federal Leadership and Coordi- Change and Extreme Weather l ncrease Innovative and Social Invest- I nation for Public Health Emergencies l A chieve Health Equity ment in Health Improvement Strategies l A ddress Major Health Issues l R everse Rising Death Rates Among l S upport Medicare, Medicaid and Private l P rioritize Healthy Early Childhoods Middle-Aged White Adults Insurer Support of Health Improvement — Reduce Toxic Stress and Adverse l P romote Positive Mental Health Strategies and Services — Including a Childhood Experiences TFAH • healthyamericans.org 13 ADDITIONAL PUBLIC HEALTH POLICY RECOMMENDATION INITIATIVES l A dvancing the Health of Communities and Populations, Vital Directions for Health and Health Care — from the National Academy of Medicine (NAM): As part of a broad effort to identify policy recommendations for the next Administration and Congress, NAM brought together more than 100 health experts to help inform key policy rec- ommendations in a collection of papers to advance the overarching goals of: better health and well-being; high val- ue-healthcare; and strong science and technology.58 The Advancing the Health of Communities and Populations paper focused on four key goals.59 l D emocratizing Health: The Power for Community, Vital Directions for Health and Health Care — from the National Academy of Medicine: Another paper in the Vital Directions series highlights Source: Brookings Institute ways to better address community needs and engage community partici- pation in health improvement efforts.60 Foundation, convened a high-level group Services (HHS) embrace the role of It highlights a people power approach of public health and private healthcare Chief Health Strategist for the nation supported by The California Endowment, policy makers, to develop a vision and in order to: which is supporting the development of a series of recommendations for the l T ransform the healthcare and public change agents around their state, par- “Federal Public Health Enterprise.”61 The health investments by the federal ticularly in 14 low-income communities. overarching vision of the group is that, government into a Health Promoting They equip community residents with “everyone in America deserves to live in System and adopt metrics that foster the skills — including through the use of a healthy nation — and in healthy states, activities that support longer, higher technology and social media — to look regions, cities, and neighborhoods. And quality life and reduce health inequities. for and identify the impacts of social and America needs a healthy population to environmental conditions and to collabo- be competitive and secure in the 21st l A ssure communities have the data, rate to advance common goals. century.” As Chief Health Strategist for evidence, analytic capacity and flexibility the nation, the Department of Health they need to build healthy and resilient l T he Department of Health and Human and Human Services should lead a communities including supporting Services as the Nation’s Chief Health national initiative that assures “America’s cross-sector collaborations at the Strategist: Transforming Public Health communities are places that provide federal, state and local levels. and Health Care to Create Healthy every person with the opportunity to Communities — from the Public Health l A ssure every community is served by a achieve optimal health and are served by Leadership Forum: Over the past year, in well-resourced public health department a strong public health infrastructure.” preparation for a new Administration, the that is accredited and able to provide Public Health Leadership Forum (PHLF), The report recommends that the U.S. foundational capabilities and respond supported by the Robert Wood Johnson Department of Health and Human to unanticipated emergencies. 14 TFAH • healthyamericans.org SECTION 1 Prioritizing Wide-Scale Implementation of the Most Effective Approaches for Improving Health in Communities Around the Country SECTION 1 SECTI O N 1 Blueprint for SECTION 1: RIORITIZING WIDE-SCALE IMPLEMENTATION Prioritizing Wide-Scale Implementation of the Most a Healthier Effective Approaches for America P Improving Health in Communities Around the Country Communities across the country are struggling with health challenges that have consequences for the well-being of children and families and for the broader productivity, vitality and economic well-being of their neighborhoods, schools and workplaces. Mental health, obesity, substance use, physical activity, nutrition, diabetes, heart disease, high blood pressure and access to medical care are consistently ranked as top health concerns.62, 63, 64, 65, 66 Priority Community Health Needs. Obesity 70% Behavioral health 64% Substance abuse 44% Diabetes 36% Cancer 35% Cardiovascular disease 29% Tobacco addiction 26% Maternal & reproductive health 19% Oral health 19% Perinatal & infant health 15% Respiratory health 15% Injury 12% Hypertension & stroke 12% Infectious disease 9% NOTE: Data compiled across surveys from the Association of American Medical Colleges (AAMC), the OCTOBER 2016 Health Research & Educational Trust (HRET), Catholic Association Member Hospitals (CAM), and the Health Policy Institute of Ohio.62-66 One category (Oral Health) from HRET review, AAMC survey and CAM survey only; one category (Cancer) from HRET review, CAM survey and Ohio review only; two categories (Social Determinants of Health and Health Insurance Coverage) from HRET review and AAMC survey only; one category (Physical Activity and Nutrition) from AAMC survey and Ohio Hospitals review only; and two categories (Preventive and Screening Services and Chronic Condition Management) from HRET review only. Only categories with at least one survey or review reporting greater than 30 percent included. * AAMC and CAM reported Heart Disease and Hypertension/Stroke together as one category. such as social services, public safety, Top Public Health PrioriƟes among County criminal justice and education. Officials l ealth services and community-wide H health improvement initiatives have Substance Misuse 84% not generally been well integrated with other social service and community Chronic Disease 59% and economic development Social and Environmental Factors 38% efforts. While many health systems and hospitals participate in local Source: National Association of Counties Survey (n=154), April 201667 community and philanthropic efforts, such as mobile screening vans, health Broad use of evidence-based and fairs and charity walks — or as anchor common sense strategies could reduce institutions, major employers and rates of these health problems and lower real estate holders in a community healthcare spending. participating in broad community improvement initiatives — most have However, there is no mechanism to ensure not often focused on developing that health improvement efforts can be strategies and partnering across sustained over time and supported at a sectors, leveraging their resources sufficient level to achieve desired outcomes and expertise to synergetically achieve in communities around the country. Some significantly better health outcomes. past barriers have included that: l he structure of the competitive T l any “population health” efforts focus M healthcare market typically does not on the disease du jour and shifting incentivize health systems, hospitals, or priorities — pulling focus and resources health insurers to work across sectors away from ongoing needs. In addition, or to collaborate within sectors to invest many public health initiatives are limited in health at the community level.68 In in duration and funding, supported by addition health systems engaging in short-term grants. But there has not “population health” improvement been sufficient investment to scale or efforts have often addressed the issue sustain them over time to achieve results. from the lens of managing the health l ealth improvement, especially H of their patients or “patient pool,” community-based or population-level such as through care coordination approaches, have not been widely “population health management,” prioritized or incentivized by the rather than by investing in broader healthcare system, where expenditures community-wide approaches.69 have been driven by fee-for-service Lessons learned from the most successful and individually-focused treatment health improvement initiatives can serve and payment approaches. In addition, as examples for national change and many healthcare decisions are made local execution. These lessons can be at the federal-state level (through used to support a scalable, sustainable Medicare and Medicaid) or through model to improve health, increase the private healthcare plans — in decision vitality of communities across the country making processes separated from and bring down healthcare costs. many other state-local cost drivers, 18 TFAH • healthyamericans.org A. POLICY PRIORITIES FOR SUPPORTING HEALTH IMPROVEMENT EFFORTS AROUND THE COUNTRY l S upport Local Health Improvement institutions or intermediary nonprofits health research centers, institutes and re- Partnerships to Address Top Priorities in communities) is around $250,000 to sources. Community-based programs at in Communities: Health improvement $500,000 per year. CDC, SAMHSA and other agencies could strategies must be flexible enough for help support this effort — and states l B roaden Implementation of Evi- local communities to be able to prioritize could provide additional funds to support dence-Based, High Impact Strategies shared goals — from prescription drug and expand the institute’s activities and — And Create Academic/Expert Health misuse to obesity to adverse childhood scope. One model center in Pennsylvania Improvement Institutes in Every State: experiences and toxic stress — and with an annual budget of $1 million works Experts at the CDC, National Institutes bring key partners and assets from the across several related disciplines to ad- of Health (NIH), SAMHSA, public health community together to achieve them. dress common risk factors associated agencies, healthcare systems and expert Effectively addressing health problems with crime, poor health and low academic organizations have been rapidly identify- requires sustained multisector collabo- achievement. The federal government ing a growing set of the strongest health rations among leaders and institutions should expand funding for additional improvement strategies — which allow from within and beyond the health sector. research and evaluation of communi- local communities and health systems Groups representing healthcare, social ty-based prevention and health improve- to determine which of the most effective services, private businesses, philanthro- ment programs and strategies. available programs best match their needs. pies, schools and faith and community For instance, in 2016, CDC released a set l F ully Fund the Prevention and Public groups all have a vested interest in of top community-wide Health Impact in Health Fund and Other Community-Based improving the health and vitality of a com- 5 Years strategies and community-clinical Health Improvement Efforts: There needs munity. In addition, state and local public approaches via the 6|18 Initiative: Acceler- to be ongoing and sufficient funding to health departments play an important ating Evidence into Action.70, 71 In addition, support health improvement efforts around role in partnerships as Chief Health Strat- the creation of an expert network in states the country. The Prevention and Public egist and in some cases as lead partners would be an important new tool that would Health Fund has been used to support key in communities. Different sectors bring provide support and technical assistance chronic disease prevention efforts at CDC. different strengths and expertise — and to local communities in their selection, It is scheduled to increase by $250 million a diversification of resources — to help implementation and evaluation of programs in Fiscal Year (FY) 2018; and by another achieve a stronger collective impact. and services. Some of the strongest exam- $250 million in FY 2020. These increased Federal public health programs and poli- ples of state and regional expert networks funds could be used to support a range of cies should focus on providing support to have helped support cross-sector youth de- federal health improvement efforts, includ- local communities to develop and man- velopment programs that reduce crime and ing chronic disease prevention programs at age these partnerships. A Local Health drug misuse while improving health and CDC; place-based multi-sector initiatives; Improvement Partnership pilot program academic achievement. These expert and/or multi-agency efforts to address should be created — via community organizations would contribute to growing health factors and improve outcomes. It health and prevention programs at the the evidence-base for programs — using is important these increases are used to Centers for Disease Control and Preven- their findings to inform and improve efforts. support new and innovative efforts and not tion, the Substance Abuse and Mental be used to supplant existing programs and The federal government should support Health Services Agency (SAMHSA), the funds. The Fund was established to pro- the creation of a network of state-based Health Resources and Services Admin- vide for expanded and sustained national expert institutes — beginning with a pilot istration (HRSA) and other agencies to investment in prevention and public health program for an initial set of states. These support planning, capacity building and programs to improve health outcomes and institutes should be developed building on implementation grants to localities. help restrain the rate of growth in private and in consultation with state and local Estimated costs for supporting a “lead and public sector healthcare costs. It health departments and existing public partner” (often established, experienced innovates and builds support for efficient, TFAH • healthyamericans.org 19 evidence-based approaches to improve health and reduce disease rates in com- Chronic Disease Funding — Fiscal Year 2003 to Fiscal Year 2016* munities across the country and should $1,500 help support expanding the wide-scale implementation of evidence-based health $1,125 improvement strategies by local coalitions $59 $301 $411 $244 $457 $452 $339 (Millions) across the country. The entire budget for $750 all chronic disease prevention activities at CDC is around $1.2 billion (about $4 per $790 $818 $900 $834 $825 $834 $882 $905 $774 $756 $740 $719 $747 $838 person per year), while more than 80 per- $375 cent of the annual $3 trillion in healthcare spending is spent on individuals with one $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 or more chronic conditions (about $8,000 Fiscal Year per person per year for chronic disease).72 ■ Funding from the Prevention and Public Health Fund ■ Chronic Disease Discretionary level (Without the PPHF) *FY 2010-2016 values are supplemented by the Prevention and Public Health Fund In addition to CDC, SAMHSA has a Preven- tion and Treatment Block grant program funded at around $1.8 billion per year and there are Drug-Free Community Grants to- taling around $86 million.73 There are also new opportunities under the Every Student Succeeds Every Day (ESSA) to support healthy school initiatives via Title I fund from the U.S. Department of Education (ED). l I ncrease Strategic Alignment of Poli- cies and Programs to Improve Health and Other Factors that Influence Health — With a Focus on Improving Outcomes: Since health is impacted by a wide range of factors, it is important to have a more strategic approach to prioritizing goals and investments that can leverage better outcomes across federal, state and local governments. The National Prevention Strategy, released in 2011, and other cross-agency efforts — such as issue-based task forces and work- ing groups — have been an important step to help federal agencies identify many joint strategies for improving health and other goals. For instance, issues like drug pre- vention require efforts of multiple agencies Source: National Prevention Council Action Plan — including the Department of Health and Human Services, Department of Justice (DoJ), Office of National Drug Control Policy (ONDCP) and ED. 20 TFAH • healthyamericans.org The next step should be a much stronger Audit Requirements in Federal Awards l I ncentivize Increased Support for purposeful approach to identifying and (Uniform Guidance) in 2013 that Community-Based Health Improvement prioritizing ways agencies can better work permits more flexibility and innovative Efforts via Nonprofit Hospital Community together and invest in the most effective models for agencies to waive certain Benefit Programs: Many hospitals are strategies to improve health and achieve requirements in grants in exchange for expanding support for upstream com- other goals — across housing, food and demonstrated improved outcomes and munity health improvement strategies by income assistance, education, transportation cost-effective approaches. 75 Additional addressing key priorities such as obesity, and other areas. This should go beyond the mechanisms should be developed that prescription drug misuse and infant mor- most obvious areas of alignment — such as can support strategies and evaluations tality and other factors that have a major healthy housing programs — to the factors of the impact of programs across impact on the health of their patients, that influence health — such as housing agencies, including of programs funded such as housing, education and transpor- assistance programs. by one agency on the goals of another tation. Nonprofit hospitals’ community agency. Mechanisms that align these benefit programs totaled around $62.4 bil- There should be increased leadership for goals among public and private partners lion in 2011.82, 83 In the past, only around developing and implementing the next are also needed. For instance, the 5 percent of the funds have been used stage of this approach and strategy — Association of Government Accountants’ to support community-based prevention and should be a priority for the White Intergovernmental Partnership initiative activities, with the majority of the funds House Domestic Policy Council and from is one example of a coordinating being used to support charity care. With the Secretary of HHS. This approach mechanism which was developed to open expanded insurance coverage — reducing should include a review and process lines of communications across all levels the need for as much charity care support for coordinating aligned programs to of government with the goal of improving — and value-based payment, hospitals can focus on improving outcomes — and to performance and accountability.76 look at upstream approaches to improve maximize efficiency and effectiveness the health of the patients and communi- of efforts. Where appropriate, there At the state and local level, a number ties they serve. Since 2012, the Internal should also be increased efforts to of projects have identified strategies Revenue Service (IRS) has required all coordinate and align grant programs for coordinating health and social nonprofit hospitals to conduct regular aimed at common goals — so funds can service investments and/or increasing community health needs assessments to be leveraged to work together to better investments in the social determinants better understand the top health concerns achieve these goals. For instance, the that impact health — toward coordinating of the communities they serve and to de- Sustainable Communities Initiative (SCI) goals, programs and funding across velop implementation plans. Community is a partnership across the Department of sectors and agencies, such as the benefit programs may be used to support Housing and Urban Development (HUD), Milbank Memorial Fund’s study of Investing health improvement initiatives. In addition, Department of Transportation (DOT) and in Social Services for States’ Health: the IRS issued follow up guidance that the Environmental Protection Agency (EPA), Identifying and Overcoming the Barriers; “some community building activities may joining together in 2009, where they have the Milbank Memorial Fund and New also meet the definition of community ben- identified shared goals and initiatives York State Health Foundations’ Medicaid efit,” which may include addressing other — and grantees can receive waivers for Coverage for Social Interventions a Road factors that influence health.84 Community multiple grant requirements in exchange Map for States; the Commonwealth Fund’s improvement and “community building” for demonstrating improved results.74 A State Policy Framework for Integrating have traditionally been reported separately, Health and Social Services and the Within the federal government, there where many community building efforts National Academy for State Health Policy’s are a number of mechanisms for have not been covered by community ben- Federal and State Policy to Promote the supporting improved cross-agency and efit programs, and cannot actually count Integration of Primary Care and Community program collaboration. For instance, the related expenses as community bene- Resources and the Center for Healthcare the Office of Management and Budget fit funds. However, the IRS has not issued Strategies, Inc.’s State Payment and (OMB) issued a Uniform Administrative any official requirements for supporting Financing Models to Promote Health and Requirements, Cost Principles and community efforts. Social Service Integration.77, 78, 79, 80, 81 TFAH • healthyamericans.org 21 l P rovide Support to Medicare, Medicaid and Private Healthcare Insurers and Providers to Expand the Use of Health Improvement Strategies and Services: Value-based healthcare models are spurring many healthcare providers and insurers to invest in innovative strategies to keep patients healthier. Medicare and Medicaid should expand support for prevention — and help speed strong emerging programs into practice. The Centers for Medicare and Medicaid Services (CMS) should lever- age existing authorities and initiatives — and create additional mechanisms as needed — to incentivize healthcare, public health and social service sectors The federal government should consider provide a scalable way for communities to work together. Key areas that should additional guidance, requirements and to have an accountable and trusted be addressed include: incentives for the use of community structure for raising and managing l ncentives for increased use of I benefit programs to support upstream the funds needed to support these covered preventive services and community health and other factors that efforts. Additional groups are exploring penalties where actual use and impact health, similar to the Community expanded use of “pay for performance” delivery rates remain low; Reinvestment Act requirements of banks and other investment models for health l xpanding coverage and use of clini- E and financial institutions to support com- improvement initiatives. cal-community programs, such as: ser- munity-based programs. In addition, the The federal and local governments vices that use lower-cost alternatives, IRS should clarify what “community build- should expand social investments — care coordination or community-based ing” efforts can be considered for support through CDFIs and New Market Tax service, and evidence-based group through community benefit programs. Credits — into health improvement diabetes and other chronic disease l I ncrease Innovative Social Investments: initiatives and programs — including prevention counseling programs;86 There is increasing use of social through healthy food financing and l rograms and systems that help con- P investments — including Community community health center initiatives, as nect patients to services that address Development Financial Institutions well as other programs that leverage unmet social needs, such as the Ac- (CDFIs) and social impact bonds — to collective benefits for improving health. countable Health Community (AHC) support health improvement initiatives, model being piloted by CMS that helps The federal government could also in- such as healthy food financing initiatives, connect patients to services that ad- crease incentives for social investing by capital development of community health dress housing instability and quality; nonprofit hospitals by crediting differ- centers and co-located health-and-social food insecurity; utility needs; inter- ences in market returns as a community service providers and family home visiting personal violence; and transportation benefit. Nonprofit hospitals are increas- programs. (See page 50: Innovative needs — and other available mecha- ingly investing in CDFIs and other social and Social Impact Funding Strategies nisms, such as state waivers, to support investments, but are not able to “count” for more on these different investing programs that help connect beneficiaries the difference in earnings between a mechanisms). Creating a financial to social services as needed; and market rate return and the return from a management mechanism — to function socially responsible investment.85 l xpanding coverage for community- E like a CDFI for health improvement based health improvements.87, 88 initiatives in communities — would 22 TFAH • healthyamericans.org ROBERT WOOD JOHNSON FOUNDATION 2016 CULTURE OF HEALTH PRIZE WINNERS89 Every year, the Robert Wood Johnson 24:1 Community, Missouri, through com- Foundation highlights and honors com- munity collaborations, has joined 24 dif- munities that improve the health and ferent communities located northwest of well-being of neighborhoods and individ- St. Louis to build strong neighborhoods, uals. The winning communities receive engaged families and successful children. $25,000 and serve as examples for In 2003, the Consortium for a Healthier other communities on how to ensure Miami-Dade County was formed to im- residents live longer, healthier and more prove the health of neighborhoods, and, productive lives. in just over a decade, has made public The Shoalwater Bay Indian Tribe, school menus healthy for the 340,000 located in Washington state, has im- children who attend school; installed proved the physical, social, emotional free fitness equipment in all 16 commu- and spiritual health of Tribe members nity parks; reduced the homeless popu- by promoting healthy behaviors and ac- lation; and offered routine HIV testing in tive living, funding a dental and mental all health facilities. health wellness center and focusing on Manchester, New Hampshire has emergency preparedness. focused on creating strong, resilient Santa Monica, California has, for four neighborhoods by investing in neighbor- years, researched community aspects hood-based, health-focused programs, which were either helping or hindering including, for example, Safe Station, health promotion — resulting in the which turned 10 of the city’s fire sta- creation of the Wellness Index, which tions into safe intake centers for those provides a framework for ensuring mu- addicted to drugs. nicipal decisions are made with health In Louisville, Kentucky, 55,000 de- in mind. grees, an innovative partnership, works Columbia George Region, Oregon and to increase the number of residents Washington attempted to address who have higher degrees; Louisville’s food insecurity — 1 in 5 residents Bold Gold initiative, a collaboration led report running out of food regularly by Humana, aims to improve the health — by focusing on food access, job of the community by 20 percent by creation and improving transportation. 2020; and YouthBuild Louisville, a voca- One initiative, the Veggie Rx program, tional, education and community service allows social service to issue a $30 program, provides ways for youth to monthly prescription for fresh fruits and learn skills, improve neighborhoods and vegetables to individuals. break the cycle of poverty. TFAH • healthyamericans.org 23 B. A PLACE-BASED STRATEGY: LOCAL HEALTH — OR WELL-BEING — IMPROVEMENT PARTNERSHIPS Currently, there is no mechanism to ensure that health improvement efforts can be sustained over time and supported at a sufficient level to achieve desired outcomes in communities around the country. Lessons learned from the most concerns — and then align their assets based partnerships may be galvanized successful health improvement and resources to achieve a stronger as broader “wellness” or “community initiatives can serve as examples to build collective impact. This has often been improvement” collaborations — where a scalable, supportable model that can a practice in economic and community improving health is one issue among be used across the country. development — but this approach many or may not be the “lead” partner has been used narrowly in some areas in a coalition. l H ealth improvement efforts must be of health management, such as by better connected to the concerns of The local health — or broader well- HIV Planning Councils and in some the local community — to demonstrate being — improvement partnership Community Health Needs Assessment their value for improving health model can help to align and integrate processes, but not widely or systematically and lowering health costs while also these different interests, while used to address health and well-being. contributing to the overall improved maintaining the flexibility to focus on a wellness and vitality of that community. A partnership creates a mechanism broader agenda with improved health to support a long-term, sustained representing one of many collective l A place-based approach provides a commitment to improving the health objectives. Key partners include: model that can be applied and scaled of a community — leveraging its to address health problems around l ublic Health “Chief Health P existing strengths, assets, expertise and the country — while giving local Strategist” Partners: Public health institutions. areas the flexibility to select from departments and experts are and implement the evidence-based Local health improvement partnerships important for playing a lead role in strategies that best match their needs may decide to focus on specific health helping communities identify their and interests. problems, such as infant mortality or biggest health concerns and the most obesity, or other factors that impact effective strategies to address them. l P lace-based approaches often focus on well-being, such as housing, education, They bring expertise in developing many different goals — and need to transportation, the availability of community-wide and population-based manage a balance of interests, goals, affordable food or conditions in a health programs — and can also help incentives, perspectives and assets of neighborhood — or a combination of prioritize and evaluate ways to work different partners and sectors. interrelated concerns. with other sectors to improve health. One of the strongest local approach In addition, there are federal, state In many cases, effective place-based to address health problems is building and local resources dedicated to help partnerships could identify priorities partnerships of key stakeholders across support key public health capabilities and strategies — where improving a range of sectors. Local stakeholders and community health programs. health is one of a range of goals and understand the problems in their While these funds are limited and not outcomes, but may not be the lead communities and have a vested interest sufficient to fully fund local health or only priority issue. Therefore, in the health, wealth and vitality of improvement initiatives on a wide- partnerships must be able to reflect their community. scale basis, they can support some of a range of participants’ interests, the essential functions for developing Working together, key partners can goals, resources and perspectives. For and evaluating efforts. identify shared goals, priorities and instance, in many communities, place- 24 TFAH • healthyamericans.org l ealth Partners: Many groups in H l nnovative, Social Impact Investors: I the health and healthcare sector are A range of new outcome-based, “pay- exploring and investing in innovative for-performance” and social investing and strategic approaches for improving initiatives are also helping to bring health in the communities they increased attention to multisector serve, particularly incentivized by the collaborations in communities. movement toward value-based healthcare l overnment Partners: Federal, G and the increased interest in expanding state and local governments should health promotion and prevention efforts play a role in helping to coordinate by many nonprofit hospital community and incentivize local communities benefit programs. Health sector to establish and support these participants should include healthcare partnerships — such as through providers, insurers, hospitals, community improved flexibility and aligning health centers and behavioral health and government programs to more public health agencies. efficiently and effectively work l ulti-Sector Partners: Health sector M together to focus on the outcomes of participants are important — but it policies and grants in exchange for is also important to engage a much improved performance. (See page 50: broader set of partners, since many of Innovative and Social Impact Funding the biggest factors that influence health Strategies for more on these different are outside of the doctor’s office, in investing mechanisms). At the state workplaces, schools and neighborhoods. and local government level, there is Social service agencies, philanthropies, also a necessary step of addressing economic and community developers, priority-setting, administrative and community and faith groups, schools, jurisdiction issues. For instance, school systems, child care centers, Medicaid programs are administered transportation authorities, businesses at a state level (accounting for nearly and other employers bring different $200 billion per year), while top expertise, perspectives and resources county expenses are often in justice toward advancing the health and and public safety (around $93 billion well-being of a community. Housing, per year) and health (community schools and universities, transportation, health, hospitals and public health at community and economic $83 billion per year).90, 91 development, employers (large and l ommunity Partners: It is essential C small), philanthropic and community to have members of the community organizations have an impact and as key members of any local place- can make significant contributions to based partnerships. These efforts improving health — and also collectively must effectively represent the interests benefit from the improved health of and needs of the community being the community they serve. In many served, including the lived experience cases, effective place-based partnerships of community members as well as could identify priorities and strategies cultural factors and considerations. — where improving health is one of a Partnerships should include community range of goals and outcomes, but may leaders as well as citizen participants. not be the lead or only priority issue. TFAH • healthyamericans.org 25 One important component of a In addition, ongoing funding and finan- partnership is to have a lead partner cial management is necessary to support — that is responsible for the ongoing health improvement initiatives. Either management of the efforts — which the lead partner — or the lead partner in can often be an already established collaboration with a financial manager — organization in the community. must prioritize how to ensure sufficient, continuing funding for the initiatives. STATE SUPPORT One Local Manager in each Health community manages Public Providers, Community, CENTER Health & Payer & community health efforts of a Hospitals Faith & Health mulƟ-sector collaboraƟve. Centers Philanthropic Groups PÊãÄ㮽 MĦ٠MĦ٠Rʽ O٦Įþã®ÊÄÝ • Convening and LOCAL • Integrator managing Social MANAGER Local • Community health community partners/ Services FOR EACH Businesses trust/fund • Community One State Support Center stakeholders COMMUNITY development provides support to all local • Strategic planning/goal financial insƟtuƟon managers within a state. seƫng (CDFI) • Managing and • Public health agency Sãã SçÖÖÊÙã CÄãÙ integraƟng funding, Community • Social service agency Rʽ programs and policies EducaƟon Housing & • Nonprofit/community • Conduct or coordinate Development TransportaƟon organizaƟon needs assessments • Analyzing outcomes and & Investors • Hospital or local • Collect/connects local shared impact (health health system data across sectors and economic) • Community health • Assists community to NECESSARY COMPONENTS WITHIN center • University define goals • Provide menu of EACH COMMUNITY • FoundaƟons evidence-based programs/policies to match needs and goals Understanding Understanding Community Exploring All Possible • Provide/coordinate Community Needs Assets and Resources Funding Streams technical assistance for implementaƟon of UƟlize Community Needs Leverage and analyze exisƟng resources in the Capitalize on all possible sources of programs/policies Assessments (CNAs) community, including: intervenƟon support and funding, for • Conduct evaluaƟon and conducted by various groups: • Underlying health system, including Public example: quality improvement for • Nonprofit (e.g., community Health Department (with foundaƟonal • Medicaid programs/policies centers, hospitals) services like epi lab surveillance) and Health • Inform advancing of • New Market Tax credits • Public Health Departments Care Systems (including hospitals, public naƟonal research efforts and private payers) • Community Development Funds/eg. • EducaƟon and Health (ESSA CDFIs requirement) • ExisƟng social service programs • Community benefit (nonprofit hospitals) PÊãÄ㮽 MÊ½Ý • Cross-sector strengths and connecƟons • EPISCenter • Community Services Block • Community Health Trust (CDFI for health) (housing, transportaƟon, educaƟon, etc.) • CommuniƟes that Care Grant • Philanthropic investments • Local insƟtuƟons and business/private • PROSPER • Child Welfare sector community • Reinvestment Grants • Government grants (across departments; • Build on Evidence Banks, e.g. • Community engagement Child Trends, NIH, CDC, etc across federal/state/local levels) 26 TFAH • healthyamericans.org The following section reviews some of the key roles and components of place-based, multisector local health improvement partnerships — and examples of existing efforts — including: 1. Lead Partner 5. nnovative Funding and Social I Investment Strategies 2. Financial Management 6. xamples of Organizations and E 3. overnment Leadership and Multi- G Efforts Advancing Place-Based Health Sector Collaboration Improvement Models 4. Health Sector Partners 1. Lead Partner A lead partner is responsible for have a strong vested interest in serving community.99, 100 They often have a lead the strategic management of the as a lead or major partner.95, 96, 97, 98 In partner or set of lead partners who help partnership and effort. It can addition, in some communities, there integrate and intermediate efforts. often be an already established may be models with multiple leads Regardless of the structure, a local community institution, health working together. health improvement partnership model organization, social service agency or In some cases, integrators may provide should be designed with flexibility philanthropy. Key functions include direct services — carrying out the to support different structures that the ability to bring partners together community-programs and efforts of match different community’s existing to develop, implement and invest the health initiative — and/or they organizations and resources. In some in strategic planning, goal setting may act as an intermediary, supporting communities, there may be a need to and needs assessments; oversee the a set of different organizations in create an organization that can fill the implementation of programs; manage the community to work together. lead partner function. and integrate funding from diverse Integrators and intermediaries can sources and programs; analyze shared Federal, state and local government play an important role in helping build impact; and ensure accountability and grants, philanthropic support, capacity and providing expert assistance continuous quality improvement. healthcare and hospital funds to other community organizations. (including community benefit A range of different models or A number of communities and programs) and other community entities can serve as a lead partner states are developing Accountable resources and assets are all sources to of local health improvement — or Communities for Health (ACH) — as help fund the management costs of broader focused wellness or vitality locally-driven models or mechanisms partnerships and for broader funding — partnerships. Some models for that bring together key partners and of the health improvement initiatives. the lead role include serving as an stakeholders around the common Reviews of a range of local health “integrator” (hands-on manager) or goal of improving health. They initiatives have found the cost of the an “intermediary” (coordinator, often typically address improving healthcare; integrator/intermediary management grant-maker to other groups).92, 93, 94 In coordination of health and social function ranges from $250,000 to some areas, major anchor institutions services; and facilitate policy changes $500,000 annually. In some cases, the — as recognized leaders, employers and and address environmental factors that administrative or operating funds from economic drivers in a community, such can help improve health in the broader broader grants can support the effort. as hospitals and universities — should TFAH • healthyamericans.org 27 l Integrators FOR EXAMPLE: Integrator examples can include public The Common Table Health Alliance, a (NHP)—an initiative aimed at addressing health departments; hospitals; community non-profit regional health improvement the social determinants of health and health centers; healthcare providers (such collaborative, serves as the integrator boosting economic security in the as an Accountable Care Organization for a Healthy Shelby initiative.101, 102, 103 Northeast Hartford community. NHP (ACO), Managed Care Organizations Healthy Shelby is part of Memphis Fast serves as backbone organization and (MCOs), integrated health systems or Forward, a collective impact strategy convenes community leaders to develop health insurance companies); local focused on economic prosperity and innovative ways to coordinate, integrate non-profits (such as YMCAs or United quality of life in the greater Memphis, and align healthcare and social services. Ways); community foundations; social Tennessee region.104 The 35-member Key partnerships with local and state service agencies; universities; community coalition brings together public health, government, hospitals, universities and development corporations or Community hospitals, healthcare providers, social community non-profits are essential to Development Financial Institutions. service providers, academic institutions, NHP’s success. To foster collaborative the faith community, local government, efforts, NHP is transforming the once businesses, the Chamber of Commerce abandoned gold-leafing factory into a and funders to address infant mortality, community hub that can centrally house chronic disease and end-of-life care. The cross-sector partners and facilitate Common Table Health Alliance serves innovative collaborations. Initial results as a backbone to identify shared goals, are promising. In a pilot intervention, collects data from across stakeholders, Community Solutions observed a 57 carries out public education campaigns percent drop in the emergency room and supports the adoption of innovative use among the high utilizers.107 Moving care methods. 105 Core funding for forward, the Cigna Foundation plans to the effort has been $300,000 from use its experience in tool development the health systems, city and county to co-develop a neighborhood health risk government. There were also additional assessment with Community Solutions grant funds won from United Way and in order to analyze the underlying Medtronic. Healthy Shelby tracks infant social, economic, and environmental mortality rates, the percent of patients determinants of health in Northeast with controlled blood pressure, heart Hartford. In 2015, NHP received a attacks or strokes and Medicare costs in $125,000 World of Difference grant a person’s last six months of life.106 from the Cigna Foundation to continue their work. NHP also receives funding To address the increasing rates of from Fidelity Charitable, Rx Foundation, mental illness, substance abuse, and The Kresge Foundation, Newman’s Own poor chronic care management in the Foundation, Boehringer Ingelheim, and Northeast Hartford community, the Cigna the John H. & Ethel G. Noble Charitable Foundation partnered with the non- Trust to support the initiative, which had profit, Community Solutions, to support a budget of $760,000 in 2015. the Northeast Hartford Partnership 28 TFAH • healthyamericans.org l Intermediaries Intermediaries help connect organizations providers.109 Intermediaries can serve that share common interests and goals as a trusted organization that provides — and help support the management of key management and fundraising skills these organizations, including fundraising, and capabilities to help support a range grant and financial management support; of other local organizations and help to enhance larger service networks; promote coordinate goals and activities across quality standards; implement evidence- these organizations. They can also serve based strategies; and monitor programs a key role in cross-agency and cross-sector on behalf of funders.108 They often data collecting and sharing — which is serve as a role between funders — such important for measuring evaluation and as government agencies, foundations outcomes of efforts and support capacity and businesses — and direct service building of local non-profits.110 FOR EXAMPLE: The Family League of Baltimore is non- private grants; and $500,000 in federal governmental local management board, grants. Around 93 percent of funds are established in 1991 by the Maryland from government grants. Eighty percent General Assembly, to target government is distributed to local organizations, 10 resources to local organizations and percent supports technical assistance coordinate services for child and family and 10 percent supports management services.111 Family League partners and administration. As one example with a variety of organizations, including effort, through B’more for Healthy Babies, My Brother’s Keeper Baltimore and the the Family League of Baltimore is working Family Literacy Coalition, to fund and with the Baltimore Health Department to support capacity building; collaboration; reduce infant mortality and improve the the reduction of duplicate services health of mothers and babies through among public and private stakeholders; fitness and nutrition for postpartum wider implementation of evidence-based women, hosting breastfeeding support programs; and the promotion of policy groups and conducting intensive and practice system changes. The community outreach to connect women program receives support from around with services. Infant mortality has been 40 different funders to support a total reduced by 28 percent since the start of budget of $29.6 million (in 2016), the initiative and is at the lowest point including around $13 million from in history.112 And the disparity between state grants; $13 million from local White and Black infant deaths has been government grants; $1.5 million in reduced by nearly 40 percent. TFAH • healthyamericans.org 29 l Accountable Communities for Health FOR EXAMPLE: The ACH model helps galvanize partners A number of states — such as considered as a key driver of change, fo- from across sectors — including health orga- California, Minnesota, Oregon, Rhode cusing on 1) health, wellness, equity, and nizations and agencies and broader sectors Island, Vermont and Washington — are prevention — not just care; and 2) on an — and aligns roles and responsibilities to developing ACH efforts. entire community, as opposed to just an achieve better impact and long-term systems organization’s enrollees or panel.119, 120 The three-year California Accountable change to support better health. 113, 114, 115 A Communities for Health Initiative (CACHI), California ACH Five Key Domains review by the National Academy for State supported by The California Endowment, Clinical Services — Services delivered Health Policies identified some key compo- Blue Shield Foundation of California and by the healthcare system, which includes nents of an ACH including:116 Kaiser Permanente, will fund six ACHs in primary and secondary prevention, disease l Shared vision and goals among partners; the state to focus on addressing a broad management programs, and coordinated l Multi-sector partnerships; span of healthcare, unmet social services care that is provided by a physician, health l Established governance or leadership; and broader factors that impact health. team, or other health practitioner associ- The goals of the effort include to 1) im- ated with a clinical setting. l Population-based prevention activities; prove personal and community-wide health l Backbone or integrator organization; outcomes and reduce disparities with Community and Social Services Programs l Community engagement activities/ regard to particular chronic diseases or — Programs that provide support to pa- interventions; health needs; 2) control costs associated tients and community members are deliv- with ill health; and, 3) through a self-sus- ered by governmental agencies, schools, l Ability to perform basic financial and taining Wellness Fund, develop financing worksites, or community-based organiza- administrative functions; and mechanisms to sustain the ACH and tions and frequently target lifestyle and l Sustainability planning. behavioral factors, such as exercise and provide ongoing investments in prevention A report by JSI Research & Training Institute and other system-wide efforts to improve nutrition habits; also include peer support identified key principles of an ACH as: 117 population health. 118 Accountability is also groups and social networks. l Leadership — Create a Center of Gravity; l Collaboration — Trust Built on Transparency; Clinical Services • Services delivered by the healthcare system l Measures — What Gets Counted Gets • Includes primary and secondary prevention, disease management programs, and coordinated care that is provided by a physician, health team, or other health practitioner associated with Measured; and a clinical setting l Investment — “All in” for Mutual Benefit. Community and Social Services Programs • Programs that provide support to patients and community members • Delivered by governmental agencies, schools, worksites, or community-based organizations • Frequently target lifestyle and behavioral factors, such as exercise and nutrition habits; also include peer support groups and social networks Clinical -Community Linkages • Mechanisms to connect community and social services and programs with the clinical care setting to better facilitate access to and coordination between healthcare, preventive, and supportive services • Can help form strong bonds between community and healthcare practitioners and, ideally, involves bi-directional feedback systems between the two Environment • Social and physical environments that facilitate people being able to make healthy choices • May include community improvements such as building parks or bike lanes, making farmers markets more available, or transforming corner stores to carry more fruits and vegetables Public Policy and Systems Change • Policy, regulatory, and systems changes that affect how the healthcare and other systems operate and influence the overall ability of people to be healthy • Address environmental issues, school policies, health and social systems coordination, and financing to support prevention-related activities 30 TFAH • healthyamericans.org Clinical-Community Linkages — Mecha- and multi-sector partnerships to focus on clinical preventions (focused on individual nisms to connect community and social common goals and strategies — and to health improvement); innovative clinical services and programs with the clinical shift for paying for value instead of volume prevention (linking individuals to com- care setting to better facilitate access in healthcare delivery.121, 122 There are nine munity services); and total population or to and coordination between healthcare, ACHs in the state, which are locally driven community-wide prevention (focused on im- preventive, and supportive services; and and are responsible for establishing their proving the health of populations).126 They can help form strong bonds between com- own governance structure and priorities from have structured Unified Community Col- munity and healthcare practitioners and, within broad state guidelines. For instance, a laboratives to align with 14 health service ideally, involves bi-directional feedback Cascade Pacific Action Alliance with partners areas and have required them to use a systems between the two from seven counties in the central Western shared governance structure that includes area of the state are focusing on a Youth Be- leaders from ACOs, medical homes and a Environment — Social and physical en- havior Health Coordination Project via health- range of community organizations. vironments that facilitate people being care, school and community efforts. 123 able to make healthy choices, may include Rhode Island has created a Health Equity community improvements such as building In Minnesota, Accountable Communities Zones initiative, as a different model, fo- parks or bike lanes, making farmers mar- for Health are focusing on meeting their cusing on creating community capacity and kets more available, or transforming corner communities’ clinical and social needs engagement, and targets resources to sup- stores to carry more fruits and vegetables via person-centered, coordinated care port efforts in communities that experience across a range of clinical and community economic disadvantage and poor health Public Policy and Systems Change — providers. Each of Minnesota’s 15 ACH outcomes.127 For instance, the Newport Policy, regulatory, and systems changes that partners with an Accountable Care Orga- Health Equity Zone’s backbone agency is the affect how the healthcare and other systems nization integrates clinical and community Women’s Resource Center and is focused operate and influence the overall ability of services through enhanced referrals, on mobilizing residents and resources of people to be healthy can address environ- transitions management and implemen- the Broadway and North End neighbor- mental issues, school policies, health and tation of new practice guidelines.124 For hoods; improving transportation; increasing social systems coordination, and financing instance, the Southern Prairie Community healthy food access; creating economic to support prevention-related activities Care ACH is focusing on delaying and pre- opportunity; securing open space, parks In Washington State, a Healthier Washing- venting type 2 diabetes for at-risk individu- and trails; embracing arts and culture; and ton initiative is establishing multiple Account- als in 12 counties through a combination developing physical and emotional health able Communities of Health across the state of clinical and community approaches. 125 through two way Wellness Hubs that house aligned with regional Medicaid purchasing. evidence-based, lifestyle change diabetes Vermont is focusing on up to 14 ACHs These ACH’s are working to leverage diverse prevention and self-management programs. to address a combination of traditional Example measures with diabetes as focal condition ACH: Example of Measure with Categories Example Measures Diabetes as a Focal Point128 » Emergency department and hospitalization rates Clinical » Diabetes and pre-diabetes prevalence rates » Percent of pre-diabetics and diabetics who have regular contact with a care coordinator Linkage » Number of community health workers employed in community Social Services » Percent of pre-diabetic population referred to and participating in Diabetes Prevention and Community Program Resources » Number of community members receiving food assistance Policy, Systems, » Retail Food Environment Index score and Environment » Local policies or organizational practices changed due to collective advocacy » Number of partnership agreements established Process/Capacity » Source: JSI Research & Training Institute, Inc. TFAH • healthyamericans.org 31 Needs Assessments and Measuring Success Local health improvement partnerships improved integration and collective learning. seeking formal voluntary accreditation should be based on shared goals and must conduct a needs assessment.130 A strong analysis of the needs and risks of definitions of success — and have the community health centers, some state a local area is important for identifying the ability to measure performance to see if and local child welfare agencies, some most effective strategies that match the goals are being met. affordable housing block grantees, issues and existing structures within a com- fair housing assessments, Head Start Needs assessments are one important munity. For instance, this type of collabora- grantees, Title 1 schoolwide programs, step in the process of identifying issues tion could help show the overlapping needs some school districts receiving Safe of concern, risk factors and assets within of health and unstable housing in segments and Healthy Student funds and some a community. of a community, or help to better identify EPA programs are required to conduct and target risk factors that can contribute to There are a number of existing needs as- assessments, and some local private substance misuse, depression or violence. sessment efforts than can be tapped into, or philanthropic organizations, such as but there is also an important opportunity l A ll 2,900 non-profit hospitals are re- many United Way affiliates and commu- to better align and integrate the process quired by the IRS to conduct regular nity foundations conduct voluntary as- and findings of different community needs Community Health Needs Assess- sessments.131, 132, 133, 134, 135, 136, 137, 138 assessments — to help reduce duplication ments — along with action plans for There is also a need to improve data of efforts and to expand and share learning addressing concerns.129 In addition, in collection and integration — to help mea- and coordinate programs and goals. Cur- some communities, a range of public sure the impact of efforts, track changing rently, there is no mechanism or incentive to health agencies and other community needs and assets in communities and to coordinate these efforts. Local health im- groups conduct other forms of needs ensure accountability and adjust for con- provement partnerships, integrators and ex- assessments. For instance, local tinued quality improvement of efforts. pert academic institutes could help facilitate and state public health departments FOR EXAMPLE: The North Carolina Community Health representatives of more than 100 a life cycle framework that incorporates Improvement Collaborative (NC-CHIC) community organizations together to research of effective community-wide has focused on developing a model for conduct a collaborative community programs to help improve children’s conducting collaborative community health needs assessment.140 upward mobility with measurement tools health needs assessments among that can help predict the potential impact Colorado and other communities are using local public health agencies, hospitals of adopting different programs on the the Social Genome Model — a partnership and other partners. For instance, in future outcomes of children, including cost- of The Brookings Institution, the Urban Wake County, Wake County Human benefit analyses.141, 142,143 Institute and Children Trends — which is Services, WakeMed Health and Hospitals, Duke Raleigh Hospital, Rex Healthcare, Wake Health Services, The Social Genome Model United Way of the Greater Triangle and the North Carolina Institute for Public Health partnered to conduct a joint assessment for Wake County.139 The Health Impact Collaborative of Cook County, Illinois brought 26 non-profit organizations and public hospitals, Source: Brookings Institution seven local health departments and 32 TFAH • healthyamericans.org 2. Financial Management Financial management is another key potential funders have a range component of the success of a local of accounting and accountability health partnership. If there is no requirements. A financial manager has to existing mechanism for raising and have the skills and credibility to engender managing the money to support local trust across a range of public and private health initiatives on an ongoing basis, sector funders and be able to meet their structures must be developed that have application and reporting requirements. the ability to raise and manage money For instance: from a range of different funders to responsibly manage the funds and to l M ost federal, state and local grants provide accountability and oversight for have distinct application and reporting the proper use of funds. requirements — tapping into healthcare funding may require billing This includes developing strategies for and reimbursement procedures; bringing existing community assets together from a range of potential l D eveloping mechanisms for “billing” funding streams, such as: or receiving funds from healthcare payment systems and evaluation l F ederal, state and local governments, metrics to show value for Medicaid including grant programs; and private managed care providers; l T he healthcare system, including public l M any community benefit programs, and private providers and insurers, economic development funds and hospitals and community benefit funds; philanthropies have unique accounting l S ocial service, housing, agriculture, and measurement structures; transportation and/or environmental l P rivate sector contributors may want agencies via cross-sector opportunities; access to shared savings and returns l Businesses; or measurement of the impact of funds used; l C ommunity and philanthropic organizations; and l S ocial investment instruments, such as Community Development Financial l S ocial impact financing mechanisms, Institutions (CDFIs) and New Market such as Community Development Tax Credits, have different funding Investment Funds, tax credits, requirements and often require revolving loan funds, program-related repayment or demonstration of return investment grants, social impact bonds on their investment — financially and/or and pay-for-performance initiatives. through “pay-for-success” outcomes; and Another potential funding model or resource is a Wellness Trust or l C reating mechanisms for demonstrating other formal structure where there is returns and value across sectors and direct community investment, from partners — including for dealing with government support, tax revenue or the “wrong pocket” issue — where another ongoing source. (See page funds may come from one funder but 50: Innovative and Social Impact the results may most directly benefit Funding Strategies for more on these another. For instance, if funding for different investing mechanisms). a housing initiative, supported by government housing agencies, yields This can be complex, since different TFAH • healthyamericans.org 33 savings for a health system and lowered In other cases, it may be helpful to develop costs of other social services without a additional supporting mechanisms that mechanism to evaluate or reinvest the can be scaled up for use across different savings accrued by the health system or communities, while being flexible social service agencies from them to the enough to support the specific needs and housing initiative. combined resources of that community. The financial manager can also help For instance, creating a version of collect the data needed to analyze the a “CDFI for Health” could establish costs and potential shared savings or a mechanism to help set baseline returns that health — or broader well- standards and credential local entities being — improvement initiatives achieve. that are qualified to take on this This is important for evaluating the financial management role. impact and benefit of the initiative — and Just as CDFIs provide a recognizable, understanding the value of the investment reliable system for groups like non- or contribution from the different funders. profit banks to use to help manage Overall, the need is to provide stable, their Community Reinvestment Act ongoing, responsible structures for (CRA) obligations, local or regional financial management needs in some CDFIs for Health could help play that communities that can be served role for non-profit hospitals — as a through existing entities. scalable, reliable resource for advising the strategic use of community The financial management role can be benefit programs to support upstream taken on by the lead partner — or by a community-based programs — and separate financial manager or trust, or providing the service of reliable other existing organizations like local financial management and fiduciary community foundations, United Ways, responsibility for the use of funds. It other established intermediary non- could also help leverage resources profits, hospitals, community health from other funders for stronger centers or health systems, or community collective impact. development corporations. Sources of Funding for Local Health Improvement Partnerships Level 1: Traditional Grants Increasing Flexibility and Scalability Increasing Need for Coordination • Government Dedicated Revenue Streams • Philanthropic Level 2: Non-Traditional Funding • Community Hospital Benefits • Medicaid and Commericial Health Insurance Reimbursement Level 3: Innovative Financing Mechanisms • CDFI Community Development • Pay for Success 34 TFAH • healthyamericans.org In the summer of 2016, TFAH and l M eet fiscal accountability standards, Monitor Deloitte conducted a series of including the ability to manage funds interviews and workshops with experts from multiple funders, monitor and to examine the potential for developing track funds and have audit and certification for financial management of evaluation capabilities; local health improvement partnerships. l H ave a defined mission, or partner For instance, building a model for certi- with an organization with a defined fication — such as the role certification mission, of advancing community plays for CDFIs — supports baseline health and wellness that aligns with criteria for operation standards, sup- identified community priorities; porting integrity and accountability — including ensuring funds are used for l D emonstrates support from designated purposes. This gives the community stakeholders, such as local communities the ability to focus on funders, community organizations and performance and delivering outcomes. political leaders; and Some benefits of a certification process l H ave mechanisms for ensuring include: generating credibility and trans- transparency to the community it parency; establishing accountability; serves and funders. creating standardized criteria and a uni- There could be increased benefits for form level of rigor; reassuring funders more advanced criteria — such as about the integrity of coordinated funds; designations or “badges” for strong providing a gateway to flexibility in ex- data capabilities and legal safeguards change for demonstrated results; and and use of evidence-based practices. facilitating a shift from reporting on Over time, financial managers with a compliance to reporting on outcomes. proven track record for management The certification process could also en- and improved outcomes could have tail benefits for financial managers. For other benefits, such as the eligibility instance, there could be mechanisms for for simplified funding — such as streamlined or coordinated processes for coordinated or combined grants — from certified integrators and intermediaries government, philanthropic and private applying and reporting on related federal, funders. state or local grants — demonstrating The certifying body could be via the outcomes for defined shared goals across federal or state governments or a programs in exchange for increased flexi- consortium of experts and affiliated bility and reduced bureaucracy. entities that help provide similar local Some potential criteria identified for certifications for other sectors, such local health improvement financial insti- as the Association of Government tutions include that they should: Accountants. There would also need to be designated funding — through l B e a legal entity, allowing them to the government and/or a set of enter into agreements and contracts, engaged stakeholders — to support the incur and pay debts and be responsi- certification process. ble for actions; TFAH • healthyamericans.org 35 3. Government Leadership and Multi-Sector Collaboration Federal, state and local governments helping to improve health, reduce rates should make supporting local health of disease and lower healthcare costs. improvement partnerships a priority The National Prevention Strategy began nationally and locally. to identify programs across federal The approach would help more departments and agencies that impact efficiently and effectively leverage health. There is an opportunity to existing resources to improve health, build on that work — and to expand expedite the implementation of consideration of how a broader set of evidence-based practices around the federal programs can be better leveraged country and help improve outcomes to improve health while achieving other across agencies and programs. goals. For instance, income, education, housing and food assistance can have a Initial steps to move from the current major impact on improving health and structure toward supporting local health health outcomes. Unmet social needs, improvement partnerships include associated with higher health spending providing seed funding for lead partner — including emergency room use and organizations and state expert institutes hospital admissions and readmissions — to launch pilot programs — potentially can be reduced by connecting patients to via prevention and community health the services they need.145, 146 funds from CDC and SAMHSA. Many government programs, however, In addition, there should be a concerted are silo-ed, that is, not connected, and effort to think about how to efficiently there are few ongoing interagency and effectively support local health efforts that have aligned performance improvement and well-being efforts objectives and strategies for how across government programs and grants. funding streams or work streams can Health is impacted by a wide range of work together for better collective factors. Where people live, learn, work impact. There are a wide range of and play can have a bigger impact on place-based grants, going to states and health than genetics or medical care.144 localities across the government, but And, policies and programs across the they are typically managed, awarded and government can have a major impact on reported separately and disjointedly. WHAT DETERMINES HEALTH? (ADAPTED FROM MCGINNIS ET AL., 2002 ) GE NE T ICS HEALTH CARE SOCIAL, ENVIRONMENTAL, BEHAVIORAL FACTORS 20% 20% 60% Source: Blue Cross Blue Shield of Massachusetts Foundation 36 TFAH • healthyamericans.org More coordinated outcome-focused and At the federal level, HHS and OMB place-based approaches are needed to should work in collaboration with other better address key health problems in federal agencies to encourage and coordination with their root causes, often incentivize the development of policies the same root causes that impact other and grants that provide communities social problems. Significant efficiencies with the ability to better address their might be gained through such alignment. health and related well-being priorities. MULTISECTOR PROGRAMS AND GRANTS National Housing Trust Fund Community Development Block Grant HOME Investment Partnerships Program Community Services Block Grant (CSBG) Emergency Solutions Grants Child Care and Development Block Grant Continuum of Care Program Social Services Block Grant Low Income Home Energy Assistance Program (LIHEAP) Block Grant Temporary Assistance for Needy Families (TANF) Block Grant Low Income Housing Tax Credit Supplemental Nutrition Assistance Program (SNAP) Mortgage Revenue Bonds Special Supplemental Nutrition Program for Women, Infants, and Children Medicaid Child and Adult Care Food Program Title V Maternal and Child Health Services Block Grant Surface Transportation Program Community Mental Health Services Block Grant Federal Reserve Banks Substance Abuse Prevention and Treatment Block Grant Hospital Community Benefit Requirements Preventive Health and Health Services Block Grant Community Development Financial Institutions (CDFIs) State and Local Public Health Actions to Prevent Obesity, Diabetes, Community Development Financial Institutions Fund (Treasury) Heart Disease, and Stroke Ryan White HIV/AIDS Program New Markets Tax Credit Programs The government should assess ways decision-making on grant awards; to create increased flexibility and streamlined grant requirements, timing incentives — and remove regulatory and performance metrics; technical and reporting barriers — for grant assistance aligned across programs; programs across different programs and allowing the use of existing or shared agencies, in exchange for demonstrated community needs assessments; results and performance. There should and sharing best practices to build be transparency and accountability capacity among grantees. The federal measures included in these joint efforts government should also support the to ensure the programs focus on and ability and/or administrative costs achieve the intended outcomes. of grantees/awardees in localities around the country (such as place- For instance, some strategies that based partnerships) to manage funding can be used include interagency from multiple sources or agencies, teams; solicitation of proposals from including assessing and developing local communities; issuing common more mechanisms that can leverage funding opportunity announcements efforts and programs across agencies. (FOAs); competitive grant preferences; This should include being able to conducting joint peer review and TFAH • healthyamericans.org 37 evaluate and account for the impact l T he Center for Health Care Strategies, l I ncentives, including financial and that funding by one agency or program Inc.’s State Payment and Financing political incentives, to improve can have on the goals of another Models to Promote Health and Social health are misaligned. For instance, — focusing on overall outcomes Service Integration looks at a continuum is the agency that is investing seeing rather than bureaucratic goals and of financing options and payment returns or is there a “wrong pocket” jurisdictions. mechanisms — such as leveraging problem where the outcomes would federal grants, healthcare payments benefit a different agency or sector; For instance, the OMB issued a Uniform and value-based care incentives and use state Medicaid systems are often Administrative Requirements, Cost of global “community health” budgets most strongly motivated by Federal Principles and Audit Requirements in — and how to phase-in integration Medical Assistance Percentages Federal Awards (Uniform Guidance) over time.153 Their findings include: (FMAP) policies; is there leadership in 2013 that permits waivers in grants flexibility is an asset; managed care that can build support across agencies to provide more flexibility in exchange organizations and accountable care with different cultures, goals and for demonstrated outcomes and cost- organizations can be effective partners; motivations; and Medicaid policies are effective approaches.147 reinvestment can help sustain a program; often state-driven while many services A range of efforts have identified and geographic- or population-based are locally-driven or delivered; and strategies for better coordinating models may have a bigger impact. l T here is a lack of consensus regarding and leveraging the use of health and l T he Milbank Memorial Fund’s who is responsible for health. social service funds to have a more Investing in Social Services for States’ collective, results-oriented impact at The report identifies some key strategies Health: Identifying and Overcoming the state level.148, 149, 150, 151 for moving forward, including: cultivating Barriers report identifies some key legitimate public-sector leadership; For instance: barriers to integration, including:154 navigating the political environment; l T he Commonwealth Fund’s State l T he health of the state’s population using evidence to support decision Policy Framework for Integrating Health is not always prioritized relative to making; and targeting populations with and Social Services identified three key other societal goals in the states; high medical and social needs. components for an integrated system:152 l A coordinating mechanism responsible Policy Principles for Improving the Health of Populations in the States for managing collaboration across services, such as an integrator; l Q uality measurement and data- sharing tools to track outcomes and exchange information; and Policy l P ayment and financing methods that Principles support and reward effective service integration. State Strategies They also identified an implementation planning framework consisting of: establishing goals; identifying gaps and Problem opportunities; prioritizing opportunities for integration; and establishing an implementation roadmap. Root Causes Source: Milbank Memorial Fund 38 TFAH • healthyamericans.org States with increased spending on a 10-year period had better health social services (including education, outcomes, including obesity, asthma, income support, transportation, mentally unhealthy days, days of activity environmental programs, housing and limitations, postneonatal mortality and public safety) and public health in lung cancer mortality.155 This held even comparison to spending on healthcare when accounting for sociodemographic, services (Medicare and Medicaid) for economic and political differences. State Social-to-Health Spending Ratio and Selected Health Outcomes, by Quintile (2009) a) Percent of adult population that is obese b) Percent of adults who reported 14 or more days in the last 30 days as mentally unhealthy days c) Lung cancer mortality rate per 100,000 d) Social-to-health spending ratio population Legend (a,b,c): dark gray indicates highest quintile (i.e., poorest health outcomes) and white indicates lowest quintile (i.e., best health outcomes). Legend (d): dark gray indicates lowest social-to-health spending ratio; white indicates highest social-to-health ratio. Source: Milbank Memorial Fund TFAH • healthyamericans.org 39 Federal safety net spending (non-Medicaid) by program area Total = $403 billion (FFY 2016) Community development, social services 14.9 Social services 3.5 Community development Public health, block grants 15.3 Public health, block grants Training and employment, unemployment 9.7 UI 32 Training and employment Program Area SSI income support 55 SSI EITC/ child 85 care tax Family/children assistance 18 Other family/child support credits 17 TANF Housing and energy 3 Energy Assistance 44.4 Housing Assistance 7 Other nutriƟon Food and nutriƟon 22 Child nutriƟon 76 SNAP 0 10 20 30 40 50 60 70 80 90 Source: Federal Budget156 Billions of dollars Medicare as a Share of the Federal Budget, 2014 Defense 17% Social Security 24% Nondefense Discretionary 17% Medicare1 14% Other2 13% Net Medicaid Interest 9% 7% Total Federal Outlays 2014 – $3.5 Trillion Net Federal Medicare Outlays – $505 Billion NOTE: All amounts are for federal fiscal year 2014. 1Consists of Medicare spending minus income from premiums and other offsetting receipts. 2Includes spending on other mandatory outlays minus income from other offsetting receipts. SOURCE: Congressional Budget Office, Updated Budget Predictions: 2015 to 2025 (March 2015) Source: Kaiser Family Foundation 40 TFAH • healthyamericans.org FOR EXAMPLE: The Sustainable Communities support the needs of at-risk youth and Initiative is a partnership across the families. At-risk youth are referred U.S. Department of Housing and Urban through a range of individuals or Development, U.S. Department of organizations or schools — and assigned Transportation and the Environmental to a local assessment and planning Protection Agency — where grantees team who develop an individualized plan. can receive waivers for multiple A case manager helps the youth navigate grant requirements in return for and receive available services — ranging demonstrating achievement of from education, healthcare, housing, outcome goals. 157 transportation and food assistance. Through improved coordination of Performance Partnership Pilots for services and funding streams, case Disconnected Youth (P3) allows managers have the flexibility to focus states and communities to enter into on tailoring services to the youth’s Performance Partnership agreements needs and avoiding unnecessary across the Department of Education, bureaucracy.159 Department of Labor, Department of Health and Human Services, the The U.S. Interagency Council on Corporation for National Community Homelessness brings together 19 Service and the Institute of Museum federal agencies — along with state and and Library Services to bring resources local governments, advocates, service and support together — waiving many providers and people experiencing individual program and grant reporting homelessness — to coordinate the requirements — in exchange for federal response to homelessness achieving and demonstrating improved and achieve the goals of the federal outcomes in programs serving strategic plan to prevent and end disconnected youth (low-income homelessness.160 14- to-24-year-olds who are homeless, The Federal Council on Prescription in foster care or the juvenile justice Drug Abuse — convened by the White system, unemployed or not in school House, Office of National Drug Control or college).158 Policy and comprised of federal agencies At the state level, Virginia’s Children’s — oversees and coordinates implemen- Services Act is a case management tation of a national Prescription Drug model that brings funding streams Abuse Prevention Plan and engages pri- together across state agencies and vate sector actors as necessary to meet allocates these funds to localities to the plan’s goals.161 TFAH • healthyamericans.org 41 4. ealth Partners: Public Health Agencies, Providers, Insurers, Hospitals and Community Health Centers H Health organizations are essential Recently, providers and insurers improvement (such as smoke-free partners in place-based health and have been increasingly incentivized air laws); leveraging and expanding well-being collaboratives — bringing to support better health for their healthcare reimbursement policies their mission, leadership, expertise “patient pools” and reduce costs to promote effective approaches to and resources to advance health as part of value-based care models. support prevention and other factors improvement goals they share with the By joining with wider community that impact health; expanding the broader community. partnerships, different components use of non-profit hospital community of the healthcare system have the benefit programs to support upstream Traditionally, population-based and ability to better maximize and leverage prevention and leveraging community public health efforts have operated their investments and to tap into the health needs assessments and action without much integration with expertise and resources that other plans to focus and galvanize community healthcare providers and insurers. The partners bring — and share in the action; and utilizing the experience individualized treatment and fee-for- returns of the collective impact. and expertise that community health service focus and market structure of centers have in serving high-need local the healthcare system has disincentivized Some key partnership strategies community members, often including investing in or developing strategies that include: serving as the lead and/ providing connections or coordination focus on wellness beyond the doctor’s or a major partner in population with other social services beyond office and ways to help people be health improvement projects; healthcare. healthier within their daily lives. implementing community-wide health l Public Health: Chief Health Strategists Public health departments serve as understanding and evaluating the impact experts are identifying ways to leverage the Chief Health Strategists in their that other programs and policies can requirements from the Every Student communities. While they often do not have have on health. Experts can advise and Succeeds Act of 2016 to work in concert sufficient resources to support broad health assess leading strategies and approaches to improve education, health and overall and well-being improvement initiatives on for addressing different health concerns, well-being of students. In addition, CDC their own, they are central to local health particularly in the context of the resources and SAMHSA prevention programs can improvement partnerships — tracking and needs of a particular community. also be one source of “seed” funding to health trends and problems in communities; support piloting local health improvement At a federal level, the community health identifying emerging programs; providing partnerships, as well as state-based and prevention divisions at CDC and information about the most effective, academic expert institutes. SAMHSA are a strong resource to help evidence-based community-wide strategies; support local communities as they At the state and local level, public health coordinating with national resources, develop partnerships by ensuring they officials and agencies bring expertise research and experts; and evaluating the are based on proven models and have and resources — with a priority focus on success of programs and ways to adapt access to evidence-based strategies, promoting better health and preventing them for continuous quality improvement. policies and programs. For instance, diseases and other health problems — to Public health professionals can provide a through Health Impact Assessments place-based initiatives. “health improvement lens” to problems — (HIA), public health and education 42 TFAH • healthyamericans.org FOR EXAMPLE: Seattle and King County’s public health department created the Live Well San Diego is a regional partnership, adopted by Steps to Healthy King County (Steps KC) initiative that brought the San Diego County Board of Supervisors and led by the together more than 75 community organizations and agencies to Department of Health and Human Services, around a vision focus on reducing the impact of chronic disease in the community of a “region that is Building Better Health, Living Safely — by preventing and controlling asthma, diabetes, obesity and and Thriving.165 Nearly 200 recognized partners — from other chronic diseases — and to reduce health inequities due county government to businesses to schools to community to chronic disease. Steps KC achieved a 9.5 percent reduction organizations — are working together to promote policies in childhood asthma hospitalizations (compared with only a 2.1 and programs focused on a set of areas of influence (health, percent reduction in the rest of King County) between 2003 and knowledge, standard of living, community and social factors) 2008; improvements were also seen in other youth nutrition indi- and indicators from cross-cutting key areas (life expectancy, cators, such as eating more produce; and other goals were also quality of life, education, unemployment rate, income, security, met, including implementing a comprehensive physical education physical environment, built environment, vulnerable populations curriculum and improving accesses to healthier, competitive food and community involvement). Some efforts have included: and snacks sold in school, including in vending machines. 162 workplace wellness initiatives, farm-to-cafeteria and safe routes to school programs, neighborhood watch programs, Get Healthy Philly is an initiative of the Philadelphia Department improving community parks and recreation facilities and of Public Health established in 2010 with CDC funding that brings extending smoke-free air protections. together government agencies, community-based organizations, academia and the private sectors, including representation from government, transportation, education, business, and health insur- ers to make healthy choices easier — and has contributed to a 6.5 percent decline in childhood obesity, an 18 percent decline in 1 VISION adult smoking, and a 30 percent decline in youth smoking through of a city-wide policy and systems changes, including:163, 164 region that is l S etting nutrition standards for over 22 million meals and Building Living snacks served through local government programs; Better Health Safely Thriving l S upporting over 900 corner stores and other food retailers to STRATEGIC offer, promote, and sell healthier foods, including a particular pro- 4 APPROACHES gram to reduce the sodium used at Chinese take-out restaurants; Pursuing Improving Building a Supporting Better Service Positive Policy & the l I ncentivizing use of federal SNAP benefits at farmers’ mar- Delivery System Choices Environmental Changes Culture Within kets through coupons for low-income families that offer more value for purchase of fresh fruits and vegetables; l R ewriting the city’s zoning code and comprehensive plan to pro- 5 AREAS OF INFLUENCE mote better health; l I mplementing a smoke-free policy for the nation’s 4th largest HEALTH KNOWLEDGE STANDARD OF LIVING COMMUNITY SOCIAL public housing authority; l E stablishing a $2 per pack tax on cigarettes; and TOP 10 LIVE WELL SAN DIEGO INDICATORS Security Vulnerable Life Unemployment I ntegrating tobacco dependence treatment and smoke-free Expectancy Physical Populations l Education Rate Environment Quality of Life Income Community policies into the city’s behavioral health system. Built Environment Involvement that measure the impact of collective actions by partners and the County to achieve The city government is working with other related efforts, the vision of a region that is Building Better Health, Living Safely and Thriving. including the State Innovation Model grant, Promise Neighbor- Source: Live Well San Diego hood, Choice Neighborhood, and metropolitan planning and transportation initiatives. TFAH • healthyamericans.org 43 l Healthcare Providers and Insurers Value-based healthcare models are provid- l E nhanced reimbursement or care pantry food assistance programs — provid- ing incentives — and penalties — based coordination payment structures, such as ing “food pantry” prescriptions for healthy, on the health status of a system’s pa- Patient-Centered Medical Homes (PCMHs) affordable meals to people with diabetes. tients. As risk-bearing entities, healthcare and Chronic Health Homes, provide extra A review by Northeastern University’s insurers, and increasingly, healthcare funding to improve coordination of care Institute on Urban Health Research providers, have strong incentives — and and social services and investment in and Practice of the Population Health could face potential penalties — based prevention, focusing on improving the well- Investments by Health Plans and Large on the status of their health systems’ pa- being of the patient, which can help reduce Provider Organizations — Exploring the tients. The federal government is moving healthcare utilization and costs; and Business Case concluded that:169 rapidly toward value-based care, with a l P enalties for readmissions are motivating goal of tying 90 percent of Medicare pay- l B usiness interests shape the magnitude, hospitals to address the factors that can ments to value by 2018. 166 scope and duration of population health help reduce these occurrences by con- investments; These models — with incentivized payment necting patients to services and improv- structures and bundled payments for pa- ing the underlying health of their patient l H ealth plans and provider systems are tients and/or global payments for patient pools, particularly their high-use patients. willing to engage in promising interven- pools — are motivated to improve health tions and understand that investments A growing number of systems are driving to- and lower costs. For instance:167, 168 in certain population health strategies ward better health outcomes and lower-cost are necessary to improve quality and l G lobal payments give providers a fixed health services by supporting initiatives that cost outcomes and to respond to payer sum for the care of a patient-group for help their patients stay healthier in their performance expectations. a defined period of time — and if the daily lives. Some key approaches include: care costs less, the system receives the l I t remains unclear to what extent l C ase management — providing patients difference; value-based purchasing strategies will with managers to help them navigate prompt effective population health l F or bundled or episode-based payments, the health and social service systems to investments; and providers receive a payment for a de- ensure they are receiving available care fined episode of care, such as care for a and services; l O ptimizing health improvements particular condition; in geographic populations requires l L ower-cost healthcare services, such as building shared strategies across plans l I n pay-for-performance, providers receive disease management programs provided and provider systems, as well as with increased or reduced payments if they by community health workers or health other partners. meet specific, measurable cost, quality educators; and or access goals, such as via Account- The American Hospital Association has l B roader community health programs, such able Care Organizations; also created a guide for creating effective as supporting active living initiatives or hospital-community partnerships.170 44 TFAH • healthyamericans.org littleny / Shutterstock.com FOR EXAMPLE: Dignity Health — formerly Catholic a 10-year population-based prevention Healthcare West — has provided more demonstration project that aims to re- than $88 million in loans to more than duce the number of heart attacks that 180 non-profits at below market rate occur in New Ulm, Minnesota. Through since 1992, which have helped finance a a combination of evidence-informed range of community development efforts health improvement practices, including in underserved communities, including a social media campaign, incentives and affordable housing, job training, commu- technical assistance for restaurants to nity facilities and medical services.171, 172 provide healthier choices, school well- ness programs such as cooking classes Molina Healthcare, which provides for young children and integrated nutri- Medicaid managed care services, uses tion curriculum, healthier concessions at community health workers or other sporting events, farmers markets, phone non-physician professionals as Commu- coaching, Complete Street policies and nity Connectors in 11 states to serve as worksite wellness programs. The project liaisons between patients and clinicians, has achieved measurable results. Since coach members to self-manage their the project began in 2009, the percent chronic conditions, connect patients to of people who: get adequate exercise community resources and help navigate increased from 67 percent to 77 per- services.173 In New Mexico alone, these cent; eat the recommended serving of community health workers have achieved fruits and vegetables increased from 19 savings of $4,564 per enrollee through percent to 33 percent; have cholesterol reductions in emergency department levels within the recommended range use, inpatient care and prescriptions. increased from 68 percent to 72 per- The Heart of New Ulm Project, a collab- cent; and have blood pressure within the orative partnership between the Minne- recommended range increased from 79 apolis Heart Institute Foundation, Allina percent to 86 percent.174, 175 Health and the New Ulm community, is TFAH • healthyamericans.org 45 l Medicaid Medicaid — as the government-supported and expanded use of lower-cost commu- health insurer for low-income families, nity health worker and peer specialist covering nearly 70 million Americans — is led programs and services — as rec- also developing value-based strategies to ommended by a physician or licensed lower healthcare costs and improve health practitioner; for its patients. l V ia waivers, where states can use A number of federal innovation strategies demonstrations to test new approaches and state Medicaid programs are focusing to the delivery system, which can include on how to improve the health of benefi- efforts to connect people to social ser- ciaries — including by reimbursements vices. Waivers must be budget neutral; for linking patients to social services that l M anaged care and alternative payment support better health and reduce their models — such as, where state agencies need for healthcare and supporting com- pay managed care organizations a set munity-based prevention initiatives. amount to cover a defined set of services, Connecting and coordinating local health and the MCOs can provide additional improvement partnership strategies and services they believe will help benefit the initiatives with Medicaid efforts and reim- patients and reduce costs, and the MCO bursement policies is a major potential benefits from the savings received. More source for significant support for local than 75 percent of Medicaid beneficiaries health improvement partnerships.176 are enrolled in MCOs;178 In July 2016, the Milbank Memorial Fund’s l S ervices for supportive housing, employ- Reforming States Group, with support ment services and food assistance. For from the New York State Health Founda- instance, for supportive housing, a num- tion, issued Medicaid Coverage of Social ber of Medicaid authorities can be used Interventions: A Road Map for States which to support beneficiaries to find and stay identified a range of legal and regulatory in housing, clarified in a June 2015 In- authorities and approaches that states formation Bulletin from CMS, but cannot can use to support some social services be used to pay for room and board.179 via Medicaid, including:177 Or providing food to low-income benefi- ciaries; and l S tate Innovation Models that help sup- port population-health initiatives and an l R eimbursement policies have been Accountable Health Community effort expanded and clarified for community that provides support to connect pa- health workers and peer support ser- tients to social services; vices in Medicaid delivery systems. For instance, delivery of some preventive l T hrough State Plan Amendments (SPAs), benefit services — such as communi- states can expand support for case ty-based health promotion programs management approaches, which also — as recommended by a physician or can support connecting patients with licensed provider are reimbursable. other services; home health services; 46 TFAH • healthyamericans.org FOR EXAMPLE: State Innovation Models (SIM) and Health ton, D.C. have received SIM grants.185 and control costs of healthcare, including Care Innovation Awards from the Center While specific interventions of each participation in postpartum depression for Medicare and Medicaid Innovation plan varied across states, most of the programs; transportation to a gym; certain (CMMI) have supported value-based programs included improving body mass home improvements, such as installing an healthcare model demonstrations — index (BMI) percentile documentation, air conditioner; and referral to job training including of patient-centered medical nutrition counseling and physical activity or other social services.187 homes, Accountable Care Organizations, counseling.186 For instance, since 2008, New York’s Medicaid Redesign Team Hous- Chronic Health Homes and bundled pay- all three MCOs in Georgia have operated ing Subsidy Program invests state-share ments.180, 181, 182 In addition, SIM grant- improvement projects focused on reducing Medicaid dollars in supportive housing, ees have been required to develop and childhood obesity. including rental subsidies, tenant advocacy implement Plans for Improving Population Oregon’s Coordinated Care Organizations and a range of services for those at risk of Health — to enhance health in the given use Medicaid dollars for a broadly defined becoming homeless; including counseling, state, particularly focusing on tobacco set of health-related supportive services case management, job development and use, diabetes and obesity.183, 184 In total, that aim to improve outcomes; quality clinical supervision.188 34 states, three territories and Washing- Accountable Health Communities information and referrals to increase ben- in some cases are also providing follow CMMI also launched an Accountable eficiary awareness of available community up support to ensure the services are Health Community model pilot initiative services; 3) providing navigation services carried out.191, 192, 193 Some Accountable in 2016 which focuses on bridging the to help high-risk beneficiaries access Communities for Health across the coun- gap between clinical medical care and community services; and 4) encouraging try are beginning to tap into healthcare community services — by systematically clinical and community service alignment dollars to fund initiatives, including Med- identifying and addressing beneficiaries’ through the development of multi-sector icaid and innovation funds, such as State health-related social needs and assessing coalitions, to identify and address gaps Innovation Models. As Accountable Com- whether establishing those clinical-com- in community services. AHCs will aim to munities for Health evolve to seek and munity linkages can reduce healthcare identify and address social needs in the manage these funds, they are finding the costs and improve quality of care and areas of housing instability and quality, need to connect to or develop sophisti- health outcomes. The model is based food insecurity, utility needs, interpersonal cated financial management skills. on emerging evidence that unmet social violence, transportation needs and others. Some states are also using some Medic- needs, such as inadequate or unstable CMS will be awarding successful appli- aid and innovation funding, such as SIM housing or food insecurity, can increase cants funding to implement and rigorously awards and/or philanthropic provisions, the risk of developing chronic conditions evaluate the AHC model, with awards ex- to help support broader state Accountabil- while simultaneously reducing the ability pected to be announced in Fall 2016. ity Communities for Health — to help sup- to manage these conditions.189, 190 A number of states have also launched port a backbone for connecting patients AHCs promote four key strategies: 1) Accountable Communities for Health with services to support unmet social screening beneficiaries to identify unmet models or other initiatives to better inte- needs and to engage healthcare to sup- health-related social needs; 2) providing grate health and social services — and port broader community-based efforts. TFAH • healthyamericans.org 47 l Hospitals Hospitals are major anchor institutions health improvement efforts across the in communities — they are tied to the country. And, the percentage of resources area and population they serve, are often devoted to community-based health im- leading employers and real estate holders provement programs, services and initia- — and can help provide important lead- tives is expected to increase, as hospitals ership, expertise and resources to local are evaluating newly required community health improvement partnerships. health needs assessments and the num- ber of uninsured and underinsured pa- In addition, non-profit hospital community tients continues to drop.196, 197, 198 benefit programs are an important source of funding for community health improvement The IRS has provided increased guidance efforts. Community benefit programs — supporting the use of community benefit from around 2,900 non-profit hospitals — fund dollars for upstream prevention activi- totaled around $62.4 billion in 2011.194, 195 ties beyond subsidized access to healthcare Non-profit hospitals are required to maintain — including community health improvement community benefit programs to qualify for and some community building activities.199 exemption from federal income taxes. Tra- Similar to direction provided to banks for the ditionally, the large majority of these funds use of their community benefit programs via have been used to support uncompensated the Community Reinvestment Act, the fed- or charity care, while around 5 percent have eral government can continue to expand the been devoted to community-based preven- guidance for hospitals and also consider tion and improvement programs. increased requirements for the use of com- Community benefit investments are an munity benefit programs to support commu- important source of funding for community nity-based prevention activities. FOR EXAMPLE: In Columbus, Ohio, Nationwide Children’s munity since the mid-1990s. Responding Hospital’s “Healthy Neighborhoods, to a needs assessment that identified Healthy Families” initiative is focused on obesity as a major problem and using improving housing quality, early childhood Community Benefit funding, Lancaster education and workforce development in General Health helped create Lighten Up the area surrounding the hospital. The Lancaster County, a coalition which has initiative includes a home visiting program helped change a city ordinance to make aiming to boost kindergarten readiness it legal for mobile fresh food vendors to and a workforce development project operate in residential neighborhoods, which, in partnership with Columbus State developed training sessions for school Community College, links unemployed wellness council coordinators, created a adults with training and job placement.200 healthy corner store initiative, conducted a food needs assessment, promoted Lancaster General Health, a healthcare complete streets policies, managed walk- delivery system in Pennsylvania, has been ability and safe routes to school audits, responsible for conducting community and supported community gardens.201 health needs assessments for the com- 48 TFAH • healthyamericans.org l Community Health Centers/Federally Qualified Health Centers Federally Qualified Health Centers Many CHCs have a long history of providing More than 98 percent of CHCs report (FQHCs) provide health services to around additional “wrap around” services to their providing referrals to programs including 20 million patients in low-income and patients — including case management and Temporary Assistance for Needy Families underserved communities, regardless connecting people to social and financial (TANF), Supplemental Security Income, of a patient’s ability to pay or insurance services — and have a majority of their Supplemental Nutrition Assistance status. The number of community board members consisting of members of Program, the Supplemental Nutrition health center (CHC) patients is expected the community they serve. CHCs can serve Program for Women, Infant and Children, to grow to 40 million as healthcare as key partners in local health improvement food banks and housing assistance. In access is increased by provisions in the collaboratives — building on their status addition, more than 80 percent have Affordable Care Act (ACA). 202, 203 CHCs as a service provider and trusted resource referred patients to Head Start programs, receive enhanced reimbursements from to lower-income and many high need employment counseling and environmental Medicare and Medicaid and other benefits patients. In many communities, they are health risk reduction services.204 A to support the infrastructure needed already engaged in collective impact efforts number of CHCs are part of “one-stop” to address the needs of the vulnerable to improve the vitality and well-being of or “no wrong door” combined health and populations they serve. underserved communities and individuals social service agencies. and are able to tap into existing assets. FOR EXAMPLE: Mary’s Center is a FQHC providing a agencies, hospitals, schools, managed ing patients and conducting home visits. comprehensive and integrated set of care organizations and housing and The program expanded over time, working healthcare, family literacy, education and employment resources. Briya students with Healthy Homes Healthy Kids, to pro- social services in the Washington, D.C. re- have demonstrated higher performance mote expanded home health visits, health gion. The organization provides medical outcomes, and Mary’s Center has healthy program enrollment, medical homes and services including healthcare for all ages, birthweights, hypertension control and policy development. They have achieved mental health services, dental services, a child immunization rates above the local a 100 percent decrease in asthma community outreach van and health pro- and national averages.207 The organiza- hospitalizations, 100 percent decrease motion — as well as social services (after tion’s $39 million annual budget consists in asthma-related missed work days by school programs, domestic violence sup- of 46 percent patient revenue; 35 percent parents, 80 percent reduction in asthma port, family support programs, home visit- government, foundation and corporate emergency department visits, 69 per- ing, insurance enrollment and connecting grants; and 19 percent fundraising, contri- cent reduction in asthma-related missed participants to other community services butions and other revenue. school days and 69 percent reduction in such as housing and job resources) doctor visits due to acute asthma attacks. St. John’s Wellchild and Family Center and education services (teen education The effort is funded by British Petroleum (SJWCFC), a FQHC network in California, program, child care licensing program, Settlement/Air Quality Management Dis- has been working to reduce the nega- medical assistant training program and trict Funds, First 5 Los Angeles, EveryChild tive impacts of substandard housing on the Briya Public Charter School).205, 206 Foundation, Housing and Urban Develop- health.208 The organization partnered with The organization partners with a range of ment Agency and the Kresge Foundation. Esperanza Community Housing Corpora- local community groups, state and federal tion to prevent lead poisoning by screen- TFAH • healthyamericans.org 49 5. Innovative and Social Impact Funding Strategies In addition to support from health, Wellness Trusts, are increasingly being cost savings and/or improved outcomes. social service, philanthropic and used in communities to help support These new investments are providing business funders, a number of financing place-based initiatives in low-income the capital to scale up evidence-based models, including Community communities that do not typically have programs and represent an exciting Development Financial Institutions access to capital — often focusing on growing source of funding for public and “pay-for-outcomes” approaches, providing “investments” and structuring health and social service programs that such as social impact bonds and systems to capture returns in the form of should be brought to scale. l Community Development Financial Institutions Community Development Financial Institu- There is growing interest in expanding development projects supported by CDFIs tions provide access to financial services, CDFIs’ investments to achieve improved help improve health along with achieving affordable credit and investment capital health in low-income communities.213, 214 other goals — such as by providing in- that are not available from conventional A number of health-related investments creased quality affordable housing and capital markets to help generate economic have focused on more classic community child care centers.217, 218 growth and revitalization of low-income and development bricks and mortar projects Local health improvement partnerships underserved communities.209 They gener- — for instance, CDFI funds have been have an opportunity to access CDFI invest- ally offer below-market and more flexible used to help support the development of ments to support their capital investment terms than conventional lenders, and pair community health centers and for healthy needs and outcome-based efforts. Be- their financial products with education, food financing initiatives, such as building yond the federal government, some funds training and technical assistance to poten- more grocery stores in lower-income com- that have helped support healthy food tial borrowers.210 There are around 1,000 munities.215 Some CDFIs are supporting financing and community health center CDFIs, managing more than $30 billion in community development projects that sup- development or expansion include the Low assets around the country.211 The U.S. port “active living” efforts (such as parks, Income Investment Fund, the Non-profit Fi- Department of Treasury CDFI Fund has pro- green spaces, sidewalks, parks, commer- nance Fund and the Lenders Coalition for vided more than $2 billion to CDFIs since cial/residential design and transportation Community Health Centers. 219, 220, 221 its creation in 1994.212 alternatives).216 Many broader economic FOR EXAMPLE: The U.S. Department of Treasury’s CDFI Loan Fund finances construction and ren- to improve primary care capacity.226 For Fund launched a national Healthy Food ovation of a range of healthy food retail example, the Illinois Facilities Fund (IFF), Financing Initiative in 2010, providing and wholesale outlets, including grocery the largest non-profit CDFI in the Mid- financial assistance awards as well as stores, corner stores, farmer’s markets, west, has provided $78.2 million in total technical assistance to more than 20 food hubs and mobile markets selling financing for community health centers, CDFIs to develop food retail financing healthy food. 224 including the provision of 84 facilities programs. Many of these programs loans to 42 community health centers Many CDFIs have financed the building focus on financing full-service super- across Illinois, Wisconsin, Indiana, Iowa, and expansion of Community Health markets in “food deserts”, while others Missouri and Kansas.227, 228 IFF also pro- Centers, including through a Lenders invest in smaller food retailers or other vides real estate development for health- Coalition for Community Health Centers food systems projects, including distribu- care centers and has helped establish (LCCHC).225 LCCHC lenders have made tion and small-scale farming. 222, 223 For 65 centers serving over 61,000 patients a total of more than $1.4 billion in loans instance, the South Carolina Community with $14.4 million in development costs. 50 TFAH • healthyamericans.org l New Market Tax Credits New Market Tax Credits are a vehicle to financing, community health centers or attract private investments into lower-income related projects that help support better communities. The U.S. Department of the health, such as affordable housing. Treasury administers a New Market Tax From 2000 through 2015, the NMTC Credit Program (NMTC Program), which gives Program has created or retained an individual or corporate investors a tax credit estimated nearly 200,000 jobs, created against their federal income tax (39 percent 164 million square feet of manufacturing, of their original investment claimed over 7 office and retail space, financed over years) in exchange for making equity invest- 4,800 businesses, and generated $8 of ments in specialized financial intermediaries private investment for every $1 of federal called Community Development Entities funding.231, 232 The NMTC program has (CDEs).229 CDEs are required to have 20 distributed over $40 billion in federal tax percent of their governing or advisory board credit authority and helped finance 49 be representative of the lower-income com- supermarket and grocery store projects munity they serve, and are certified by the between 2003 and 2010, enhancing U.S. Department of the Treasury.230 access to healthy food in low-income A number of health-improvement related communities for over 345,000 individuals, NMTCs have supported healthy food including nearly 200,000 children.233 TFAH • healthyamericans.org 51 FOR EXAMPLE: New Market Tax Credits have sup- and wellness services and education financial capital). SPARCC is an initiative ported a wide range of healthy food and job training. 237, 238 HFF offers New of Enterprise Community Partners, the financing initiatives, such as Grays Ferry Market Tax Credits and loan capital at Federal Reserve Bank of San Francisco, Education and Wellness Center in South very low transaction costs to Federally Low Income Investment Fund and National Philadelphia (projected to create 105 Qualified Health Centers and other Defense Council and has received full-time jobs, serve more than 1,000 community-based health centers seek- support from the Robert Wood Johnson children and families and treat 6,000 ing to expand their facilities and ser- Foundation (RWJF), the Ford Foundation patients through a health clinic); 234 the vices. HFF also offers competitive Low and The Kresge Foundation.242 Shops at Park Village Shopping Center Income Housing Tax Credit equity for Equity with a Twist (EQT) is a social (including the only full-service grocery affordable housing projects as well as capital product out of the Low Income store in Ward 8 of Washington, D.C. grants and other loan resources.239 For Investment Fund and JP Morgan Chase generated 188 construction jobs and example, in Toledo, Ohio, HFF invested aimed at providing up to 10-years of flex- 172 full time jobs);235 and the creation $6.5 million to help the Neighborhood ible, low-cost financing to support innova- of a supermarket in a neighborhood in Health Association replace outdated tive cross-sector solutions to poverty.243 St. Louis, Missouri where 15 percent clinics with a larger, state-of-the-art facil- Each EQT investment will incorporate of the low-income population previously ity that houses a variety of primary care mixed-income housing, kindergarten (K)– lived more than a mile away from the services, a credit union, a community 12 education and early learning, as well nearest grocery store.236 garden and a low-cost pharmacy.240 as other fields of interest to the investee. Healthy Futures Fund (HFF) is a $200 The Strong, Prosperous, and Resilient By tracking social outcomes and demon- million initiative, formed by the Local Communities Challenge (SPARCC) 241 strating project impact, the EQT pilot Initiatives Support Corporation, Morgan is a three year initiative aiming to spark programs aim to create models for future Stanley and The Kresge Foundation, community-driven investments in city and investors seeking social and financial that builds cross-sector partnerships regional transit, infrastructure, climate returns. Pilot EQT investments will be between healthcare centers and com- resilience and health to promote more directed towards transitioning dilapidated munity partners (including affordable equitable communities. Ten cross-sector, public housing in San Francisco and Los housing providers) that address the multi-disciplinary SPARCC teams are work- Angeles into mixed-income communities, various upstream factors that impact ing to develop local strategies to influence as well as ongoing community revital- the health of low-income communities. their community’s health, economic and ization efforts in New Orleans neighbor- Through co-location of health centers, environmental outcomes. The six teams hoods affected by Hurricane Katrina. The non-clinical services and affordable selected as national models in early 2017 Low Income Investment Fund (LIIF) has housing projects, HFF seeks to expand will receive grant funding, technical assis- also created a Social Impact Calculator healthcare access and address other tance, programmatic support, and financ- that allows local areas to estimate the community needs, such as affordable ing from SPARCC to bring their initiatives value of community development proj- housing, healthy food access, fitness to scale (totaling $90 million in grants and ects: http://www.liifund.org/calculator/. 52 TFAH • healthyamericans.org l Community Development Corporations Community Development Corporations are services. Similar to community health community-based, non-profit organizations centers, a substantial portion of the Com- with a focus on community revitalization. munity Development Corporations board is Generally serving low-income, underserved usually composed of community residents, neighborhoods, Community Development enabling grass-roots participation and Corporations often develop affordable community empowerment. The Commu- housing, engage in a range of community nity Development Corporations also play health initiatives (including economic a role in bringing capital to communities, development and neighborhood planning) generally by developing residential and and contract for education and social commercial property.244 FOR EXAMPLE: Chicanos Por La Causa (CPLC), a multi- the housing, health and other services state Community Development Corpora- it provides.246 In Phoenix, Arizona, via tion, focuses on economic development, a partnership with UnitedHealthcare education, housing development and (which has 25,000 members within a delivering of social services. 245 CPLC 3 mile radius of the center), all clients serves over 200,000 low-income indi- are screened for social needs and re- viduals annually through program sites ferred to social services including job in Arizona, Nevada and New Mexico. It training, housing, financial services and provides a range of services, including transportation. A new data system en- youth and adult education, scholar- hances communications between social ships, behavioral health, domestic service providers, including referrals. violence services, substance abuse To finance the effort, UnitedHealthcare treatment, parenting classes, HIV ser- has committed to provide CPLC access vices, senior and immigration services, to up to $20 million in capital to ac- workforce development, real estate, quire, develop and operate multifamily housing and loans for entrepreneurs housing units and to provide a variety of and small businesses. CPLC generates need-based services for residents. more than $50 million in revenue from TFAH • healthyamericans.org 53 l Pay-for-Performance and Social Impact Bonds Pay-for-performance models are innova- ary to issue a bond to obtain social ser- whether established performance targets tive mechanisms for addressing social vices to address the challenge. 249, 250 The are met — and the investors are repaid challenges — where through contracts or social service might be a local program with a certain rate of return for taking on loans, the government pays for the deliv- that has demonstrated success and can the risk.252, 253 The goal is for successful ery of certain services based on positive, be expanded, or one that has worked programs to allow investors to get their measured performance outcomes. 247, 248 elsewhere and can be replicated. 251 The money back and earn a return, for the gov- bond-issuing organization raises the funds ernment to address a policy priority and Social impact bonds are one form of a to finance costs of the program from pri- possibly achieve long-term savings and pay-for-success approach. The govern- vate investors. The government pays the for the larger community to benefit from ment identifies a challenge and contracts bond-issuing organization back based on improved social outcomes.254, 255 with a private-sector financing intermedi- Status of Social Impact Bonds with a Public Health Focus as of April 2015256 from the National Governors Association Status of Social Impact Bonds with a Public Health Focus as of April 2015i State Status of Operationii Focus Areas Arkansas Considering Recidivism California In Development Maternal and Child Health Colorado Considering Recidivism Connecticut In Development Substance Abuse/Maternal and Child Health Hawaii Considering Early Childhood Education/Development Illinois In Development Recidivism/Youth Development Massachusetts Active Recidivism/Chronic Homelessness/Supportive Housing Michigan In Development Maternal and Child Health Minnesota In Development Supportive Housing/Workforce Development Nevada Considering Early Childhood Education/Development New Mexico Considering Mental Health New York Active Recidivism New York In Development Diabetes/Maternal and Child Health New York Considering HCBS/Supportive Housing North Carolina Considering Early Childhood Education/Development Oklahoma Considering Recidivism Oregon Considering Preventive Health South Carolina In Development Maternal and Child Health Utah Considering Recidivism/Substance Abuse/Mental Illness Virginia Considering Maternal and Child Health Washington Considering HCBS/Supportive Housing/Early Childhood Education/Development Note: SIBs that have a public health focus include those that target social determinants of health, including housing, education, and economic and job stability. i Nonprofit Finance Fund, “Pay for Success U.S. Activity,” http://payforsuccess.org/pay-success-deals-united-states#sc (accessed June 3, 2015). ii Status of Operation: An “active” classification means that services are already being delivered. States that have identified a scope and are in the process of finalizing contracts are classified as “in development.” States that have not defined scope and are in the process of soliciting stakeholder feedback are classified as “considering.” 54 TFAH • healthyamericans.org FOR EXAMPLE: The South Carolina Department of increase in first-time mothers who live Health and Human Services launched in poverty served by the program. a pay-for-success initiative in February The Connecticut Department of Chil- 2016 to improve health for mothers dren and Families (DCF) and the Fam- and children living in poverty.257 They ily-Based Recovery Services (FBR) at are expanding the evidence-based the Yale Child Study Center and Social Nurse-Family Partnership to an addi- Finance launched a $12.5 million Family tional 3,200 low-income mothers over Stability Pay for Success Project in Feb- six years. The program sends trained ruary 2016.259, 260, 261, 262 The program is nurses to conduct home visits with vul- focused on serving families struggling nerable, first-time mothers from early with substance use by expanding an in- pregnancy through a child’s second home Family-Based Recovery program to birthday. The project is mobilizing $30 families currently receiving child welfare million in funds (including $17 million services, in an effort to reduce the need from private funders plus $13 million for foster care placements and keep from South Carolina Medicaid) — and children with their parents.263 More than if positive results are found, South Car- half of all child abuse and neglect cases olina (state government) will make up investigated in the state are related to to $7.5 million in success payments parental substance use, costing the to sustain Nurse-Family Partnership’s state more than $600 million annually. services.258 Funding sources include The four-and-a-half year program will a 1915(b) Medicaid waiver that will serve around 500 families with services contribute approximately $13 million including individual, couples and family and a combined $17 million from the therapy; positive parent-child interaction; BlueCross BlueShield of South Caro- parental awareness of child develop- lina Foundation, The Duke Endowment, ment; case management; and weekly Greenville First Steps, Children’s Trust relapse prevention and parenting group. Fund of South Carolina, Laura and John Outcome payments to DCF are triggered Arnold Foundation, the Boeing Company by prevented out-of-home placements (which manufactures in the state) and (foster care), prevented re-referrals to a consortium of private funders, along child welfare, reductions in substance with technical assistance from the use and Family-Based Recovery enroll- Government Performance Lab at the ments.264, 265 The Harvard Kennedy Harvard School of Government and a School Government Performance Lab randomized control trial evaluation by will provide technical assistance and the Massachusetts Institute of Technol- University of Connecticut Health Center ogy. Evaluation metrics will include: will conduct a randomized controlled reduction in preterm births, reduction trial evaluation. Project funders include in child hospitalization and emergency BNP Paribas, QBE Insurance Group Lim- department use due to injury, increase ited, Reinvestment Fund and others. in healthy spacing between births, and TFAH • healthyamericans.org 55 l Wellness Trusts A number of groups have proposed the tobacco), private or corporate philanthropy, ability to the loss of any single funding model of establishing a Wellness or fees charged to health insurers or hos- stream. Other considerations in establish- Health Trust — a pool of funds set aside pitals, community benefit programs from ing Wellness Trusts include administrative to finance evidence-informed community hospitals, voluntary contributions or pur- oversight and transparency; community prevention in a strategic and coordinated chases and legal penalties or settlements. engagement; deciding on priority activities way — that does not rely on federal grants and how funds will be distributed; cre- Once community prevention efforts or state general revenue — but rather ating a balanced portfolio of prevention demonstrate savings, some models sug- provides a steady, predictable source of investments that include interventions gest that a portion of savings could be funding.266, 267, 268 Funds for the proposed with short, medium, and long term returns reinvested in the Wellness Trust, providing Wellness Trusts can be raised in differ- on investment; assessing process and one source of funding. Having multiple ent ways from various public and private outcomes; and capturing and reinvesting funding streams can increase participa- sources, including taxes or fees on prod- savings in community prevention.269, 270 tion and flexibility, and reduces vulner- ucts with known health risks (such as FOR EXAMPLE: The Massachusetts Prevention and participation.271 Through a competitive infrastructure. The funds are available to Wellness Trust Fund was the first application process, four-year grants ACHD and requests are made quarterly. established state-based trust — a from the Trust were awarded to nine In its initial phase, the PHI Fund has four-year, $60 million commitment to community partnerships in January 2014, focused on public health infrastructure community prevention and wellness in the amount of up to $250,000 for the improvement and provided short-term efforts, financed via a one-time first phase and a potential additional funding to rebuild ACHD. Funds were assessment on the state’s large insurers $1.5 million for each of the following directed towards information technology and hospitals. The Trust was established three years. Applicants were required to (IT) assessments, outreach, community by the passage of new cost containment demonstrate robust community-clinical health needs assessments and the legislation in 2012, and thus did not linkages; as well as outline their plans development of the Plan for a Healthier require annual approval through an to improve health outcomes and reduce Allegheny. Today, a shift is ongoing to appropriations process. Identified health costs related to at least two of the four redirect funds towards addressing specific priorities for the Trust included tobacco priority health conditions, to reduce health focus areas within the county’s Plan for use, childhood asthma, hypertension and disparities and to sustain their efforts. 272 a Healthier Allegheny. While Allegheny elder fall prevention. At least 75 percent County benefits from its resources from In an effort to coordinate the various of the funds were awarded in grants to local foundations, the county has had less streams of foundation funding available to local community-wide initiatives, up to 10 luck attracting dollars from its two major the Allegheny County Health Department percent was used for workplace wellness healthcare systems. As such, the PHI (ACHD), foundations executives estab­ efforts and up to 15 percent was spent on Fund currently only incorporates foundation lished a joint fund known as the Public grant administration, including evaluation. money and has yet to tap into available Health Improvement Fund (PHI Fund).273 The Department of Public Health healthcare dollars. The county continues The PHI Fund is run out of the Pittsburgh oversees the fund, in consultation with to investigate additional methods to Foundation and centralizes and combines an Advisory Board established specifically increase PHI Fund participation and solicit funds from six different local foundations for the Trust. Public comment meetings additional dollars from existing members. into a single fund to support public health were also held to facilitate public 56 TFAH • healthyamericans.org 6. xamples of Organizations and Efforts Advancing Place-Based E Health Improvement Models ReThink Health has developed models and simulations to help communities examine different possible strategies and programs for improving health and wellness — and to view their potential impact.274 The ReThink Health Dynamics Model is an empirically-based, analytical computer tool that brings formal modeling to health system change. The model is a simplified, realistic representation of a local health system that can track changes in population health, healthcare delivery, healthcare costs and workforce productivity under a variety of conditions. Health sys- tem planners can test the possible impact of several dozen different strategies and initiatives, either individually or in combina- tions, to study the likely consequences over time on health outcomes, quality of care, ties framework to select and pursue ten cost, productivity and return-on-investment. key initiatives including: expansion and A range of communities around the country enhancement of an industrial corridor to are using the tool — such as the Atlanta bring in new industry and livable-wage Regional Collaborative for Health Improve- jobs; commercial development around ment and Pueblo, Colorado Triple Aim Co- an existing train stop; housing redevelop- alition — to help determine priorities and ment; a campaign to boost neighborhood consider the potential impact and return on safety and cleanliness through reduction investment of different strategies. of liquor stores, youth employment and Healthy Cities/Healthy Communities is a other efforts; and employment and train- framework — originally developed by the ing in the environmental field for high World Health Organization — for an inclu- school students, in partnership with a na- sive, participatory process to improve the tional laboratory located in the area.276 health and quality of life of a city or com- l A iken, South Carolina: The Healthy munity. The framework rests on two basic Communities Program in Aiken, South premises: a comprehensive view of health Carolina has successfully reduced infant and community issues — that includes mortality through a combination of strat- education, shelter, food, income and social egies identified and implemented using justice — and a commitment to the active the Healthy Communities Framework, promotion of a healthy community — not including a mentoring program for at-risk just treating health problems.275 Some girls; community policing; instant crime communities using this framework include: reporting via donated cell phones; dem- l C hicago: Bethel New Life, a grassroots, olition of unsafe homes; free installation church-based urban development effort in of smoke detectors; and parental educa- Chicago has used the Healthy Communi- tion on child brain development.277 TFAH • healthyamericans.org 57 Invest Health — a collaboration between create a sustainable infrastructure that in- Pioneering Healthier Communities (PHC) The Reinvestment Fund and RWJF — in- cludes quality housing and healthcare, and initiative uses funding from CDC and cor- corporates health into community devel- to increase job opportunities and access porate and foundation donors to support a opment by providing $60,000 grants and to healthy food and places to be physically collaborative community process to develop technical assistance and other support to active.281 The effort will focus on develop- policy, system and environmental changes new multi-sector partnerships in 50 mid- ing health improvement strategies with a that promote healthy living.286 Launched sized cities across the country. The goal shared measurement system. It will focus in 2004, PHC empowers communities with is to increase and leverage private and resources in neighborhoods where health strategies and models to support sustain- public investment in neighborhoods facing inequities are concentrated and build a field able change in their communities. Partic- the biggest barriers to health, particularly of practice that provides the tools, evidence ipating YMCAs, as a major partner, bring by helping these cities attract capital and models to support local scaling and together a cross-sector team with leaders to advance systems-focused strategies replication around the country. Five pilot from the private, public and non-profit sec- and helping them use data as a driver site grantees (in Portland, Oregon; Boston; tors. These teams each have two coaches for change. Grantees will bring together Atlanta; Dallas; and Detroit) are receiving to guide, support and facilitate the team multiple sectors over 18 months to collect $20,000 in direct funding and $60,000 of through its process — including a coach data, test solutions and advance strate- in-kind technical assistance.282 from the YMCA, as well as one of the part- gies that address factors that drive health nering institutions. There are currently 129 The Building Healthy Places Network in low-income neighborhoods, including communities participating in PHC. aims to improve well-being in low-income a lack of quality jobs, affordable housing communities by connecting leaders and The Blue Zones Project is a community and nutritious food, high crime rates and practitioners in health and community devel- improvement initiative that brings together unhealthy environmental conditions.278 At opment; curating examples of collaborative community leaders and citizens to im- the end of the grant period, the cities are models with proven outcomes so these ef- pact the environment, policy and social expected to have investment plans and forts can be replicated; and providing tools networks to help make healthy choices interested investors. The Reinvestment to build the capacity for health and commu- easier.287 Certified Blue Zones communi- Fund, one component of the project, is a nity development sectors to partner together ties implement long-term, evidence-based Community Development Financial Insti- (e.g., a collection of directories to help users policies and interventions to improve the tution that manages $946 million from find the community development and health built environment; create and enforce over 850 investors to support low-income organizations closest to them; a virtual live health-promoting municipal policies and or- communities through investments, real discussion series connecting community dinances; form and nurture social groups estate development, data analysis and ad- development and health practitioners; and that support healthy habits; and build vocacy.279 The Reinvestment Fund’s invest- mapping and measurement tools to help healthier options in schools, grocery stores ments have generated 71,550 jobs; 17 identify community needs and assets).283 and workplaces. Current project sites in- million square feet of commercial space; clude California, Florida, Hawaii, Iowa, Min- and 163 supermarkets, grocery stores and The Healthy Communities Initiative — a nesota, Oregon, Texas and Wisconsin. fresh food retail.280 partnership of the Federal Reserve Sys- tem and RWJF — brings together health The BUILD Health Challenge288 brings The Alignment for Healthy Equity and De- practitioners and community development together funding from The Advisory Board velopment (AHEAD), a partnership by the workers to share knowledge (about data Company, the de Beaumont Foundation, Public Health Institute and The Reinvest- collection, outcomes measurement, part- the Colorado Health Foundation, The ment Fund, funded by The Kresge Founda- nerships, etc.) and information on how to Kresge Foundation and RWJF to identify, tion, works in communities where poverty harmonize health funding streams with tra- accelerate and spotlight upstream initia- and health inequities are concentrated. ditional community development programs tives and best practices working to give The partnership seeks to create balanced (investment and lending motivated by the everyone a fair chance to be healthy. The portfolios of aligned investments and in- Community Reinvestment Act, New Market BUILD Health Challenge promotes bold, terventions across hospitals, public health Tax Credits, Low Income Housing Tax Cred- upstream, integrated, local, data-driven agencies, financial institutions, businesses its and other social funding efforts).284, 285 (BUILD) initiatives. The BUILD Health and others, so resources are coordinated to 58 TFAH • healthyamericans.org Challenge awards funding and technical assistance to communities who have built innovative collaborations between hospi- tals and health systems, community-based organizations and local health depart- ments to address the social determinants of health and promote health equity in their community. The BUILD Health Chal- lenge currently funds 18 communities across the country.289 The Moving Health Care Upstream (MHCU) initiative290 identifies the most promising community health and health delivery innovators and provides them with a structured platform through which they can connect and share their efforts. MHCU works by developing and testing promis- ing tools and strategies in communities, community health centers, and community health systems that have committed to work with MHCU to identify “what works.” The organizations receive technical as- sistance, coaching, and facilitation from MHCU. Tested best practices are spread through a learning network of organizations and networks to stakeholders who are inter- ested in adopting the innovative strategies. Through these platforms, MHCU creates work with local leaders to assess their vironments. In Phase One of the project, partnerships among healthcare, public neighborhood’s unique situation; identify these community-based networks will form health and non-health sectors with the aim and engage with key partners and resi- a common governance and policy structure of addressing of Triple Aim. MHCU is a dents; and develop, implement and evalu- — local coalitions or collaborative net- collaborative effort led by a team of collabo- ate strategic and operational plans. Each works — that guide collective and coordi- rators from UCLA and Nemours with funding community establishes a single purpose nated work carried out by each partner. In from The Kresge Foundation. non-profit Community Quarterback charged Phase 2 of the project, the local networks with building partnerships with cross-sec- will coordinate efforts to address child- Purpose Built Communities291 is a non- tor stakeholder and investors, coordinating hood and community adversity through profit consulting firm that works with sustainable funding streams and serving specific programs and strategies that communities to develop tailored master as a single accountability point for part- are collectively measured and monitored. plans to implement a holistic revitalization ners and funders. BCR, a project of The George Washington effort. Purpose Built Communities works University Milken Institute School of Public to break the cycle of intergenerational pov- The Building Community Resilience (BCR) Health, is being tested in Cincinnati, OH; erty, unsafe environments, high crime and collaborative is a national effort to create Dallas, TX; Portland, OR; Washington, DC; failing schools in neighborhoods through community integrated systems of care by and Wilmington, DE. BCR is supported concentrated and sustained efforts with joining public health, health systems and through funding from The Doris Duke Char- a special focus on cradle-to-college pro- other cross-sector agencies and partners itable Foundation, The Kresge Foundation grams, mixed-income housing initiatives to address adverse childhood experiences and The Nemours Foundation. and community wellness. Their teams in the context of adverse community en- TFAH • healthyamericans.org 59 THE CALIFORNIA ENDOWMENT: BUILDING HEALTHY COMMUNITIES Building Healthy Communities (BHC) is a SLABHC and its partners have also suc- borhood safety and reductions in reported 10-year, $1 billion place-based initiative of ceeded in securing over $30 million from drug dealing, use and violence.298 The California Endowment working in 14 the University of Southern California’s com- California communities to promote pre- munity benefit agreement for affordable Fresno vention policy, system and environmental housing and local hiring requirements. The area served by the Fresno BHC is home changes through cross-sector collaborations to over 90,000 residents. Over 40 percent and community engagement. Launched in East Oakland of these residents live below the poverty 2010, BHC aims to reduce health inequities Located in Alameda County, East Oakland line, 22 percent are unemployed and more through improvements in neighborhood has high rates of health inequities perpet- than 60 percent have less than a high safety, unhealthy environmental conditions, uated by economic decline and unhealthy school degree.299 The community is also access to healthy foods, education, housing living conditions. These inequities man- home to many immigrant and refugee pop- and employment opportunities. Each BHC ifest themselves in a 10 to 15 year gap ulations. As such, one of the Fresno BHC’s appoints a BHC Hub Host to act as the cen- in the average life expectancy for an East guiding missions is to provide equal access tral coordinator for implementation of health Oakland resident compared with someone to preventive health services to all of its improvement initiatives.292 living less than just two miles away.296 residents regardless of immigration status. A five-year review of BHC found some key In East Oakland, the Alameda County Depart- In 2014, the Fresno County Board of Su- achievements have included: improved cov- ment of Public Health (ACDPH) serves as pervisors voted to remove eligibility for erage for the underserved; strengthened the East Oakland BHC (EOBHC) Hub Host. Medically Indigent Services Program (MISP) health coverage policy for the undocu- ACDPH is the only public health department for undocumented Fresnans which led to mented; school climate, wellness and eq- selected as a Hub Host across the BHC increased use of emergency room care uity improvements; prevention and reform sites and is uniquely positioned to leverage rather than their usual safety net disease support in the justice system; public-private funds made available through the Measure management services. In response, mem- investments and policy changes for boys A Essential Health Care Services Tax to im- bers of the Fresno BHC started an advo- and young men of color; and local and re- plement its local health improvement initia- cacy campaign, #Health4AllFresnans, to gional progress in “health in all policies.”293 tives. The Measure A Essential Health Care ensure their undocumented residents had Services Tax is a half-cent sales tax passed access to safety net services. Through the South Los Angeles by California voters in 2004 that supports campaign Fresno BHC secured $5.5 million South Los Angeles (LA) has had a long emergency medical, hospital inpatient and in budget flexibility to provide short-term history of community improvement initia- outpatient, public health, mental health and specialty healthcare to Fresno County’s un- tives, which provided a foundation for the substance abuse services for low-income or documented through April 19, 2016.300 South Los Angeles BHC (SLABHC) to build uninsured individuals in Alameda County.297 In a separate initiative, the Fresno BHC on — to use strong coalitions of community ACDPH works with community-based successfully advocated for a $450,000 organizations and existing community ties to organizations to utilize Measure A dollars allocation from the Fresno City Council to advocate for a wide-range of initiatives ad- to promote health equity through their Com- update the City of Fresno Parks Master dressing the underlying social and economic munity, Assessment, Planning, Education, Plan. The Fresno BHC and its community causes of their community’s health dispar- and Evaluation (CAPE) Unit established partners brought attention to a noted ities. Through persistent advocacy efforts under EOBHC. Through the City County disparity in park access for residents in two and a strong partnership with the Legal Aid Neighborhood Initiative (CCNI), the CAPE different zip codes in the City of Fresno. Foundation of Los Angeles, SLABHC worked Unit builds the capacity of residents in the For those in the South Fresno zip code, to secure a rent-free lease for a new South Sobrante Park and Hoover Historic District one acre of park was available per 1,000 LA health clinic to help expand access to in West Oakland to identify and take actions residents while in Northern Fresno, over high quality preventive services for more to address health inequities in their commu- 4.6 park acres were available per 1,000 than 30,000 patients.294 The St. John’s nities by helping residents understand and residents. Since then, Fresno BHC and its Well Child and Family Center’s new Health navigate the multi-sector systems affecting partners have helped secure bids for the and Wellness Campus also offers child health. An evaluation of CCNI from 2004 City Council to build several new parks in dental services, a community garden and to 2010 found improvements in resident-re- South Fresno — including a 15,000 square diabetes management services.295 ported community involvement and neigh- foot skate park that opened in May 2016.301 60 TFAH • healthyamericans.org C. REATING AN EXPERT INSTITUTE NETWORK TO SERVE COMMUNITIES IN C EVERY STATE Local communities should have access to the best available information — with expert guidance to help define their goals; assess their needs and assets; and understand their options for evidence-based strategies and programs to determine what best matches their needs and priorities — and technical assistance to help implement and evaluate their efforts. This type of technical assistance has not been supportable on a national scale. Expert institutes, housed at academic institutions, public health institutes or qualifying non-profits, could serve this role — providing efficiencies of expert- assistance to help communities within the state meet their local needs. There should be institutes in every state that would be part of a collective network — to learn from and inform national research efforts, which advance the development and continued quality improvement of community and place-based prevention efforts. State and local health departments should NIH institutes or academy models or most effective, evidence-based programs; be involved in the creating and CDC research centers of excellence. l E nsure programs are adopted and supporting of the institutes — and the Community health and prevention implemented successfully by providing network should also be developed in funds from CDC and SAMHSA could technical assistance and access to coordination and consultation with also be used to support the pilot state learning networks; existing public health research and institutes. support entities, such as Prevention l T rain and support a range of While local health collaboratives provide Research Centers, the National professionals from different communities with the ability to more Network of Public Health Institutes and backgrounds and sectors; effectively implement strategies to Area Health Education Centers. address their top priorities, state-based l C onduct regular evaluations — Pilot initiatives would help determine expert centers are needed to provide measuring results and ensuring the best structures and needed assistance and support to communities accountability; and capacities for scaling the model. to help select, implement and evaluate l P erform continuous quality their health improvement strategies. Prevention programs at CDC, SAMHSA, improvement and updates to An example model approach is a the Administration for Children and improve programs. private-public partnership housed at Families and other agencies can help an academic institution or non-profit Technical support and ongoing provide national level support to these organization that serves to: data collection and analysis at a institutes — and connect networks of community level can help identify experts and information — and then l H elp conduct needs assessments to patterns of concerns — including risk analyze and disseminate the findings match the best policy and program and protective factors — and help back to the field to continue to improve choices to specific community needs, understand where and how to direct and expand programs — similar to tapping into the latest research on the programs and efforts. TFAH • healthyamericans.org 61 EXAMPLES OF ACADEMIC AND EXPERT ASSISTANCE MODELS Evidence-based Prevention and EPISCenter is a collaborative partnership Intervention Support Center between the Pennsylvania Commission on (EPISCenter)302 Crime and Delinquency (PCCD), the Pennsyl- Evidence-based Prevention and Inter- vania Department of Human Services (DHS) vention Support Center (EPISCenter) is and the Bennett Pierce Prevention Research a state-level backbone organization that Center, College of Health and Human Devel- supports community-level infrastructure opment at Penn State University. for prevention planning; evidence-based The annual estimated cost for an EPIS- programs and practices; and continuous Center initiative is around $1 million per improvement of locally-developed juvenile year per state, depending on the structure justice and substance use programs, and scope of the program. which also provide much broader support for positive childhood and youth devel- Communities that Care303 opment. EPISCenter helps communities Communities that Care (CTC) was devel- identify and prioritize risk and protective oped by the Social Development Research factors and determine which interventions Group at the University of Washington to can best address the identified needs provide a prevention-planning system and (many of which start in early childhood), a network of expert support for the use of as well as provides technical assistance evidence-based approaches that promote and support for quality implementation of the positive development of children and the programs. EPISCenter also supports youth and prevent problem behaviors. the Pennsylvania Youth Survey — which Hundreds of U.S. and international com- helps communities collect data about munities have used the approach, which rates of substance use, as well as under- involves all parts of a community to target lying protective and risk factors to inform predictors of problems, rather than waiting needs assessments and evaluations. Translating Science to Practice Assess Monitor Public Quality of Health Set & Collect Program Impact Provide Performance Implementa- Technical Measures tion Implement Assistance & Evaluate Develop & Programs Identify Test Inter- Risk and ventions Define the Protective Problem Factors Problem Response Source: EPISCenter multiple, coordinated steps involved in taking research from the lab into communities (“research to This diagram shows the practice”). The first four steps show the research activities that lead up to introducing programs into the field. The last four steps show the translation and implementation activities that are undergone to run programs in “real-world” settings. 62 TFAH • healthyamericans.org Pennsylvania’s Approach to Research-based Prevention As a state-level intermediary organization, developed in partnership between PCCD and the PRC, the EPISCenter is in a unique position to put research into real-world practice. We focus on promoting the dissemination, high-quality implementation for problems to occur. It is grounded in re- substance use; improve school engagement search from public health, psychology, ed- and academic outcomes; reduce conduct/ ucation, social work, criminology, medicine behavior problems; build protective factors and organizational development. and skills; and demonstrate positive returns on investments, including:307 A randomized controlled test of CTC programs in 24 communities across seven l I owa Strengthening Families Program states that followed 4,407 fifth grade (ISFP) — estimated reduction of adult youth found that by the spring of eighth alcohol use disorder rates by 13 grade, significantly fewer students from percent, returning $9.60 for every $1 CTC communities had health and behavior spent in implementing; problems and were 25 percent less likely l P reparing for the Drug Free Years (PDFY) to have initiated delinquent behavior; 32 — estimated reduction of adult alcohol percent were less likely to have initiated use disorder rates by 6 percent, returning alcohol use; and 33 percent were less $5.85 for every $1 spent on the program; likely to have initiated cigarette use.304 The results were sustained through 10th l L ife Skills training returned $25.61 for grade. And, by the end of 10th grade, every $1 invested; and these students also had 25 percent lower l P roject Alert returned $18.02 for every odds of engaging in violent behavior. $1 invested. Similar results were demonstrated in a study of 12th graders who were part PROSPER308, 309 of CTC. A cost-benefit analysis found a $4.23 benefit for every dollar invested in The PROSPER project (PROmoting the CTC operating system. 305 School/community-university Partnerships to Enhance Resilience), developed by Partnerships in Prevention Science the Partnerships in Prevention Science Institute at Iowa State University306 Institute and the Cooperative Extension, is an evidence-based delivery system Since the early 1990s, the Partnerships for supporting sustained, community- in Prevention Science Institute has been based implementation of scientifically- a large-scale research program focused proven programs that reduce adolescent on leveraging community partnerships substance use or other problem behaviors to implement and scientifically test and promote youth competence. The interventions designed to build family PROSPER delivery system has been and youth competencies, which would shown to reduce a number of negative likely prevent substance use and other behavioral outcomes, including behavioral problems. drunkenness, smoking, marijuana use, Over the past few decades, 17 studies have use of other substances and conduct been conducted, including six randomized behavior problems, with higher-risk youth controlled intervention outcome studies. benefiting the most.310, 311, 312 PROSPER The Institute has demonstrated that also demonstrates positive effects on school:community:university partnerships family strengthening, parenting and youth are effective in delivering and evaluating skills outcomes and reduces negative evidenced-based interventions that reduce peer influences. TFAH • healthyamericans.org 63 D. MPROVING AND SCALING EFFORTS TO ADDRESS I UNMET SOCIAL NEEDS THAT IMPACT HEALTH Factors and influences in people’s daily lives can have a bigger impact on health than genetics or medical care.313 There is wide recognition of the influence that other factors have on health — such as housing, income, education, transportation, the environment and other social determinants.314 For instance, a meta-analysis of nearly Despite the understanding of the 50 studies found that social factors, interplay between health and other including education, racial segregation, factors, this has not broadly translated social supports and poverty accounted into developing policies and programs for more than a third of total deaths in that consider how these factors the United States per year.315, 316 interrelate or how to collectively leverage resources and expertise to generate better results. WHAT DETERMINES HEALTH? (ADAPTED FROM MCGINNIS ET AL., 2002 ) There are a growing number of efforts to identify the most effective strategies for improving health by GE N ETICS HEALTH CA RE SOCIAL, ENV I RONM E N TAL , BEHAVIORAL FACTORS also addressing social needs — and to 20% 20% 60% increase prioritization and investments to support them.317, 318, 319, 320 Source: Blue Cross Blue Shield of Massachusetts Foundation Addressing the social needs and factors that impact health are among the most important priorities for improving the Social Determinants of Health health, well-being and quality of life of Neighborhood Community millions of Americans. It is important to Economic Health Care and Physical EducaƟon Food and Social expand these efforts — investing in the Stability System Environment Context most effective strategies and continuing Employment Housing Literacy Hunger Social Health integraƟon coverage to develop additional approaches. Income TransportaƟon Language Access to Different strategies can help address healthy Support Provider Expenses Safety Early childhood opƟons systems availability different aspects of support — and are educaƟon Debt Parks Community Provider often complementary and should be VocaƟonal engagement linguisƟc and Medical bills Playgrounds considered synergistically. training cultural Support Walkability DiscriminaƟon competency Higher Some key approaches include: educaƟon Quality of care l I mproving integration of healthcare and social services: Health Outcomes Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, FuncƟonal LimitaƟons l “ Navigator and referral” models that Source: Kaiser Family Foundation identify unmet social needs and refer individuals to service; 64 TFAH • healthyamericans.org l M ore comprehensive “navigator, accompanied by reduced healthcare referral and care coordination” costs); and models that not only identify needs l E xpanding and increasing integration but also support patients to access of community-based health and social and receive services; support programs. Many of these l “ One stop” or “no wrong door” models programs go beyond addressing systems where health and social services are that support individualized-services highly integrated and/or co-located; to the broader factors that influence health, such as improving transportation l I ntermediaries — where an systems or food financing initiatives organization helps coordinate a to bring more affordable healthy number of community-based efforts options to underserved communities and programs, including helping and addressing public safety issues manage funding and accounting, to encourage physical activity and evaluation and capacity building; community connectedness. l A broader Accountable Communities for Federal and state governments and Health model that also works to address private healthcare systems should factors in the environment and policy adopt and expand the use of all of the changes — which can combine and models that increase integration and coordinate the place-based local health coordination of health, social services partnership improvement model with and broader community-based initiatives the clinical-social service connection to help ensure people are connected models. The referral and coordination to services that can help support their elements are often supported through unmet social needs — and that help community health workers, social address the broader context of their workers or other case coordinators; environment — to support healthier l I ncreasing funding for key social communities and make healthier choices programs to help improve health easier in their daily lives. outcomes; l A djusting/increasing healthcare payments to pay more for low-income ADDRESSING HIGH NEEDS populations, such as risk-adjusted Housing: 1.2 million people are homeless and 110,000 are chronically homeless. approaches for low-income patients Food and nutrition: 50 million people lack and/or patients impacted by multiple resources to purchase sufficient food and factors. With guidance, this could nutrition. help incentivize health organizations Energy and utilities: 44 percent of low- to invest in social support and income families are economically energy prevention programs and offer insecure. better access and care for medically Transportation: 3.6 million people miss or delay care each year because of and/or socially complex patients transportation barriers. and to help address the true needs Safety: 200,000 ER visits per year are of patients and disproportionaltely attributed to intimate partner violence injuries. affected populations (perhaps, TFAH • healthyamericans.org 65 1. otential Savings from Health and Social Service Coordinator P Systems: Addressing Unmet Social Needs of High-Cost Individuals An new analysis by TFAH and supported (i.e., potentially reaching Healthsperien estimates that investing in between 12 percent and 25 percent of low- Health and Social Service Coordinator income Americans — between 13 million Systems that address gaps between medical and 28 million people). care and effective social service programs Over the next decade, this represents the with a range of strategic and targeted opportunity for a 1 percent to 4 percent interventions — through a “navigator-plus- reduction in healthcare spending for support” approach — could yield between individuals living under 200 percent of $15 billion and $72 billion in healthcare the federal poverty level, with potentially savings a year within 10 years, depending greater savings over the longer term. on how broadly these programs are Impact of Different Factors on Risk of Premature Death Health Care 10% GeneƟcs Social and 30% Environmental Factors Health 20% and Well Being Individual Behavior 40% SOURCE: Schroeder, SA. (2007). We Can Do BeƩer — Improving the Health of the American People. NEJM. 357:1221-8. Source: KFF Source: Healthsperien analysis of Medical Expenditure Panel Survey (MEPS) data on concentration of health spending by income and CMS National Health Expenditure data 66 TFAH • healthyamericans.org TFAH and Healthsperien developed these illustrative savings and cost scenarios based on current health spending in low- income populations and assumptions about potential adoption and program impact. This analysis provides ten year spending estimates for three scenarios that illustrate the impact of investments in this type of connector model that can establish mechanisms that identify patients with unmet social needs — and helps them navigate the system and receive services that address those needs. For instance, case managers or It is intended to be illustrative of the community health workers help these potential impact of this approach patients navigate the system — providing and also raises key considerations. referrals and follow up support to For instance, the impact of targeting help them access key services — such different populations (high cost, as stable housing, adequate food, low income and/or broader focus); and needed non-emergency medical evaluating the existing evidence-base transportation services — which can and the broader potential for increased help improve health and quality of life. programs; the need to increase research These approaches also can serve as a and sophisticated analyses of programs platform to administer targeted social with multi-sector stakeholder/payers programs that address healthcare needs, and potential “savers”; and considering collaborate with partner organizations, total costs as well as net costs. and identify ways to generate and share This analysis considered the current in program savings with the healthcare healthcare spending for low-income sector. Some of these models offer a Americans (individuals living under pathway to a more integrated system 200 percent of the federal poverty that aligns health and social services in a level (FPL)) and reviewed research on manner that lowers costs and improves a targeted social service programs that person’s well-being. have shown results in improving health This analysis considers the impact that and lowering healthcare costs. It then these connectors could have by focusing examined the potential for healthcare on identification, referral, system savings that could be achieved if more navigation and social service models that high-need individuals received targeted affect healthcare utilization and costs. It social services under a connector does not include the impact of the many approach in their communities. healthcare delivery models or public Healthcare spending, primarily health initiatives currently used today Medicare and Medicaid, for individuals — for example, diabetes prevention living under 200 percent FPL is around initiatives, primary care medical homes, $922 billion annually. More than half and asthma reduction — or broader ($589 billion) of that is spent on the policy change and community-wide healthcare needs of 10 percent of that approaches — for example, active living population (around 11 million “highest community development. cost” individuals). TFAH • healthyamericans.org 67 This approach helps identify the The analysis looked at gross savings, as unmet needs of super-utilizers and the a way of identifying the impact on the broader lower-income population and, healthcare sector, and did not include connect them to relevant services in an costs (which are addressed in the organized way. Under more evolved discussion below). forms of the model, which include l low-impact scenario: If 12 percent A partnerships with the healthcare sector, of the low-income population were new models of social programs (e.g., included in ACH programs, there would supportive housing, meal delivery for be an opportunity to save around $15 chronic illness and transport to medical billion per year by 2026. This assumes appointments) can address a range the connector could help identify 20 of community health needs and have percent of super-utilizers — around 2 an impact on a wider range of people. million individuals that have the highest This analysis captures the potential healthcare costs — and spending would opportunity for savings from super- decrease by 10 percent per capita for utilizers, other high-cost individuals and this group (by receiving services). the broader low-income population. l medium-impact scenario: If 19 A The analysis included three illustrative percent of the low-income population scenarios under which Health and were included in connector programs, Social Service Connector System models the opportunity could increase to spread across the United States to $39 billion in savings per year by different degrees in different parts of 2026. This assumes the connector the country. In the scenarios, there organizations could reach 35 percent were varied assumptions about the of the super-utilizers and spending potential target population and the would decrease by 15 percent for extent to which the programs run by the individuals in this group. connector entity resulted in healthcare savings. A review of 15 leading health- l high-impact scenario: If 25 percent of A and-social needs programs found the low-income population were targeted healthcare spending could be reduced by programs operated by connector by 10 percent to 20 percent among entities, the opportunity could increase the highest cost patients. The primary to $72 billion per year by 2026. This source of savings are decreases in assumes the connector and services could avoidable emergency department reach 50 percent of the super-utilizers visits, preventable hospitalizations and and spending could decrease by 20 intensive and long hospital stays. percent per capita for this group. 68 TFAH • healthyamericans.org “LINKED” PROGRAMS YIELDING 10 PERCENT TO 20 PERCENT SAVINGS The program review identified 15 of the to 26 percent for the broader Medicaid pop- but also on other high-cost services like leading social determinant programs that ulation or homeless individuals with lower specialty care. For example, in one of the have achieved improved health outcomes, healthcare needs and costs. Relying on this studies, the impact of supportive housing as well as healthcare cost savings. Most range to inform our scenario development, on Medicaid enrollees in Oregon, emer- of these programs focused on targeted this analysis incorporated the potential gency room utilization declined 18 percent, programs that provided supportive hous- impact for the broader population (where specialty care decreased by 22 percent, in- ing services for homeless individuals with the impact is the greatest for the high need patient events declined (including inpatient high healthcare costs and many showed population but still has an impact for the low- behavioral health), while reported access savings that exceed the cost of running er-need segment of this population). to primary care increased 40 percent.322 the program. For instance: The potential savings analysis also consid- High costs for emergency room and in- l A number of supportive housing ered that in the coming decade, a broad patient services often result from acute programs have shown results in both and growing mix of programs and interven- incidents that could have been avoided with health improvements and cost savings tions could be implemented to address upstream interventions, for example in pri- for high healthcare utilizer homeless social determinants and these estimates mary care, chronic condition management or patients with chronic conditions. These assumed there would be a range of pos- other interventions that addresses deficits programs have demonstrated return on sible scenarios and evidence-based inter- in social factors (unmanaged diabetes, investments ranging from 2:1 to 6:1; ventions, including supportive housing; for example). Research shows that about transportation for the mobility-impaired; 56 percent of emergency room visits are l A large-scale navigation and referral nutrition for people with chronic conditions; potentially avoidable.323 Medicare-focused program for high healthcare utilizers and general programs that keep complex research found that for the highest-cost delivered via community health workers patients out of the emergency room, hos- patients, almost 41 percent of costs associ- shows a return of 4:1; and pital and nursing home. While most of the ated with emergency room visits are prevent- l A program for “transportation current programs that have been evaluated able. For those same patients, research disadvantaged” individuals demonstrated and demonstrated direct healthcare sav- showed that about 10 percent of hospital a ROI of more than 8:1. ings have been targeted to homeless pop- costs are considered preventable.324 ulations, the opportunity curve was based See the following Results from Studies Social programs that can reduce high costs on potential savings for the broader low-in- and Initiatives Designed to Address the of care and prevent the need for utilization come, but still high-cost population. Social Determinants of Health chart on of high cost services are those that help pages 72-74 for the programs included In the studies reviewed, the primary patients access and engage more with in the review. sources of savings are decreased emer- primary care models, that identify and ad- gency department visits and inpatient dress upstream risk factors and that enable The analysis factored in potential savings in hospitalizations. In the healthcare system greater management of chronic conditions. the range of 10 percent to 20 percent for in- overall, those categories of spending com- Programs with the greatest potential iden- dividuals with the greatest healthcare needs prise a substantial share of spending; hos- tify and prospectively target individuals who (the top 10 percent of spenders) and as- pital spending comprises about 40 percent tend to use high-cost services when they sumed lower savings for low-income individ- of total spending. For the highest cost in- could more effectively have been treated in uals with less complex needs. For instance, dividuals, facility costs play an even larger lower cost settings. Addressing social defi- the review found savings for the supportive role. An analysis of the Medicare popu- cits faced by individuals in their homes and housing programs were between 45 percent lation showed that about 79 percent of community is important for effective chronic to 75 percent for super-utilizer, homeless inpatient costs and 33 percent of all emer- condition management, prospective care populations; those populations tend to have gency visits were for those individuals. 321 planning, post-discharge condition monitor- costs at the very high end of the distribution The studies reviewed commonly showed ing and the establishment of stable primary (closer to the top one percent). Other stud- an impact on those facility-based services, care relationships for at-risk patients. ies found a savings potential of 12 percent TFAH • healthyamericans.org 69 HEALTHCARE SPENDING AND POTENTIAL SAVINGS Assumptions and Primary Outcomes from Scenario Analysis Units in billions of dollars, millions of people Baseline (2014) by Low-impact scenario category of spending Spending People % savings % people $ savings people Top 10 percent 589 11 10% 20% 12 2 11% to 25% 231 17 8% 15% 3 2 26% to 100% 101 83 5% 10% 1 8 Total 922 110 2% 12% 15 13 Medium-impact scenario Spending People % savings % people $ savings people Top 10 percent 589 11 15% 35% 31 4 11% to 25% 231 17 13% 25% 7 4 26% to 100% 101 83 8% 15% 1 12 Total 922 110 4% 19% 39 20 High-impact scenario Spending People % savings % people $ savings people Top 10 percent 589 11 20% 50% 59 6 11% to 25% 231 17 15% 35% 12 6 26% to 100% 101 83 10% 20% 2 17 Total 922 110 8% 25% 73 28 In 2014, around $920 billion was spent meaningful interventions would address on healthcare for Americans living below underlying social challenges for the higher 200 percent FPL, based on Medical Expen- cost group more than they would for the diture Panel Survey (MEPS) data.325 This lower-cost segment of the low-income is around $8,000 per person. The analy- population. The analysis assumed in the sis assumes healthcare spending would low-impact scenario is that participation increase each year at roughly the rate overall would be about 12 percent, and of National Health Expenditures (about the highest scenario would be around 5.5 percent per year) and that system twice that amount (25 percent). The esti- stakeholders would incrementally phase in mates assume limits in scaling the model adoption of those programs over the 10- within a 10-year horizon. year period.326 The potential net savings described would Research shows that about 53 percent of accrue to both the Medicaid and Medi- healthcare spending for low-income indi- care programs, as well as other health viduals is for 5 percent of that population programs, though they would have a (including super utilizers); 10 percent of greater impact on Medicaid. The analysis the spending is for 64 percent of this pop- incorporated a long phase-in to reflect the ulation; and 25 percent of spending for early stage of endeavors today and the about 90 percent of this population. effort and evidence required to pursue robust initiatives at scale. As part of that Because of the distribution of spending, phase-in assumption, it is anticipated the analysis assumed that the most 70 TFAH • healthyamericans.org that programs only reach half of their program designs, the integration of partner full potential by the 10-year mark. New organizations working with the connector spending on some health services, such and the need for external funding. Taken as higher use of primary care and pre- as a whole, innovations in the various scription drug use that result from those aspects of those programs and resulting initiatives is included in these estimates. synergies might lead to net savings in the future. An example might include support This analysis only looked at healthcare from the Medicaid program for connecting spending. It did not include costs of non- to housing services plus direct rental as- health services — such as housing, food sistance from other sources and broader or transportation programs. But, for in- resources for other supportive services. stance, under the low-impact scenario, with close to $80 billion in 10-year savings, if It is expected that healthcare systems there was an ROI of 3:1, it would result in and other systems will look to support the a net of $53 billion savings if all program most effective — including cost-effective spending were taken into account. — programs. As these types of efforts proliferate, there would be increased Many of the programs reviewed showed understanding and evaluation of their per- ROIs from 2:1 to 6:1 (direct costs). How- formance — and also increased consider- ever, others had a 1:1 return or did not ation for how to determine the collective show cost savings when all costs were impact — and collective potential returns, taken into account. The healthcare sav- across sectors (for instance, for linked ings component, however, remains im- housing and health programs). portant to consider in the development of Estimated 10-Year Costs Net 10-Year Savings Based on All figures in billions of dollars Based on ROI Assumptions ROI Assumptions 10-Year Scenarios Estimated 2 to 1 3 to 1 4 to 1 2 to 1 3 to 1 4 to 1 Savings Low 80 40 27 20 40 53 60 Medium 200 100 67 50 100 133 150 High 400 200 133 100 200 167 300 TFAH • healthyamericans.org 71 RESULTS FROM STUDIES AND INITIATIVES DESIGNED TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH INITIATIVE FOCUS INTERVENTION FINDINGS ANALYSIS/CONSIDERATIONS Supportive housing – Medicaid Oregon Center for Outcomes This analysis of Medicaid administrative Annual cost of supportive homeless Research and Education (CORE) claims data and survey responses housing in the study was (Portland, Oregon) This pilot study analyzed relative (retrospective and longitudinal) found $11,600 (roughly $960 per Medicaid costs for 98 homeless significantly lower overall healthcare spending member per month), so the individuals before and after for individuals after they moved into supportive healthcare savings did not receiving supportive housing housing.a Results indicate per member per offset intervention costs. with integrated health services month expenditure reduction of $727 (from Survey data indicate that in a project-based housing $1,626 to $899 per month) for the Medicaid the population had improved arrangement between 2010 and participants in the pilot in the first year after access to care and better 2014. The study site was the they received supportive housing. Sources of health outcomes. Bud Clark Commons in Portland, the 45 percent reduction in Medicaid costs Oregon (130 units), a “housing include reductions in emergency department first” facility which has on site use, inpatient care use, outpatient labs and services for case management, specialty care. The study observed lower substance abuse, mental health monthly costs in second year after moving in and employment counseling. ($995 per member per month — a reduction of $631 per member per month). Supportive housing – Medicaid Oregon Center for Outcomes The retrospective analysis of Medicaid The analysis noted that Research and Education (CORE) claims data (2011 to 2015) showed the healthcare savings did not This pilot study analyzed the intervention reduced Medicaid spending by offset the cost of housing. impact of affordable housing on 12 percent on average, a decrease from Medicaid spending for 1,625 $386 per member per month to $338 per individuals in 145 participating member per month. Reductions in costs for properties. Researchers joined with Health Share of Oregon, individuals in permanent supportive housing, an Oregon coordinated care with case management and mental health/ organization.b substance abuse treatment, were 14 percent. For seniors and disabled individuals, costs declined 16 percent. Use of emergency services decreased by 18 percent; primary care service use increased by 20 percent. Supportive housing for high- This cost analysis is from a The study (a follow up to earlier JAMA research/ Although the study results cost homeless with chronic randomized control trial (one Housing for Health Partnership) showed net were not statistically conditions of the first in this area) of annual savings of $6,307 per person (roughly significant, findings (Chicago) 407 homeless adults with $500 per month) for all services, including offer model for future housing.c Net costs were about 17 percent investigations. Spending chronic conditions in Chicago, lower than for the non-intervention population; on housing and case many of whom were post- healthcare costs were 26 percent lower management services was hospitalization analyzed costs (about $716 per month). Primary savings about one-third of health and for medical, housing, legal and came from reduced hospitalizations. Offsetting legal savings, suggesting a case management services. costs came from spending on housing and potential return of about 3:1. It analyzed the impact of the case management, which accounted for about provision of housing (per a half of the net savings and was $3,337 more “Housing First” model) and case (about $278 more per month) than for the non- management during 2003-2007. intervention population. Supportive housing for homeless Pittsburgh (UPMC for You) – In A pre-post study analyzed claims experience The pilot project remains Medicaid population with high its Shelter Plus Care program, of 22 enrollees and found that the program active and expects additional utilization the health plan provided primary reduced per member per month healthcare findings about the return on (Pittsburgh) care clinical services and high- costs by 23 percent, decreasing from $4,100 investment. touch care coordination to a to $3,200 in the first year after the program.d high-cost homeless population in Additional analysis published in March 2016 partnership with a local human showed average per member per month services agency and relying medical costs decreasing by 11.5 percent.e on federal rental assistance subsidies. Supportive housing for high-cost This Los Angeles 10th Decile The study found current public spending on the For every dollar spent, there homeless Project targeted supportive target population (including health and other were savings of $2 in the (Los Angeles) housing services to a high services) was $5,500 per month on average, following year, and $6 in cost subset of the homeless 55 to 60 percent of which was for hospital savings in subsequent years population – in the highest tenth services.f Service use reduction came from (a return on investment of decile of spending. The pilot emergency rooms, hospital readmissions, 2:1 to 6:1). program covered 2011 -2013. and time in the hospital. Based on 2 years of observation, the project saw a 73 percent reduction in spending, with average public and hospital costs (excluding housing) decreasing from $63,808 to $16,913.g 72 TFAH • healthyamericans.org RESULTS FROM STUDIES AND INITIATIVES DESIGNED TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH INITIATIVE FOCUS INTERVENTION FINDINGS ANALYSIS/CONSIDERATIONS Supportive housing for This intervention analyzed public The supportive housing intervention Savings were not exclusively for chronically homeless spending (including for prison, reduced monthly public spending after healthcare spending. In this with severe substance shelter, substance abuse treatment, six months from $4,066 per person a example, the return on investment abuse problems and Medicaid) for a Seattle-based month to $1,492 and to $958 after 12 for supportive housing was about (Seattle) population in a “Housing First” facility months in housing. Savings per month 4.7:1. (Downtown Eastlake Emergency Service over a year period were $3,108, or a Center). 76 percent decrease in spending. After accounting for housing costs of $659 per month, net savings per person was $2,499 per month. Supportive housing for Massachusetts study focuses on The study looked at Medicaid costs pre Additional supportive housing costs chronically homeless chronically homeless and intervention and 1 year post supportive housing. offset about half of the healthcare (Massachusetts) effect on congregated and scattered Average annual Medicaid costs per person savings in the original study; that site housing. The 2006 study analyzed decreased to $8,499 (from $26,124), equates to a return on investment of 2:1. The ongoing program shows the impact on Medicaid spending. a 67 percent reduction in spending. a similar rate of return. Subsequently, the state implemented a Inclusion of housing costs yields net “Housing First” program. savings for housing and Medicaid of $8,949.j Recent estimates from a state-funded study suggest the program reduced per person annual spending from $37,525 to $9,955 (a reduction of 73 percent). Savings primarily were for medical spending, but also for shelter and incarceration costs. Housing costs driving this savings were $15,468.k Supportive housing for Intervention from 1989 to 1997 in Public costs (including, but not homeless New York City quantified costs of exclusively health, for target population homelessness and supportive housing fell by $16,282 (from $40,451), about (New York City) for 4,679 homeless and mentally ill a 40 percent reduction.l individuals. Care management and New York City Health and Hospitals Preliminary analysis found that for the supportive housing for Corporation 3-year pilot (ending in homeless patients, the intervention high-cost Medicaid 2012) targeted high-cost Medicaid led to a 20 percent reduction in enrollees with complex conditions with monthly Medicaid spending. Factors (New York City) supportive housing, care coordination driving that reduction include a 47 and social services. Half of target percent reduction in hospitalizations population was homeless. and more than a 50 percent reduction in emergency room visits. (Spending for hospital services decreased by 27 percent and for emergency room visits decreased by 30 percent.)m Community Health Molina navigation and referral program Early results collected in this Results indicate a return on Worker Intervention for connected community health workers retrospective study over a 25-month investment of 4:1. Estimated High Utilizers (CHWs) with high-utilizer members to period from 2007 to 2009 indicated spending for the program was about help them navigate the healthcare savings from reduced hospital use, $521,000 during the study period. system and connect them with including emergency department Starting in 2014, the state housing, education, and employment visits and inpatient days, improved included the program (Community resources.n,o Joint financing came patient outcomes, and a lower rate of Connectors) in its contracts with from Molina and the University of New substance abuse. Medicaid managed care plans. Mexico: The University paid for CHW Molina plans to expand the program training with Kellogg Foundation; Molina into all states in which it operates. paid salaries. Housing supports for Medicaid managed care organization A 12-month pilot demonstrated that members with behavioral Centene (IlliniCare/Cenpatico) the program lowered hospital costs health needs collaborated with Thresholds, a by 60 percent and encouraged better provider organization, to coordinate outpatient care.p From those results, (Chicago) care for plan members with behavioral Centene decided to pay Thresholds a health needs. The approach includes per member per month fee for their a comprehensive team consisting of services with flexibility for housing psychiatrists, psychotherapists, nurses, services built into the rate. Assuming and community support specialists. hospital spending is about 40 percent of total healthcare spending, savings approximated 24 percent. TFAH • healthyamericans.org 73 RESULTS FROM STUDIES AND INITIATIVES DESIGNED TO ADDRESS THE SOCIAL DETERMINANTS OF HEALTH INITIATIVE FOCUS INTERVENTION FINDINGS ANALYSIS/CONSIDERATIONS Accountable care Hennepin Health is a county-run A 2014 evaluation of Medicaid housing services Researchers attribute reduction organization with accountable care organization in Minnesota commissioned by the federal Department of in utilization to the proximity of housing component - that grew out of a Medicaid demonstration Health and Human Services reports that at the urgent care center and the community level project and began enrolling patients in the end of its first year, the Hennepin initiative emergency department. Experts (Hennepin County, 2012. It is part of a partnership with the achieved a 24 percent reduction in emergency have also suggested that the Minnesota) county human services and public health department visits and a 29 percent decrease co-location of behavioral health department, a provider system, a health in inpatient hospitalizations.q services may have contributed to center, and a Medicaid health plan. It Hennepin Health expects that investments in the reduction in emergency visits. integrates health and social services and social services will decrease healthcare costs No information on the impact shares risk with the partners in a capitated further. For example, it assisted 200 patients of the housing intervention is model. with complex medical needs or a history of available. repeat hospitalizations to access housing.r Supportive housing This collaborative effort – the Collaborative Findings from the study showed improvements and substance Initiative to Help End Chronic Homelessness in healthcare outcomes and a reduction of 50 abuse treatment for – is a federal program that provides percent in total average quarterly health costs. homeless individuals multiple, coordinated services to homeless Spending per person per month decreased (Federal) individuals. from $6,832 to $3,376, a 50 percent drop.s Statewide approach Vermont’s Blueprint for Health relies on Analysis of Medicaid members in pilot sites for Medicaid medical homes, practice facilitators and showed lower hospitalization rates, fewer visits (Vermont) Community Health Teams that provide care with medical specialists and fewer surgical coordination, counseling, substance abuse specialty visits. Per member per month costs treatment support, health coaching and for inpatient services decreased by 22 percent linkages to affordable housing. overall; emergency room costs declined 36 percent. Overall, per member per month costs declined by 11.6 percent.t Community wide The Camden Coalition for Health Care Research shows that monthly hospital charges Replication of the model is approach for high Providers targets high utilizers with intensive for individuals in the intervention fell by 56 underway in other communities utilizers care management services and links percent, with utilization declines in emergency with foundation and CMMI (Camden, individuals to appropriate medical and social room and hospital visits.u Research about the funding. New Jersey) services. program’s impact is ongoing. Transportation Analysis calculated the return to the Overall, Florida invested $372 million in The estimated return on (Florida) state of Florida for its investments in transportation programs for disadvantaged investment for transportation “transportation disadvantaged” programs individuals in five areas: medical, employment, assistance programs was in 2007 – that is, programs for individuals education, nutrition and life sustaining. State 8.5:1 overall. The highest who because of age, disability or income savings related to those investments (including, returns were in the area of do not have access to public transport but not exclusively health) were $3.2 billion. nutrition (12.5:1) and medical options.v About one-third of the transportation investment care (11:1). was for medical-related trips, however. Food – Diabetes CareSource of Ohio partnered with a local food The Diabetic Food Pack Initiative is a 2-year pilot focus bank to create a portable, diabetic-friendly program supported by a grant of $140,000 to (Ohio) food pack that cost less than 15 dollars each. the food bank from the CareSource Foundation. The food pack allows the care management The program is still new, but the program has team to expand the member’s understanding delivered 1,350 diabetic food packs so far of diabetes basics, discuss diabetes self- and CareSource is still collecting survey data. management, support health goals, and An initial survey of more than 80 participants connect members to relevant social services. shows a high level of program satisfaction.x a right BJ, Vartanian KB, Li HF, Royal N, Matson JK, W g aylor, L et. al, “Leveraging the Social Determinants T m vans, M., “Residential therapy: Hospitals take on E Expanded Medicaid Population,” Health Affairs, “Formerly Homeless People Had Lower Overall of Health: What Works?” Yale Global Health Lead- finding housing for homeless patients, hoping to 2014 Nov;33(11):1975-84. Health Care Expenditures After Moving Into Support- ership Institute and the Blue Cross and Blue Shield reduce readmissions, lower costs,” Modern Health- s aylor, L et. al, “Leveraging the Social Determinants T ive Housing,” Health Affairs, 35, no. 1 (2016):20-27. Foundation of Massachusetts, June 2015 care, September 22, 2012. of Health: What Works?” Yale Global Health Lead- b Health in Housing: Exploring the Intersection “ h aylor, L et. al, “Leveraging the Social Determinants T n Johnson, et. al, “Community health workers and D ership Institute and the Blue Cross and Blue Shield between Housing and Health Care,” Center for of Health: What Works?” Yale Global Health Lead- Medicaid managed care in New Mexico,” J Com- Foundation of Massachusetts, June 2015 Outcomes Research and Education (CORE) and ership Institute and the Blue Cross and Blue Shield munity Health, 2012 Jun; 37(3):563-71. t Gottlieb, L, et. al, “Clinical Interventions Addressing Enterprise Community Partners, 2016. Foundation of Massachusetts, June 2015 o Population Health Investments by Health Plans “ Nonmedical Health Determinants in Medicaid c Basu A, et. al. “Comparative Cost Analysis of Hous- i In Focus: Using Housing to Improve Health and “ and Large Provider Organizations – Exploring the Managed Care,” American Journal of Managed ing and Case Management Program for Chronically Reduce the Costs of Caring for the Homeless,” Business Case,” Institute on Urban Health Research Care, May 2016. Ill Homeless Adults Compared to Usual Care,” Quality Matters Archive, The Commonwealth Fund, and Practice, Northeastern University, March 2016. u achrach, D et. al., “Addressing Patients’ Social B Health Services Research, February 2012. October/November 2014 Issue. p In Focus: Using Housing to Improve Health and “ Needs: An Emerging Business Case for Provider d ottlieb, L, et. al, “Clinical Interventions Addressing G j Summary of Studies: Medicaid/Health Services “ Reduce the Costs of Caring for the Homeless,” Investment,” Manatt Health Solutions, May 2014. Nonmedical Health Determinants in Medicaid Utilization and Costs, Corporation for Supportive Quality Matters Archive, The Commonwealth Fund, v ronin, JJ et. al, Florida Transportation Disadvan- C Managed Care,” American Journal of Managed Housing, September 2009. October/November 2014 Issue. taged Programs, Return on Investment Study, The Care, May 2016. k Home and Healthy for Good, Permanent Sup- “ q urt, Martha et. al, “Medicaid and Permanent B Marketing Institute, Florida State University College e Population Health Investments by Health Plans “ portive Housing: A Solution-Driven Model,” Massa- Supportive Housing For Chronically Homeless of Business, March 2008. and Large Provider Organizations – Exploring the chusetts Housing and Shelter Alliance, Progress Individuals: Emerging Practices From The Field,” w K Seligman, et. al., “A Pilot Food Bank Intervention H Business Case,” Institute on Urban Health Research Report, June 2015. Office of the Assistant Secretary for Planning and Featuring Diabetes-Appropriate Food Improved and Practice, Northeastern University, March 2016. l In Focus: Using Housing to Improve Health and “ Evaluation (ASPE), August 2014. Glycemic Control Among Clients in Three States,” f In Focus: Using Housing to Improve Health and “ Reduce the Costs of Caring for the Homeless,” r Sandberg SF, Erikson C, Owen R, Vickery KD, Health Affairs, 34(11):1956-63, November 2015. Reduce the Costs of Caring for the Homeless,” Quality Matters Archive, The Commonwealth Fund, Shimotsu ST, Linzer M, Garrett NA, Johnsrud KA, x Association for Community Affiliated Plans, “Posi- Quality Matters Archive, The Commonwealth Fund, October/November 2014 Issue. Soderlund DM, DeCubellis J, “Hennepin Health: A tively impacting social determinants of health: How October/November 2014 Issue Safety-net Accountable Care Organization for the safety net health plans lead the way,” June 2014 74 TFAH • healthyamericans.org Leveraging Social Determinants of Health The Blue Cross Blue Shield of l H ousing support for low-income care costs has not been adequately Massachusetts Foundation and Yale individuals and families; examined, including income support and Global Health Leadership Institute l N utritional assistance for high-risk early childhood education; and reviewed a range of programs and women, infants and children, as well as l A dditional research on the return on studies in Leveraging the Social older adults and people with disabilities; investment is needed to fully appreciate Determinants of Health: What Works?, and l C ase management and community and quantify the value of these types of some key findings included that:327 outreach for high-need, low-income programs. l T here is strong evidence that increased families and older adults, as well as In addition, the Commonwealth Fund, Skoll investment in selected social services for children with asthma; Foundation and Pershing Square Founda- as well as various models of partnership l I ntegrated healthcare and housing ser- tion’s Addressing Patient’s Social Needs: between healthcare and social services vices for at-risk individuals and families; An Emerging Business Case for Potential can confer substantial health benefits l I nvestment in some other social service Investment report identified a number of and reduce healthcare costs for targeted programs result in improved health out- techniques for addressing patients’ social populations, including: comes, although their impact on health- needs, including: housing, food, public benefits and employment. 328 TECHNIQUES FOR ADDRESSING PATIENTS’ SOCIAL NEEDS Social Need Technique to Address it Housing Assess home safety • Connect individuals to housekeeping services • Connect individuals to pest extermination services • Connect individuals to appliance repair services • Assist individuals with legal needs related to housing, such as housing code violations and utility shutoffs Food Connect individuals to food supports, such as the Supplemental Nutrition Assistance Program, a food bank, the Women, Infants and Children Program, and Meals on Wheels • Connect individuals to a home care agency that can prepare meals • Provide prescriptions for healthy foods Public Benefits Help individuals apply for Medicaid and overturn wrongful denials • Help individuals apply for Social Security Disability Insurance and Supplemental Security Income, and overturn wrongful denials • Provide counseling on available public benefits Employment Offer workshops to improve professional qualifications FOR EXAMPLE: As one example of the types of policies l H ousing: Federal rental assistance Caps; Unemployment Insurance; Child Sup- that can impact health, in 2015, TFAH programs — Housing Choice Vouchers, port; Family and Medical Leave Act (FMLA); released A Healthy Early Childhood Action Section 8 Project-Based Rental Assis- l A ffordable Quality Child Care: Child and Plan: Policies for a Lifetime of Well-being tance, Public Housing; National Housing Adult Care Food Program (CACFP); Child report, which included a review of broad Trust Fund; Care and Development Block Grant Act range policies beyond direct health poli- l S afe, Stable and Nurturing Relationships: of 2014 — Child Care and Development cies and programs that can help improve The Maternal, Infant and Early Childhood Fund (CCDF); Social Services Block Grant the lives of young children, such as: Home Visiting Program (MIECHVP); Child (SSBG or Title XX); Child and Dependent l F ood Assistance: Supplemental Abuse Prevention and Treatment Act Care (CADC) Tax Credit; Dependent Care Nutrition Assistance Program (CAPTA); Flexible Spending Accounts; and (SNAP); Women, Infants and Children l I ncome Support Programs: Earned In- l E arly Childhood Education: Head Start Program; Healthy Food Financing come Tax Credit; Temporary Assistance & Early Head Start; Race to the Top Initiatives (HFFI); New Markets Tax for Needy Families (TANF) program; State Early Learning Challenge; Preschool De- Credits (NMTC); Minimum Wage Levels; State Payday Loan velopment Grants. TFAH • healthyamericans.org 75 E. CALING HIGH-IMPACT COMMUNITY-BASED AND CLINICAL-COMMUNITY S HEALTH IMPROVEMENT STRATEGIES A number of government and other expert groups have identified leading health improvement strategies — that, if scaled, could have a dramatic impact on improving health. Efforts like local health or well-being reimbursement policies; strategically improving core public health systems improvement partnerships; Accountable aligning federal, state and government are all foundations and mechanisms to Communities for Health; Medicare, programs to focus on health and other help support the proliferation of these Medicaid and private insurance outcomes; social impact financing and programs around the country. Examples for Resources for COMMUNITY GUIDE TO PREVENTIVE SERVICES339 Community-Based Health Improvement Programs 20 TOPICS ADDRESSED BY TASK Some resources that identify high-impact FORCE REVIEWS* community-based health improvement Adolescent Health: Improving programs include: Alcohol: Preventing Excessive Consumption CDC’s Guide to Community Preventive Using Evidence Asthma Control to Improve Health Services, a compendium review of 2016 Outcomes Birth Defects: Preventing Annual Report to Congress, Federal prevention programs by The New York Agencies, and Prevention Stakeholders Cancer Prevention and Control* ANNUAL REPORT TO CONGRESS Academy of Medicine (NYAM), series A Report by the Cardiovascular Disease Prevention and of reviews by evidence-based research ...Working to Promote the Nation’s Health since 1996... Control* www.thecommunityguide.org at NIH, SAMHSA’s National Registry of Diabetes Prevention and Control* Evidence-based Programs and Practices Emergency Preparedness and Response (NREPP), the Coalition for Evidence- Health Communication and Social Marketing based Policy, Communities that Care, Health Disparities—Health Equity* Child Trends, The Institute of Education HIV/AIDS, Sexually Transmitted Diseases, Sciences’ What Works Clearinghouse, and Teen Pregnancy: Preventing County Health Rankings and Roadmaps’ Mental Health: Improving PRIORITY AREAS FOR FUTURE What Works for Health and CDC’s Health Motor Vehicle–Related Injury Prevention COMMUNITY GUIDE REVIEWS Education Curriculum Analysis Tool Obesity Prevention and Control* (includes Cardiovascular Disease Prevention Nutrition: Promoting Good) (HECAT).329, 330, 331, 332, 333, 334, 335, 336, 337, 338 and Control Oral Health: Improving Environmental Health Physical Activity: Increasing* Injury Prevention Tobacco Use and Second-Hand Smoke Mental Health: Improving Exposure: Reducing Obesity Prevention and Control (also Vaccination: Increasing Appropriate* includes Nutrition: Promoting Good) Violence Prevention* Older Adults Worksite Health Promotion Physical Activity: Increasing *Asterisks and dark blue text indicate topics Sleep Health with active systematic reviews in FY 2015. Social Determinants of Health Substance Abuse (e.g., Prescription Drug Overdose) Violence Prevention 76 TFAH • healthyamericans.org CDC’s Health Impact in 5 Years (HI-5) Initiative highlights top evidence-based community-wide approaches that can help im- prove health within five years — and reduce costs beyond five years.340 Public and private organizations can use this list to as- sess the scientific evidence for short-term health outcomes and overall cost impacts of these community-wide approaches. Strategy Outcomes and ROIs CHANGING THE CONTEXT School-based Efforts to Increase Elementary or middle school programs that added additional physical activity to the school day for students were Physical Activity estimated to result in a benefit to cost ratio of approximately $33:$1 (in 2015 dollars) over time (decreased healthcare costs and increased labor market earnings).341 School-based Violence A review of 53 school-based violence prevention program studies found reduced violence rates of 29.2 percent Prevention among high school students, 7.3 percent among middle school students, 18 percent among elementary school students and 32.4 percent among pre-kindergarten and kindergarten students — and led to decreased substance misuse and increased academic performance.342 In addition, evaluations of three of the programs found ROIs ranging from $15 to $81 for every $1 spent.343, 344, 345 Safe Routes to School An evaluation of projects in four states found increases in overall active school travel (13 percent to 18 percent), walking (10 percent to 14 percent) and bicycling (3 percent).346 In New York City, Safe Routes to School roadway modifications (e.g., installing new traffic and pedestrian signals) were projected to result in a net benefit of $230 million due to reductions in injuries.347 Motorcycle Injury Prevention Motorcycle helmet laws increase helmet use from around 50 percent or less to more than 90 percent.348, 349, 350, 351 A National Highway Traffic Safety Administration analysis found that helmets saved an estimated 1,630 lives, $2.8 billion in economic costs and $17.3 billion in overall costs including health and lost quality of life. Tobacco Control Interventions Studies of mass media campaigns have found a 6.7 percentage point decrease in initiating tobacco use among youth and a ROI ranging from $7 to $74 saved per $1 spent.352 Increasing the price of tobacco products by 20 percent was associated with a 15 percent reduction in demand for tobacco and a 19 percent increase in quitting among youth and young adults, and healthcare cost savings ranging from -$0.14 to $90.02 per person per year.353 Smoke-free policies were associated with a 5 percent reduction in cardiovascular and a 20 percent reduction in asthma-related hospital admissions. Estimates for nationwide smoke-free policy would result in net savings ranging from $700 to $1,297 per person not currently covered by a smoke-free policy.354 Access to Clean Syringes Estimates that an additional U.S. investment of $10 million to $15 million per year to expand access to clean syringes could avert 194 to 816 HIV infections annually with an ROI of $7.58 to $6.38 per $1 spent.355 Pricing Strategies for Alcohol Across all alcoholic beverages, a 10 percent increase in price is estimated to reduce consumption by 5 percent.356 Products Current alcohol tax rates implemented over 10 years in the North American region could avert 1,224 disability- adjusted life years at a cost of $395 per year of disability avoided.357 Multi-Component Worksite A study of ROI to employers found that a 5 percent weight loss among overweight and obese employees would reduce Obesity Prevention employer expenditures by $90 per employee (due to reductions in medical costs and costs of missed work days).358 SOCIAL DETERMINANTS OF HEALTH Early Childhood Education Benefits to cost ratio estimates range from $3 to $5 for every $1 invested in early childhood programs, including Head Start, Child-Parent Centers and state and district level programs.359, 360, 361 Clean Diesel Bus Fleets Retrofitting existing buses with clean diesel technology can reduce diesel emissions by up to 85 percent — and in Washington state, retrofitted school buses helped decrease pediatric asthma and bronchitis by 23 percent and pneumonia by 36 percent by month.362, 363 According to the Environmental Protection Agency, every federal dollar invested in clean diesel projects yields $5 to $21 in public health related savings.364 Public Transportation Systems Public transportation systems has less than one death per billion passenger miles traveled compared to more than seven in cars and trucks — and produces only 5 percent as much carbon monoxide and 50 percent as much carbon dioxide than cars and trucks.365, 366 Public transport is associated with 8 minutes to 33 minutes of additional walking per day.367 For a city with a million residents, an increase from 10 percent to 20 percent in households located in transit-oriented developments produces health benefits ranging from $71 million to $216 million annually and saves travel time and costs.368, 369 Home Improvement Loans and The overall ROI from improvements to health and energy efficiency due to insulation is estimated to be $1.50 to Grants $2 per $1 of installation costs (including better respiratory and mental health and fewer missed school and work days.370, 371 Earned Income Tax Credits Infant mortality drops by 23.2 per 100,000 for every 10 percent increase in Earned Income Tax Credits (EITC).372 A $1,000 increase in ETIC income for single mothers with limited education income has been associated with a 7 to 11 percent reduction in rate of low birthweight babies.373 EITC payments to eligible California residents contributed over $5 billion in business sales and nearly 30,000 jobs to the state economy.374 Water Fluoridation Fluoridating the water supplies lead to a 15 percent decrease in dental cavities — and can lead to a return of $1.01 to $135 for every $1 invested .375, 376 TFAH • healthyamericans.org 77 SIX WAYS TO SPEND SMARTERCDC is providing intervention strategies. SIX WAYS TO SPEND SMARTER FOR HEALTHIER PEOPLE technical assistance and collaborating FOR HEALTHIER PEOPLE THE 6|18 INITIATIVE THE 6|18 INITIATIVE with employers, private insurers and Medicaid programs to implement priority 6|18 strategies.377 With support from Accelerating Evidence into Action REDUCE CONTROL PREVENT HEALTHCARE- TOBACCO USE BLOOD PRESSURE ASSOCIATED INFECTIONS (HAI) the RWJF, CDC, the Center for Health Accelerating Evidence into Action Care Strategies (CHCS), ASSOCIATED HEALTHCARE- the Association (HAI) REDUCE CONTROL PREVENT TOBACCO USE BLOOD PRESSURE INFECTIONS CONTROL ASTHMA PREVENT UNINTENDED CONTROL AND PREGNANCY PREVENT DIABETES of State and Territorial Health Officials The Centers for Disease Control and Prevention (CDC) is partnering with health care purchasers, payers, and providers to and the National Association of Medicaid CDC is improve health and control health care costs. CDCwith thesesystem. These initiatives help identify taking a lead role in partnering provides partners with rigorous evidence about high-burden health conditions and associated interventions to inform their decisions to have the greatest health and cost impact. This initiative Directors are working with state Medicaid healthcare purchasers, payer and providers top initial priority areas of focus and align aligns evidence-based preventive practices with emerging value-based payment and delivery models. and public health agencies to CONTROL AND the help with to identify some key high-impact, evidence- evidence-based prevention practices with ASTHMA CONTROL PREVENT UNINTENDED PREGNANCY PREVENT DIABETES HIGH-BURDEN HEALTH CONDITIONS AND EVIDENCE-BASED INTERVENTIONS implementation of 6|18 tobacco, asthma based strategies for addressing high-burden value-based healthcare models. The following is a list of six high-burden health conditions with 18 effective interventions and unintended pregnancy efforts in nine health conditions that to improve health and control health care costs. support better patient The Centers for Disease Control and Prevention (CDC) is partnering with health care purchasers, payers, and providers to that CDC is prioritizing The 6|18 Initiative: Accelerating Evidence states: Colorado, Georgia, Louisiana, health beyond traditional medical care improve health REDUCE and control health PREVENT costs. CDC provides these partners with rigorous evidence about high-burden health care into Action targets six common HEALTHCARE- ASSOCIATED INFECTIONS PREVENT UNINTENDEDand Massachusetts, Michigan, Minnesota, New practices —TOBACCO USE the use and support to expand PREGNANCY conditionstreatments,associated interventions nursing facilities.health •conditions withfull rangeproven and including individual, • Expand access to evidence-based tobacco • Require antibiotic stewardship programs intheir decisions for the 18 of to inform all costly Reimburse providers to have the greatest health and cost impact. This Carolina.378 York, Rhode Island and South initiative for thesecessation telephone counselingthe healthcare hemodialysis-related infections approaches by and hospitals and skilled contraceptive services (e.g., screening for alignsFDA-approved cessation medications—in evidence-based preventive practices with emerging value-based payment and delivery models. group, and • Prevent through immediate coverage for insertion of pregnancy intention; tiered contraception counseling; insertion, removal, replacement, accordance with the 2008 Public Health permanent dialysis ports. or reinsertion of long-acting reversible Service Clinical Practice Guideline. contraceptives (LARC) or other contraceptive • Remove barriers that impede access to devices; and follow-up) for women of child- CONTROL covered cessation treatments, such as cost bearing age. HIGH-BURDEN HEALTH CONDITIONS AND EVIDENCE-BASED INTERVENTIONS ASTHMA sharing and prior authorization. • Reimburse providers or health systems for the • Promote increased utilization of covered • Promote evidence-based asthma medical actual cost of LARC or other contraceptive treatment benefits by tobacco users. management in accordance with the 2007 devices in order to provide the full range of National Asthma Education and Prevention The following is a list of six high-burden health conditions with 18 effective interventions CONTROL HIGH Program guidelines. contraceptive methods. • Reimburse for immediate postpartum BLOOD PRESSURE • Promote strategies that improve access insertion of LARC by unbundling payment for that CDC is prioritizing to improve health and control health care costs. • Promote strategies that improve access and adherence to asthma medications and devices. LARC from other postpartum services. • Remove administrative and logistical and adherence to anti-hypertensive and • Expand access to intensive self-management barriers to LARC (e.g., remove pre-approval lipid- lowering medications. education for individuals whose asthma is not requirement or step therapy restriction and REDUCE • Promote a team-based approach to hypertension control (e.g., physician, management alone. PREVENT HEALTHCARE- well-controlled with guidelines-based medical manage high acquisition and stocking costs). PREVENT UNINTENDED TOBACCO USE pharmacist, lay health worker, and • Expand access to home visits by licensed ASSOCIATED INFECTIONS CONTROL AND PREGNANCY patient teams). professionals or qualified lay health workers PREVENT DIABETES • Provide access to devices for self-measured to improve self-management education and • Expand access to evidence-based tobacco blood pressure monitoring for home-use • Require antibiotic stewardshipDiabetes • Expand access to the National programs in all reduce home asthma triggers for individuals • Reimburse providers for the full range of Prevention Program, a lifestyle change cessation treatments, including individual, and create individual, provider, and health system incentives for compliance and hospitals and skilled nursing 2 diabetes. program for preventing type facilities. whose asthma is not well-controlled with guidelines-based medical management and contraceptive services (e.g., screening for group, and telephone counseling and meeting of goals. • Prevent hemodialysis-related infections • Promote screening for abnormal blood intensive self-management education. glucose in those who are overweight or obese pregnancy intention; tiered contraception FDA-approved cessation medications—in through immediatecardiovascular riskfor insertion of as part of a coverage assessment. counseling; insertion, removal, replacement, » To learn more, contact the CDC Office of the permanent dialysis ports. accordance with the 2008 Public Health Associate Director for Policy at healthpolicynews@cdc.gov. or reinsertion of long-acting reversible Service Clinical Practice Guideline. contraceptives (LARC) or other contraceptive • Remove barriers that impede access to Services devices; and follow-up) for women of child- Department of Health and Human CONTROL covered cessation treatments, Control and Prevention Centers for Disease such as cost bearing age. ASTHMA November 2015 sharing and prior authorization. • Reimburse providers or health systems for the • Promote increased utilization of covered • Promote evidence-based asthma medical actual cost of LARC or other contraceptive treatment benefits by tobacco users. management in accordance with the 2007 devices in order to provide the full range of National Asthma Education and Prevention contraceptive methods. CONTROL HIGH Program guidelines. • Reimburse for immediate postpartum BLOOD PRESSURE • Promote strategies that improve access insertion of LARC by unbundling payment for and adherence to asthma medications LARC from other postpartum services. • Promote strategies that improve access and devices. • Remove administrative and logistical and adherence to anti-hypertensive and • Expand access to intensive self-management barriers to LARC (e.g., remove pre-approval lipid- lowering medications. education for individuals whose asthma is not requirement or step therapy restriction and • Promote a team-based approach to well-controlled with guidelines-based medical manage high acquisition and stocking costs). hypertension control (e.g., physician, management alone. pharmacist, lay health worker, and • Expand access to home visits by licensed CONTROL AND patient teams). professionals or qualified lay health workers PREVENT DIABETES • Provide access to devices for self-measured to improve self-management education and • Expand access to the National Diabetes blood pressure monitoring for home-use reduce home asthma triggers for individuals Prevention Program, a lifestyle change and create individual, provider, and health whose asthma is not well-controlled with program for preventing type 2 diabetes. system incentives for compliance and guidelines-based medical management and • Promote screening for abnormal blood meeting of goals. intensive self-management education. glucose in those who are overweight or obese Source: Centers for Disease Control and Prevention as part of a cardiovascular risk assessment. 78 TFAH • healthyamericans.org » To learn more, contact the CDC Office of the Associate Director for Policy at healthpolicynews@cdc.gov. 86 MILLION adults have prediabetes Without weight loss and moderate physical activity 15–30% of people with 5 prediabetes will 9 10 develop type 2 diabetes Y E ARS OUT people with prediabetes within 5 years EXAMPLE HIGH-IMPACT 6|18 INITIATIVE STRATEGY: OF don’t know they have it DIABETES PREVENTION PROGRAM The Diabetes Prevention Program can cut participants’ risk for type 2 diabetes by REDUCING THE IMPACT OF DIABETES more than half.379, 380 DPP is an example of Congress authorized CDC to establish the NATIONAL DIABETES how improved integration of medical care PREVENTION PROGRAM (National DPP)—a public-private and support in daily life can improve health. initiative to o er evidence-based, cost e ective interventions in communities across the United States to prevent type 2 diabetes l T he program reduced the risk for devel- oping diabetes by 58 percent.381 Even after 10 years, people who completed It brings together: a diabetes prevention lifestyle change HEALTH CARE program were one-third (34 percent) less EMPLOYERS ORGANIZATIONS Research shows FAITH-BASED structured lifestyle likely to develop type 2 diabetes. For PRIVATE INSURERS ORGANIZATIONS interventions can people over 60 years of age, the pro- COMMUNITY GOVERNMENT cut the risk of AGENCIES ORGANIZATIONS type 2 diabetes in gram reduced risk by 71 percent. 382 l T he lifestyle intervention was even more HA LF effective — and lower cost — than using to achieve a greater impact on reducing type 2 diabetes the diabetes drug Metformin, which low- Source: Centers for Disease Control and Prevention ered risk by 31 percent.383 l D PP has resulted in average savings in the Centers for Medicare and Medicaid their community benefit dollars to develop of $600 to $2,200 annually;384 and Services certified that expansion of DPP or improve diabetes prevention programs.391 over 10 years ranging from $5,280 to would reduce net Medicare spending and $6,300 per participant.385, 386, 387 DPP is an evidence-based lifestyle change improve the quality of patient care without program that supports healthier eating, l A review of the cost-benefits of the pro- limiting coverage or benefits. Specifically, incorporating physical activity into daily gram to insurance payers found a private results indicated statistically significant sav- life and improving problem-solving and payer could reimburse $655 (24 percent) ings of $2,650 for each enrollee, sustained coping skills. The program, developed by of the $2,715 in DPP costs during the weight loss of approximately 11.7 pounds NIH and CDC, is now offered by more than first three intervention years and still after one year and reductions in inpatient 625 organizations, including many local recover all of these costs in the form of hospital admissions and Emergency De- YMCAs, employers and health plans, and medical costs avoided. If Medicare paid partment visits.389 This marks the first time is recommended by the AMA. Physicians up to $2,136 in intervention costs over a preventive service model from the CMS and specialists refer patients to the the 15-year period before participants Innovation Center has become eligible for program, which is managed by trained reached age 65, it could recover those expansion into the Medicare program.390 educators, community health workers or costs in the form of future medical costs The American Medical Association (AMA) other providers — supporting “lifestyle avoided beginning at age 65.388 also adopted a policy, in June 2016, call- coach” case management, behavior self- In addition to being a top evidence-based ing for private and public health insurance management training and group sessions strategy in the 6|18 Initiative, in March plans to include diabetes prevention pro- and supervised physical activity sessions 2016, the independent Office of the Actuary grams as covered benefits and to leverage as well as clinical support.392 TFAH • healthyamericans.org 79 Diabetes: Health and Cost Impact l N early 10 percent of Americans (9.3 l D iabetes costs the country $245 billion percent, 29 million people) have type 2 a year (including $176 billion in direct diabetes.393 medical costs; diabetes patients have 2.3 times higher medical costs).365 l M ore than one-third of adults (86 mil- lion) have prediabetes and could be eli- l O ne in three adults could have diabetes gible for and benefit from DPP. 365 by 2050, according to CDC projections.394 l B lacks, Latinos and American Indian/ Alaska Natives are around twice as likely to have diabetes as Whites.365 Examples of DPP in Action l C MS supports a DPP-demonstration and a 58 percent risk reduction in Type program among 10,000 Medicare benefi- 2 diabetes rates over three years.397 ciaries with prediabetes that runs through The state’s Medicaid program opted to 2016. YMCA and a subsidiary of United- provide DPP as a covered benefit start- Health Group are working with a number ing in 2012.398 of states and communities to examine the l T he School District of Palm Beach effectiveness of the program in improving County reported a 9 percent reduction health and reducing healthcare costs.395 in total net costs from offering DPP as l P revent by Omada Health in San a covered benefit to employees — sav- Francisco, California is using an online/ ing about $2.9 million.399 digital enhanced version of DPP for l T he Florida Health Care Coalition, a patients at risk for heart disease — with group of employers representing nearly a simulated ROI of more than $1,500 2 million insured individuals, is en- for people with prediabetes and heart couraging its employers to work with disease — and reduction in diabetes insurers to provide coverage for DPP . rates by more than 30 percent and They estimate the ROI for a company reduction in stroke rates by 11 percent that offers eligible employees a DPP to 16 percent — within five years.396 program is about $55,000 over 10 l A number of state health departments and years for each employee with predia- healthcare coalitions are encouraging DPP betes who does not eventually develop coverage and programs for employers: diabetes. One Florida employer offer- ing the program, the Orange County l T he Montana Department of Public government, made an investment of Health found that if 700 Montanans with $57,185 in preventive wellness claims prediabetes enrolled in DPP, it could that is projected to result in over $2.5 yield an annual return of $1,132,394 million in savings over 10 years.400 80 TFAH • healthyamericans.org Diabetes Self-Management Education/ control their glucose levels and diabetes.401 Training (DSME/T): There are also pro- Economic analyses indicate net savings of grams that help individuals with diabetes $0.44 to $8.76 for every $1 spent on DS- manage their disease and avoid escalating ME/T and commercially insured members health problems or conditions — with sup- using diabetes education cost on average port to develop knowledge, skills, problem 5.7 percent less than members who do not solving strategies and behaviors needed to participate in diabetes education.402, 403 Additional Self-Management Programs Self-management strategies help bridge visits and hospital utilization ($364 the divide between care inside and outside net savings). If scaled to 10 percent the doctor’s office. The strategies often of Americans with chronic diseases, provide group workshop or counseling the estimated savings would yield $6.6 series led by trained facilitators, health ed- billion annually. More than 20 studies ucators or community health workers that have shown improved health results from include support for issues from pain man- these programs, and they have been agement and medication to nutrition and endorsed and/or supported by CMS, exercise to mental and behavioral health CDC, Agency for Healthcare Research to communicating with doctors.404, 405 and Quality, HHS Administration on Aging, the Surgeon General, the Arthritis l S tanford’s Self-Management Programs Foundation and the American College of have been found to result in $714 per Rheumatology.406, 407, 408 person savings in emergency room The AMA has developed an ROI calculator ered benefit (potential cumulative and net for employers to calculate potential med- savings over a 3-year period), available at: ical savings from providing DPP as a cov- https://ama-roi-calc ulator.appspot.com/ TFAH • healthyamericans.org 81 EXAMPLE HIGH-IMPACT 6|18 INITIATIVE STRATEGY: CHILD ASTHMA PREVENTION PROGRAMS In Boston, Massachusetts, Boston visits, care conferences and school/ Children’s Community Asthma Initiative daycare visits and social worker (CAI) employs a nurse and community services. Over the past 20 years, the health worker model to provide support efforts have contributed to significant to improve the health of children with reductions (64 percent) in the number moderate to severe asthma in targeted of hospitalizations, days hospitalized Boston neighborhoods who have visited for children and emergency department emergency departments or who were visits (from 60 percent to 35 percent). hospitalized. The initiative provides a The program results in around $800 in home environmental assessment and net healthcare savings per child per year asthma management and medication (and an estimated $1,625 in savings education, while working with the family from reduced hospital charges among and the child’s healthcare providers low-income children with moderate to to remove barriers to improve asthma severe asthma). The social benefit-cost control. A nurse also works with ratio for asthma case-management community organizations, day care services over a two-year period is $1.53 centers and schools to provide asthma for every dollar spent. education in the community. CAI led to The Asthma Starts program, supported a return of $1.46 to insurers/society by the Alameda County Public Health for every $1 invested; an 80 percent Department in California, includes reduction in the percentage of patients home visiting by social workers to help with one or more asthma-related with medication adherence; addressing hospital admission; and a 60 percent potential asthma triggers (including reduction in the number of patients with HEPA-filter vacuum cleaners and non- asthma-related emergency department bleach mold cleaners as needed); and visits in FY 2011.409 referrals and case management to other The Asthma Network of West Michigan needs that increase risk for asthma- (ANWM) is a grass-roots coalition that related problems (including housing, addresses the high rates of pediatric job referral, food, access to medical asthma morbidity and mortality, with care and insurance). The program has initial funding from three acute care an ROI of $5 to $7 for every $1 spent; hospitals and two local foundations, has reduced emergency department and partners with the Healthy Homes visits and hospitalization; maintained Coalition. 410 The coalition implements or reduced symptoms for 95 percent home-based asthma case management of participating children; and results programs for young and school-aged in savings of up to 50 percent for the children and adults with uncontrolled Alameda Alliance of Health Medicaid asthma. The model includes: home managed care organization.411 82 TFAH • healthyamericans.org F. IMPROVING USE OF PREVENTIVE SERVICES Another key component of improving health is through preventive healthcare services. While the ACA required most health insurers to cover the evidence-based preventive services recommended by the U.S. Preventive Services Task Force (such as seasonal flu vaccines and screenings for cancers, obesity and tobacco use) without out-of-pocket co- payments, millions of Americans are still not regularly receiving these benefits.412 Preventive services have been shown to improve health outcomes and reduce costs by identifying illnesses earlier, managing them more effectively and treating them before they develop into more complicated conditions.413, 414 Simulation models suggest that increasing use of clinical preventive services could avert up to 100,000 deaths and save $3.7 billion in medical costs annually.415, 416 However, the delivery of these services remains low. For instance: medication; one in four below age l O nly 21 percent of children aged 10 65 receive a flu vaccine; and only two to 47 months undergo recommended thirds have had cholesterol levels developmental screenings.417 checked during the past five years.421 l A mong children ages 19 to 35 months, l 3 3 percent of children ages 1 to 2 only 46.5 percent of uninsured, 68.9 years are screened and reported for percent of those with public health lead poisoning.422 insurance and 76.1 percent of those with private health insurance receive l 1 4 percent of those under 21 receive all recommended vaccinations.418 dental preventive services (topical fluoride, sealant or both) in a given l O nly 20.9 percent of 11- to 21-year- year.423 old tobacco users receive tobacco cessation assistance during outpatient l 2 5 percent of 50- to 64-year-olds visits, and more than a third (37.3 and less than 50 percent of those percent) of adult outpatient visits 65 and older are up to date on have no documentation of tobacco recommended clinical preventive use status.419, 420 services, including cancer, obesity, diabetes and other screenings and l A mong adults, fewer than half preventive medication and counseling with cardiovascular disease are for those with cardiovascular risk.424, 425 prescribed aspirin or other preventive TFAH • healthyamericans.org 83 l L ess than 1 percent of Medicare l I ncrease payment and reimbursement enrollees — 120,000 — have for preventive services to encourage participated in obesity counseling providers to deliver them. For since it became available in 2011, example, the Million Hearts although more than 15 million Cardiovascular Risk Reduction Model Medicare enrollees are obese and for Medicare patients identifies would be eligible for the benefit.426 patients with high cardiovascular risk and offers providers financial There are a number of reasons for the incentives for improving their care via low-usage rates. preventive and other services. Many insurance plans and providers l I nclude recommended clinical interpret the guidelines in different preventive services in electronic ways — including in terms of what type medical records and clinical reminder of provider can provide a service, in systems to improve delivery and what setting and how often the service tracking of these services. is provided. For instance, some plans may restrict tobacco use screening l E xpand and enhance delivery of to primary care providers, some may preventive services by allowing restrict frequency of screening and non-physician healthcare providers others may restrict the types of FDA to provide preventive services, approved cessation medications that are encouraging use of preventive services covered. The National Commission on via case management and delivering Preventive Priorities will be releasing preventive services in community updated rankings of clinical preventive settings beyond the clinic. services by health impact and cost l R educe barriers to accessing effectiveness in 2017. preventive services, especially among CDC, the Office of the Surgeon populations at risk, by expanding General and others have highlighted hours of operation, providing child strategies that can increase use of care, using linguistically and culturally preventive services: 427, 428, 429, 430, 431, 432 appropriate communication and reminder systems and coordinating l C learly define preventive services care among diverse providers. in health plan benefit language and ensure consistent implementation l E ducate the public and providers and eligibility criteria, as well as to increase awareness of insurance clear communication of benefits to coverage of preventive services and consumers and providers. promote their delivery. 84 TFAH • healthyamericans.org A Public Health and Healthcare System SECTION 2 Prepared for Emergencies SECTION 2 SECTI O N 2 Blueprint for SECTION 2: A PUBLIC HEALTH AND HEALTHCARE SYSTEM PREPARED FOR EMERGENCIES A Public Health and Healthcare System Prepared for Emergencies a Healthier Health emergencies are unpredictable, but regularly arise. America America’s public health system, however, Some key priorities for achieving a more cannot consistently respond effectively and prepared system include: efficiently when major new crises occur, l R equiring strong, consistent baseline largely because periods of important public health abilities in regions, states investment were followed by significant and communities around the country. budget cuts. Instead, the country Communities should maintain a key becomes complacent, and is often caught set of Foundational Capabilities and “off guard” when a new threat arises — focus on performance outcomes in whether it is Zika, Ebola, a pandemic flu, a exchange for increased flexibility and natural disaster or a bioterrorist threat. reduced bureaucracy. Reasons for this situation include: l S table, sufficient emergency l R eliance on unpredictable and delayed preparedness funding to maintain a emergency supplemental funds rather standing set of core capabilities so they than steady investments to be ready to are ready when they are needed. In respond to emergencies before they addition, a complementary Public Health become serious problems and that pro- Emergency Fund is needed to provide vide insufficient resources to backfill immediate surge funding for specific longstanding gaps in the nation’s public action for each new emerging threat. health system, particularly when core pro- The current process of insufficient grams have been gutted by funding cuts; funding means there are long-standing gaps in the baseline system. Emergency l L ack of clear, consistent core supplementals are often delayed and not preparedness, response and recovery able to backfill ongoing vulnerabilities in capabilities that each state or region the response system. should be able to maintain — which means that the abilities of the public l Improving federal leadership before, health and health system range during and after disasters — including dramatically from zip-code to zip-code at the White House level, such as by and community to community; and creating a permanent Special Assistant to the President for Health Security l D isjointed response planning between — to provide leadership, coordination the public health sector, healthcare and expertise for a government-wide providers and other emergency first approach to preparedness, response and responders and between federal agencies. recovery efforts. Clear federal leadership OCTOBER 2016 In the following section, TFAH reviews and an agreed upon framework of recommendations from public health responsibilities — including fully experts for how to improve the nation’s utilizing authorities in existing laws — emergency response system to ensure can clarify roles particularly in health stronger foundational capabilities are emergency responses that cross federal in place and more flexibility is possible agencies and involve domestic and when emergencies arise. international actions. l A more focused investment strategy support private-public partnerships to support science and technology and regionalized health models. upgrades that leverage recent Engage all of the partners to invest breakthroughs and hold the promise in building a broader community of transforming the nation’s ability to response strategy since all partners promptly detect and contain disease in a community are at risk and outbreaks and respond to other stand to benefit from more effective health emergencies. For example: preparedness and response abilities. advances in genomics; near real- l upport a culture of resilience so S time, interoperable surveillance; and all communities are better prepared developing the next generation of to cope with and recover from medical countermeasures, including emergencies, particularly focusing on antivirals and vaccines. those who are most vulnerable. l R ecruiting and training a new The Bipartisan Report of the Blue Ribbon generation public health workforce Study Panel on Biodefense, a 2015 report, with expert scientific abilities to concluded that: “Simply put, the Nation harness and use technological does not afford the biological threat advances, critical thinking and the same level of attention as it does management skills to serve as Chief other threats: There is no centralized Health Strategist for a community. leader for biodefense. There is no The workforce should be able to lead comprehensive national strategic plan health investigations; build plans to for biodefense. There is no all-inclusive address problems; bring partners dedicated budget for biodefense. The and resources together across health Nation lacks a single leader to control, and other sectors impacted by health prioritize, coordinate and hold agencies for increased collective impact; and accountable for working toward communicate and effectively educate common national biodefense. This the public on how to reduce risk weakness precludes sufficient defense and better protect themselves, their against biological threats.”433 families and their neighborhoods. A modern and stable biodefense ability l Reconsidering health system requires refocusing public health preparedness for new threats and departments and resources to be able mass outbreaks. Develop stronger to effectively use workforce, emerging partnerships among providers, technology and strategies to achieve hospitals, insurance providers, better outcomes and results — and pharmaceutical and health equipment better protect Americans from new and businesses, emergency management ongoing threats. and public health agencies to help 88 TFAH • healthyamericans.org l Reforming Baseline Abilities to Diagnose, Detect and Control Health Crises: Foundational Capabilities Americans deserve and should expect basic health protections, no matter where they live. Yet, while there have been many reorient its resources and operations improvements in national health when a major disaster hits, resulting in security in the 15 years since the anthrax gaps in basic public health functions. and terrorist attacks of 2001 and 11 A leading recommendation by the years since the landfall of Hurricane Health and Medicine Division of Katrina, funding has been unstable the National Academies of Science, and insufficient to maintain baseline Engineering and Medicine (formally capabilities. As a result, fundamental the Institute of Medicine) and public health services intended to other experts is to establish and protect our health and the funding of maintain a clear, consistent set of key these programs often vary dramatically foundational capabilities — that focus from state-to-state and among on performance outcomes in exchange communities and territories. And for increased flexibility and reduced disease and death rates vary significantly bureaucracy.436, 437 from city to city and region to region. The expert-defined foundational TFAH’s 2015 report, Outbreaks: Protecting services should include: 1) Americans from Infectious Diseases, communicable/infectious disease found that more than half (28) of prevention; 2) chronic disease and states scored a five or lower out of 10 injury prevention; 3) environmental key indicators related to preventing, public health; 4) maternal, child and detecting, diagnosing and responding family health; and 5) access to and to outbreaks.434 And the latest National linkage with clinical care.438, 439 Health Security Preparedness Index found that, despite progress over the past few In addition, 19 state, 130 local and years, the nation’s health protections are one tribal health department have not distributed evenly across the United been accredited through the voluntary States, with a preparedness gap of 36 national accreditation program (as of percent between highest and lowest August 2016) — a measurement of states in 2015.435 So while public health health department performance against is now able to prepare for and respond a set of nationally recognized, practice to many small scale emergencies, such focused and evidence-based standards.440 as isolated foodborne outbreaks and The Public Health Leadership Forum some types of natural disasters, this has recommended that there should be instability leaves first responders without financing mechanisms to help all states adequate tools and systems to respond and localities achieve accreditation and and an unsteady foundation to build the ability to deliver foundational public upon when significant emergencies health services, either directly or through arise. At the same time, unstable cross-jurisdictional collaboration.441 funding means that public health must TFAH • healthyamericans.org 89 VISION FOR A BASELINE PUBLIC HEALTH SYSTEM: To Address Emergencies and Ongoing Health Concerns Surveillance & Data/ Laboratory Capacity Epidemiology/Investigations Information Systems Trained Expert Workforce + Research/Evidence-Informed Strategies Accountability & Continuous Quality Improvement Sustained, Stable Funding This approach means changing siloed l C ommunicating with the public and grant and budget structures that often other audiences to disseminate and fund different aspects of these core receive health-related information in capabilities separately and do not an effective manner, including health focus on performance, capabilities or promotion opportunities, access to outcomes for the overall integrated, care and prevention; coordinated system. l M obilizing the community and forging For instance, many current grants partnerships to leverage resources for epidemiological, laboratory and (including funding); surveillance support are administered l B uilding new models that integrate separately and for specific diseases. clinical and population health; A foundational capabilities model includes the ability and flexibility l C ultivating leadership — along with for communities to build upon organization, management and business foundational capabilities to meet their — skills needed to build and sustain specific needs and concerns, contingent an effective health department and on additional available resources. workforce to effectively and efficiently Jurisdictions that could demonstrate promote and improve health; their ability to meet the foundational l D emonstrating accountability for capabilities could be given greater what governmental public health flexibility in their use of federal support does directly and for those things that for core public health functions. it oversees through accreditation, Ensuring the workforce is well trained continuous quality improvement and to carry out these capabilities and that transparency; and a mechanism for continuous quality improvement and stable, sufficient l P rotecting the public in the event of funding are in place are all inherent to an emergency or disaster, as well as the success of this model. responding to day-to-day challenges or threats, with a cross-trained workforce. The defined foundational capabilities include: More than perhaps any other role of health departments, the l A ssessment (surveillance, foundational capabilities model is key epidemiology and laboratory capacity); to strengthening preparedness for l D eveloping policy to effectively public health emergencies. These core promote and improve health; functions of modern public health — such as modernized laboratory, l U sing integrated data sets for workforce, and surveillance capabilities assessment, surveillance and evaluation — are the cornerstone to a community’s to identify crucial health challenges, capacity to track and contain disease best practices and better health; outbreaks or respond to disasters. 90 TFAH • healthyamericans.org EXAMPLES OF STATES ADOPTING FOUNDATIONAL CAPABILITIES A number of states, including Colorado, it would require an additional $21.8 Oklahoma and Washington, have taken million and local health jurisdictions steps to move toward a foundational in the state would need an additional capabilities approach within the state $78.0 million (2013 dollars) (total $99.9 and local public health departments. million statewide) to fully and effectively implement foundational capabilities.442 For instance, Washington State has: engaged stakeholders (such Ohio has also been developing as hospitals, community health strategies for implementing foundational organizations, service providers and capabilities, and has moved forward laboratories) to partner with public to consolidate some local health health departments and improve or departments and cross-jurisdictional increase health information exchange; services and programs and to prioritize reviewed state public health laws to funding streams.443, 444 Colorado legally identify governing power and regulations defined foundational “minimum quality across jurisdictions; reviewed funding standards,” and within two years has streams to determine what mandatory shown significant increases in the delivery services may or may not be attached to of several programs and service areas.445 funding; identified which services can be The Public Health Cost Estimation Work provided by state health departments Group has developed a methodology versus local health departments; to help state and local health and engaged with policy makers to departments determine the cost of gain support of legislative changes adopting foundational capabilities, needed to fully develop and implement and the data will be used to generate foundational public health services. The national estimates.446, 447 state’s Department of Health estimated TFAH • healthyamericans.org 91 l Stable, Sufficient Funding for Ongoing Emergency Preparedness — and Funding a Permanent Public Health Emergency Fund to Support Immediate and “Surge” Needs During an Emergency The country has not provided sufficient funds to maintain an adequate and stable level of preparedness for public health emergencies — whether an act of bioterrorism, major disease outbreak, natural disaster or an accidental man-made incident (such as a chemical spill). Federal funding for state and local and administration; surveillance preparedness has been cut by about one- and epidemiologic investigation; third (from $940 million in FY 2002 to information sharing and $651 million in FY 2016) and hospital communications; legal and liability emergency preparedness has been cut protections; increasing and upgrading in half (from $515 million in FY 2004 to public health staffing trained to $255 million in FY 2016).448 The Zika prevent and respond to emergencies; outbreak has illustrated how the erratic and limited improvements in medical nature of funding for infectious disease surge capacity. capacity impacts our ability to respond, l ome significant, never-well- S such as the initial ramp-up of funding for addressed gaps include: Coordinated, vector-borne diseases after West Nile Virus interoperable, near real-time outbreaks, followed by a decline in that biosurveillance; maintaining a stable capability at many health departments.449 medical countermeasure strategy There have been a series of emergency and funding to continue research, supplemental funds appropriated as development and purchase of vaccines, new threats have emerged, but they are antiviral medications and antibiotics; often delayed and they are inadequate to chemical and radiation laboratory backfill gaps or to support ongoing needs. services; surge capacity within the As a result, when the next emergency healthcare system for a mass influx arises, many basic competencies and of patients — along with standards of capabilities are not in place to respond care and in-place tiered systems of care effectively. Another challenge is that state for a range of threats; and the ability to and local governments are reluctant to help communities, and especially their hire new personnel using short lived, one- special need populations, become time funding. In the past 15 years: more resilient to cope with and recover from emergencies. l ome major areas of accomplishment S include: Emergency operations Like police, firefighters and Federal planning and coordination; Emergency Management Agency public health laboratories; vaccine (FEMA) personnel, public health manufacturing; development of the professionals are first line responders. Strategic National Stockpile (SNS), However, they do not currently have the a federal repository of medical ongoing support — resources, supplies countermeasures, as well as an and training — needed to be able to improved system to develop MCMs effectively manage crises. Maintaining a more quickly; pharmaceutical and steady public health system is analogous medical equipment distribution to having a ready military defense — 92 TFAH • healthyamericans.org where the country maintains a standing, complex, multipronged outbreak, Sandy, or similar event. Federal agencies trained force on a consistent basis, but while federal agencies were forced to could release the emergency funds to aid additional resources and support are reprogram funds from other important the immediate state and local response, needed to fight a war. health programs, like the Ebola response jumpstarting research and development and the all-hazards Public Health until additional funds arrive. And such a And once there is a perception that a Emergency Preparedness cooperative contingency fund, if deployed early in a widespread threat has been averted, the agreement. Supporting a standing crisis, could help prevent an event from funding falls back, even though funds Public Health Emergency Fund as a becoming a disaster. are often still needed to support the complement to ongoing funding streams measures that were taken to contain it, A standing Public Health Emergency is an important step to be able to provide such as providing continued support Fund would complement ongoing “surge” resources and immediately and to prevent and contain Ebola in West preparedness, but cannot replace effectively respond to a new serious Africa. This cycle puts the nation at ongoing funds to support baseline threat when it emerges. A Public Health unnecessary risk when new threats preparedness. This Fund would need Emergency Fund is currently authorized emerge and hampers the ability to tackle to be paired with ongoing support for that allows the Secretary of Health and ongoing problems — like HIV, antibiotic- preparedness through programs like the Human Services to access funds when resistant infections or even the seasonal Public Health Emergency Preparedness a public health emergency is declared flu. Currently, without sufficient support and Hospital Preparedness Programs and — however it has not received resources for emergencies, funds and personnel funding for medical countermeasures since FY 1999. Such a fund would need end up being diverted from other public development, as well as cross-cutting to be maintained and replenished at health priorities to respond to a new programs that support capacity. Without a funding level sufficient to respond problem, like the Zika outbreak. this base of support, the cost of ramping to an emerging public health threat. up quickly during an emergency is In addition to ongoing investments, the Providing contingency resources for a significantly higher than if a solid federal government needs immediate, public health emergency fund would foundation is maintained. And in major flexible funds to respond to significant bridge the gap between the smaller-scale disasters, supplemental funds are often crises. Delays in appropriation of emergency response that public health still needed to support the long-term emergency funds for Zika, for example, conducts on a day-to-day basis and the needs — such as vaccine development — has meant health departments, arrival of supplementary emergency to contain an emergency after the initial healthcare providers and researchers appropriations, if the crisis rises to the response has concluded. were ill-equipped to respond to a level of an Ebola, H1N1, Superstorm U.S. Public Health Expenditures in Dollars per Capita and as Percentage of National Health Expenditure (NHE): 1960-2023 300 3.5 250 3 2.5 $ Per Capita 200 Percentage 2 150 1.5 100 $ per capita (inflation adjusted) 1 Percentage of NHE 50 0.5 0 0 60 63 66 69 72 75 78 81 84 87 90 93 96 99 02 05 08 11 14 17 20 23 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 Year Source: American Journal of Public Health, 2016 TFAH • healthyamericans.org 93 OUTBREAKS: PROTECTING AMERICANS FROM INFECTIOUS DISEASE In December 2015, TFAH and RWJF outbreaks.450 Five states — Delaware, The report concluded that the United released the Outbreaks: Protecting Kentucky, Maine, New York and Virginia States must redouble efforts to better Americans from Infectious Diseases — tied for the top score, achieving protect the country from new infectious report, which found that more than half eight out of 10 indicators. Seven states disease threats, such as MERS-CoV (28) of states scored a five or lower out — Idaho, Kansas, Michigan, Ohio, and antibiotic-resistant superbugs, and of 10 key indicators related to preventing, Oklahoma, Oregon and Utah — tied for resurging illnesses like whooping cough, detecting, diagnosing and responding to the lowest score at three out of 10. tuberculosis and gonorrhea. MAJOR INFECTIOUS THREATS AND KEY FINDINGS Embargoed until ISSUE REPORT Outbreaks: 10:00 am ET on December 17 WA 2015 PROTECTING MT ME ND AMERICANS FROM VT INFECTIOUS DISEASES OR MN ID NH SD WI NY MA WY MI H ealthcare workers in West Africa report that some personnel are able to wear their PPE for only 40 minutes at a time CT RI because of high temperatures and humid conditions. Even in the United States, where NE IA PA NJ NV management of patients with Ebola is done in air-conditioned environments, uncomfortable PPE is a common complaint and causes a OH burden for healthcare workers. In September 2014, President Obama announced a “Grand Challenge” to design IL IN DE UT improved PPE for use by healthcare workers CA MD during treatment of Ebola patients. CDC’s National Institute for Occupational Safety CO and Health (NIOSH) is partnering with other WV U.S. agencies on the “Fighting Ebola: A Grand Challenge for Development” to help MO VA healthcare workers on the front lines provide better care and stop the spread of Ebola. The USAID-led Grand Challenge includes KS DC KY developing, testing, and improving PPE to address issues of protection, heat stress, and comfort for healthcare workers. NIOSH conducts research that supports the epidemic response and the Grand Challenge NC and is working closely with federal partners on the Grand Challenge, including (but not limited to) participating in crowdsourcing events to promote innovation, reviewing promising ideas that can be scaled to the field, and setting performance, test, and AZ TN evaluation requirements. OK NM AR SC A NIOSH sweating thermal manikin with the PPE ensemble commonly used by Doctors Without Borders (MSF) for high CDC artist’s rendering of the Ebola virus. There are five identified Ebola virus species, four of which are known to cause disease in humans. GA exposure areas. 44 10 MS AL Scores Color TX LA 3 4 DECEMBER 2015 FL 5 AK HI 6 7 8 SCORES BY STATE 8 7 6 5 4 3 (5 states) (6 states) (11 states) (12 states) (9 states & D.C.) (7 states) Delaware Alaska Arkansas Arizona Alabama Idaho Kentucky California Illinois Colorado D.C. Kansas Maine Maryland Iowa Connecticut Florida Michigan New York Massachusetts New Hampshire Georgia Indiana Ohio Virginia Minnesota New Jersey Hawaii Louisiana Oklahoma Nebraska New Mexico Mississippi Nevada Oregon North Carolina Missouri South Carolina Utah North Dakota Montana South Dakota Vermont Pennsylvania Tennessee West Virginia Rhode Island Wyoming Wisconsin Texas Washington 94 TFAH • healthyamericans.org NATIONAL HEALTH SECURITY PREPAREDNESS INDEX The National Health Security Community Planning and Engagement, Occupational Health. In 2016, the total Preparedness Index™ (NHSPI) was Incident and Information Management, national average for the indicators was a developed in 2013 as a new way to Healthcare Delivery, Countermeasure 6.7 out of a possible 10. measure and advance the nation’s Management and Environmental and readiness to protect people during a disaster — including major infectious disease outbreaks caused by nature or acts of bioterrorism.451 The NHSPI measures the health security preparedness of the nation by looking collectively at existing state-level data from a wide variety of sources. Uses of the Index include guiding quality improvement, informing policy and resource decisions and encouraging shared responsibility for preparedness across a community. NHSPI aims to provide an accurate portrayal of how prepared our nation is to both prevent health incidents and effectively respond should an incident occur. The Index was developed by the Association of State and Territorial Health Officials (ASTHO) in partnership with CDC and more than 20 developmental partners as a tool for advancing health security preparedness — the ability to serve and protect the nation’s greatest asset, its people. In 2015, the National Coordinating Center for Public Health Services and Systems Research at the University of Kentucky, with support from RWJF, took the lead for managing and maintaining the Index. The Index consists of six domains, including Health Security Surveillance, Source: National Health Security Preparedness Index TFAH • healthyamericans.org 95 l Improved Federal Leadership Before, During and After Disasters In addition to funding, recent disasters have illustrated gaps in federal leadership. In particular, emergencies that cross coordinators — has been important, — including the use of a Public Health federal agencies and/or have both an there is an ongoing gap in the permanent Emergency Fund. international and domestic component, structure of the White House to respond In addition, there is a need to review the such as the Ebola and Zika outbreaks — effectively to emerging and ongoing roles and responsibilities across the federal have demonstrated the lack of clarity of threats. A White House-level leader agencies (with national, state and local roles and responsibilities as well as the would be able to trigger and coordinate stakeholder participation) involved in need for cross-cutting national leadership a multi-agency response, identify the emergency health response — including as well as coordinated national/state/ lead agency and be the ultimate arbiter Office of the Assistant Secretary for local leadership. There is a need for contested decisions. A permanent Preparedness and Response (ASPR), for a permanent Special Assistant to position would also ensure a major focus CDC, CMS, the agencies within the U.S. the President for Health Security to on the national security risks posed by Department of Homeland Security (DHS), provide leadership and coordination health emergencies and bring health FDA, NIH and USAID — to ensure efforts for a government-wide approach to expertise to the role. Additionally, there are as efficient and effective as possible preparedness, response and recovery must be better use of existing authorities, and bureaucracy is limited. This should efforts. While the appointment of such as roles outlined in the Pandemic include better alignment and leveraging emergency coordinators — such as and All-Hazards Preparedness Act,452 and public health programs and efficiencies the Ebola or pandemic flu response an agreed-upon framework for response across federal, state and local efforts. A NATIONAL BLUEPRINT FOR BIODEFENSE: REPORT OF THE INDEPENDENT PANEL ON LEADERSHIP AND MAJOR REFORM NEEDED THE U.S. DEPARTMENT OF HEALTH AND TO OPTIMIZE EFFORTS453 HUMAN SERVICES EBOLA RESPONSE454 In October 2015, the biparti- Wainstein. The Blueprint for In June 2016, an the recommendations san Blue Ribbon Study Panel Biodefense recommenda- independent panel of were: implement the Global on Biodefense issued a tions included: centralized experts, led by Jonathan Health Security Agenda; Blueprint identifying the need biodefense leadership at Fielding, MD, published its improve coordination for increased leadership to the national level, having a review of the HHS response between HHS and other elevate coordination and strong comprehensive na- to the Ebola outbreak. government partners, collaboration and drive inno- tional biodefense strategy The report found the U.S. including clarifying roles vation to improve the nation’s and plan, modernizing and government was not well and responsibilities; ensure preparedness for biological updating biosurveillance and prepared to respond to effective communications threats. Panel members information systems, im- a crisis that had both with the public; and provide included: former Senator proving and incentivizing the domestic and international sustained funding for Joseph Lieberman (co-chair), medical countermeasures elements and did not emergency preparedness, as Governor Thomas Ridge (co- enterprise, providing support effectively use existing plans well as contingency funding chair); former U.S. Secretary to build and maintain coordi- during the outbreak. Among for initial response activities. of HHS Donna Shalala, Sen- nated and functional hospital ator Thomas Daschle, Repre- preparedness and maintain- sentative James Greenwood ing sufficient and ongoing and former U.S. Homeland support for state and local Security Advisor Kenneth preparedness capacity. 96 TFAH • healthyamericans.org l Building an Ongoing, Focused Strategy to Support Scientific and Technological Upgrades, Including Wide Implementation of Faster Diagnostics, Biosurveillance and Medical Countermeasures. New technologies, such as whole genome sequencing, are increasingly used by CDC, the military and other state-of-the-art national laboratories to more quickly and effectively identify the reason for and extent of a disease outbreak. The leading current use of these technologies is in the area of foodborne illnesses — in some cases speeding up investigations by several days or being able to determine the cause of an outbreak that would not have been possible using the last generation of investigative tools. Scientists are working on similar technologies for other pathogens. Other emerging technologies, such as metagenomics, hold the potential to advance the ability to better diagnose and track patients for diseases ranging from Zika to Ebola to new strains of antibiotic-resistant Superbugs. Being able to use and scale these advances around the country will require an investment to upgrade the technology, as well as training for how to use the technology and to conduct these different types of epidemiological (disease detective) investigations. The underlying public health system would also need to adapt to match a faster pace and different types of investigations and Source: Centers for Disease Control and Prevention containment strategies. These scientific changes provide an important new opportunity to “leap outbreaks. However, historically the 2014 to bring DNA sequencing (“next- frog” to overcome longstanding gaps public health system has not had generation sequencing” (NGS) which and problems within the system. built-in mechanisms to support and enables “whole-genome sequencing” incorporate developments in science (WGS)), bioinformatics, and related Upgrading to Modern Molecular and technology. For many years, technology into public health in the Technologies there had not been a meaningful United States. With funding through Advances in diagnostic technologies investment toward upgrading many of the AMD program, these technologies allow scientists to identify the causes the basic systems used by public health are now being brought to bear against of outbreaks and connections between laboratories — which hampered the a wide range of infectious disease different cases much faster. This ability to incorporate new technology, threats across the United States helps identify how widespread an identify both emerging and ongoing and are rapidly transforming the outbreak may be and how to treat health problems in a community and monitoring of these threats, as well as it. In public health, the revolution track patterns to better discover the the response to outbreaks. Whereas in DNA sequencing technologies causes and cures of diseases. U.S. public health agencies three over the past decade is having a years ago were behind in the adoption CDC’s Advanced Molecular Detection dramatic impact on the detection of, of these technologies, they are now (AMD) program was established in and response to, infectious disease leading the world in many areas. TFAH • healthyamericans.org 97 Whole genome sequencing prevents Listeria illness Before using whole genome sequencing (WGS) (Sept 2012–Aug 2013) Year 1 of WGS (Sept 2013–Aug 2014) Year 2 of WGS (Sept 2014–Aug 2015) Source: Centers for Disease Control and Prevention To explain the technology in general increased the need for epidemiologic terms, CDC has said, “imagine doing a “boots on the ground” to investigate 10,000-piece jigsaw puzzle in the time possible sources of illness. On top it takes to finish a 100-piece puzzle. of this, the revolution in sequencing Apply that to infectious disease control, technology and analysis is continuing, and that is AMD at work. Now imagine with sequencing costs decreasing, putting together that 10,000-piece automation increasing, and analytic puzzle when key pieces are missing, methods improving, all of which are disease is spreading and people are continuing to open up opportunities dying. AMD gives CDC scientists the to prevent disease, intervene earlier ‘key pieces’ to protect people from ever- in outbreaks, and ultimately to save changing infectious disease threats.”455 costs. Scaling these and other emerging technologies requires a long-term AMD technologies are now being strategy and an investment in the applied in many areas, such as food technology and the training of scientists safety, influenza prevention and to use equipment effectively. tuberculosis control. While CDC has this technology, it is starting to scale New diagnostic technologies; changes broader use to targeted public health in data-management capabilities labs to be able to test for certain to more quickly identify and track pathogens. With assistance from CDC, outbreaks and problems; and the ability many state health laboratories are now to develop new vaccines, diagnostics acquiring the technology and applying it and antivirals — particularly for to detect outbreaks and improve health. emerging diseases — and to counter With improved funding and reduced growing antibiotic-resistant threats all price points, the technology could be hold tremendous promise, but will not used to support disease investigations be realized unless there is continued around the country. While this investment and a fundamental change means that more outbreaks are being in how the country thinks about and detected and detected earlier, it has also invests in public health. 98 TFAH • healthyamericans.org EXAMPLES OF CDC INVESTIGATIONS USING ADVANCED MOLECULAR DETECTION (AMD) AMD Helps Trace Connections in some state public health labs, CDC used HIV Outbreak456 AMD methods to gain more information on In January 2015, there were 11 con- the virus. As a result, in little over three firmed cases of HIV in one county in months, CDC and the state labs had iden- rural southeastern Indiana — by May tified 1,116 people across 47 states who there were 135 HIV-infected people con- had suffered respiratory illness that was nected to this community, which had a caused by EV-D68. With the AMD pro- large number of injection drug users. In gram’s resources, CDC was able to quickly addition to traditional epidemiological ap- map the entire genomic sequence of the proaches, CDC scientists helped Indiana virus along with six other viruses repre- by using AMD methods — combining de- senting the three known strains. The pro- mographic data gathered from labs and gram also helped develop a rapid lab test. genetic sequences of each individual’s This work improved the capacity of public HIV strain — to find the links between health laboratories to perform molecular the infected and how the virus was typing tests that more rapidly identify and spreading. This enabled researchers to detect enteroviruses and thus enhance quickly, in near real-time, identify where outbreak investigations and response. the most transmissions were occurring, Whole Genome Sequencing Pinpoints thereby allowing public health workers to Source of Listeriosis Outbreak458 target prevention efforts and researchers In the fall of 2014, seven people died and to use additional AMD tools to predict 34 were hospitalized during a multi-state how fast the outbreak could grow. Going Listeriosis outbreak. Since the outbreak one step further, scientists used the was spread over several states, research- technology to ascertain the overlap of ers needed to quickly identify which cases hepatitis C virus (HCV) and HIV transmis- were related. Using the traditional labora- sion, which helped public health officials tory technique, scientists found the DNA of strategically assign additional resources the germs, identifying two different strains. to reduce further HCV and HIV infections. In addition, scientists began using WGS Identifying Enterovirus D68 in and other AMD methods, allowing them to Children with Respiratory Illness457 investigate one cluster a week earlier than In summer 2014, hospitals in Missouri if they had used only traditional methods. and Illinois were experiencing increased Researchers soon found one individual admissions of children with severe respi- infected with both strains, leading them to ratory illness — some children were so ill conclude that there was a common source they needed intensive care and ventilators of the outbreak. Through patient inter- to breathe. The hospitals quickly tested views, it became evident that most had specimens from the children and found eaten caramel apples before becoming ill, enterovirus. After being notified, CDC tracing the apples back to a single sup- confirmed the finding and identified entero- plier. AMD methods and whole genome virus D68 (EV-D68) in most specimens. sequencing helped quickly identify that Soon thereafter, CDC began to test speci- the source of the outbreaks were contam- mens from across the country, discovering inated Granny Smith and Gala apples and EV-D68 in almost every state. Along with likely prevented many additional illnesses. TFAH • healthyamericans.org 99 l Modernizing to Real-Time, Interoperable Disease Surveillance One of the most fundamental components of disease prevention and control is the ability to identify new outbreaks and threats and track ongoing ones. But, U.S. health surveillance systems on improve the dissemination of real- many levels are often disjointed and out- time, interoperable and interactive of-date. Public health departments tend information across public health, to have different, unconnected systems healthcare providers and other systems. tracking different health problems, In addition, there is growing capability which often contributes to a significant to connect health trend information time lag in the collection, analysis and with risk factor data sources — to look reporting of information, including at the impact of different factors on of new infectious or foodborne illness health and better identify outbreaks outbreaks. Health departments are or the potential causes of health often burdened with redundant, siloed problems in particular neighborhoods disease reporting systems. or regions. Any new system should There are around 300 different health be able to identify health trends at a surveillance systems or networks neighborhood or zip code level — to supported by the federal government.459 be able to effectively identify trends Most of the systems are not interoperable and contributing factors to many health and serve an array of different purposes. inequities, which cannot be discerned The lack of cross-cutting surveillance through county or state level data. capacity has led to serious gaps in visibility Achieving a modern biosurveillance on pressing health crises. For instance, system would help faster, more effective there has been a lag in a number of identification and tracking of outbreaks communities in tracking and recognizing and other health problems, while hepatitis C outbreaks — stemming making surveillance less burdensome from a rise in heroin use — which has on state and local public health exacerbated the spread of the disease departments. It will require upgrading and constrained the ability to use early hardware and software; maintaining containment and prevention strategies. A these technologies around the country; foundational capabilities approach could standardizing efficient reporting help address these types of gaps. standards; and hiring and training staff Health information technology is with computer science and information transforming the way healthcare is technology skills, including in how to delivered, and public health must adapt use systems and to interpret data. In just as quickly to take advantage of these addition, there will need to be effective advancements. These transformations integration with electronic health mean public health must also envision records and electronic laboratory public-private partnership in new ways. reporting. Supporting and incentivizing New data systems and sources, electronic real-time and two-way communications health records, electronic laboratory between healthcare providers and health reporting, mapping systems, cloud-based departments are critical components. disease reporting systems and relational There are also significant barriers in databases have the ability to significantly changing the culture and practice of 100 TFAH • healthyamericans.org how disease surveillance is conducted at all levels of public health. Agencies may have to let go of legacy systems, while public health may have to work with state lawmakers to address barriers in electronic disease surveillance while maintaining patient privacy. To help overcome fragmentation in health information systems, reduce the burden in reporting and better analyze existing data, CDC, ASTHO and other groups explored the creation of a Public Health Community Platform based on shared infrastructure and services. The goal is to provide a forum where common data can be exchanged, analyzed and visualized through an interoperable system.460 With RWJF leadership, public health departments (including CDC) of these plans do not include funding identified that “if managed more have partnered with the healthcare estimates for the coming years. There effectively, federal investment in HIT industry and developers of electronic is not sufficient funding currently to (whether through the [Office of National medical records to begin implementing carry out all of the aspects of these Coordinator for Health Information a scalable demonstration in a few states plans. Implementing a modern disease Technology (ONC)] or through CMS, to notify state health departments surveillance system will require up-front which is now actively encouraging states automatically when cases of reportable investments in technology and a trained to develop all-payer data systems) and diseases are detected in the healthcare workforce, as well as the political will public-health surveillance… could system. This first electronic case to let go of legacy systems. There must achieve better outcomes without reporting service (on a community public also be a long term funding strategy for necessarily requiring new resources.”464 health platform) in a few states sets the federal, state and local public health To help improve the integration way forward for a host of needed services to achieve the goal of a modernized and alignment of public health and to exchange data between healthcare and system. An investment in modernization healthcare surveillance, they identified public health for prompter action. would save money in the longer term by policy initiatives including that: reducing duplicative and work-intensive Funding — at the federal, state and l P ublic health departments should legacy systems and preventing avoidable local level — remains a significant have the right workforce and outbreaks. There are also significant challenge. From 2012 to 2014, the technology to advance surveillance and barriers in changing the culture and federal government released a series of epidemiological functions, including practice of how disease surveillance is biosurveillance strategies and road maps by aligning CDC programs to support conducted at all levels of public health. to help consolidate systems, eliminate foundational capabilities; and Agencies may have to let go of legacy redundancies and reduce unnecessary systems, while public health may have l O NC should set standards for the reporting burdens. These focus on the to work with state lawmakers to address nation’s HIT system that ensure ability to integrate with electronic health barriers in electronic disease surveillance better coordination with public health record systems and other emerging while maintaining patient privacy. departments as they develop the health information technologies — capability to work in the HIT system, including calling for partnerships NAM’s Vital Directions for Health and and that ONC should work with CDC across private and public healthcare Health Care paper on Information and other public health agencies to systems and state and local public health Technology Interoperability and Use ensure interoperability of their systems. departments.461, 462, 463 However, most for Better Health Care and Evidence TFAH • healthyamericans.org 101 l Incentivize and Support Medical Countermeasure Research, Development, Stockpiling and Distribution The government is often the only real customer for most MCM products, such as anthrax and smallpox vaccines. As a result, the U.S. government has invested in the research, development and stockpiling of emergency medical countermeasures for a pandemic, bioterror attack, emerging infectious disease outbreak, or a chemical, radiological or nuclear event. A successful domestic MCM enterprise the initial investment was depleted, is an important aspect of preparing Congress began funding BioShield by for new threats, expected or an annual appropriation for purchase unexpected, by building the science, of products, appropriating $520 million policy and production capacity in in FY 2016. The FDA also launched advance of an outbreak. the Medical Countermeasures Initiative (MCMi) in 2010 to coordinate research, Congress created Project BioShield (in set deployment and use strategies and 2004) and authorized the Biomedical facilitate access to MCMs, which has led Advanced Research and Development to greater transparency and efficiency Authority (BARDA, in 2006). HHS for MCM developers.467 created a multi-agency Public Health Emergency Medical Countermeasures Ebola supplemental funding also Enterprise (PHEMCE) partnership helped BARDA to develop 12 potential (in 2006) to speed the development of Ebola vaccine and therapeutic MCMs by supporting advanced research, candidates.468 Thus far in 2016, some development and testing; working with promising areas under development manufacturers and regulators; and with HHS investments include: helping companies devise large-scale assisting Zika vaccine advancements, manufacturing strategies.465 The Project a new anthrax vaccine and diagnostic, BioShield Special Reserve Fund (SRF) new broad spectrum antibiotics and was originally established as a $5.6 pathogen reduction technologies for billion fund, over 10 years, to guarantee blood products.469 Once a new MCM a market for newly developed vaccines is developed, the FDA can expedite and medicines needed for biodefense the ability to use the product if needed that would not otherwise have a and if there is no other alternative commercial market. The investment available under the Emergency Use has supported 190 new candidate Authorization (EUA) authority. projects and 16 new MCMs for purchase In 2015, ASPR released an updated under Project BioShield.466 After 102 TFAH • healthyamericans.org PHEMCE Strategy and Implementation Plan for the next five years, and federal law requires them to send a five-year spending plan to Congress for the enterprise based on anticipated needs. However, recent budget requests and funding levels have not kept up with estimated needs, including replenishing expiring products already in the Strategic National Stockpile.470 Achieving a strong MCM strategy in the United States that continues to support research and development of vaccines, antivirals and other countermeasures requires continued support for incentives for biopharmaceutical companies to invest in the research and development of MCMs, particularly due to the limited funding for purchase under Project Source: Bavarian Nordic BioShield. Unpredictable funding, such as the delayed funding to respond to the Zika outbreak, could discourage potential innovation if researchers do not feel the government will be a reliable partner. In addition, there needs to be ongoing funding to support the Strategic National Stockpile — to restock and upgrade — so MCMs are available and not expired in the event they are needed. Also, there must be better established systems to support public-private partnerships for distributing and administering vaccines and medicines, including insurer support for MCM payment when appropriate and possible. And, without a robust public health infrastructure to ensure SNS and other MCM products reach the individual patient, research and Source: Alliance for Biosecurity development on its own is not enough to ensure products are used effectively. TFAH • healthyamericans.org 103 l Maintaining a Robust, Well-Trained Public Health Workforce Many leading experts — including initiatives led by the Association of State and Territorial Health Officials, the National Association of County and City Health Officials (NACCHO), the Association of Public Health Laboratories (APHL), the de Beaumont Foundation, schools of public health and other expert groups — are focused on the need to recruit and retain a next generation of public health workforce. The public health workforce is Needs Survey (PH WINS) conducted experiencing major challenges. The by ASTHO and the de Beaumont current state and local public health Foundation to highlight the need for workforce is not large enough nor cross-cutting skills include that:474 professionally diverse enough to meet l R etirements and high turnover rates community needs, and there are major present challenges in maintaining gaps in the training and capabilities of experience, leadership and continuity the existing workforce to meet modern in core capabilities; health problems. l M any public health jobs require The size of the workforce has been highly-trained, specialized scientific cut over the past 35 years — and there skills — such as laboratorians and needs to be greater training to match epidemiologists — and it is important the skills of the workforce to the most to build career tracks that attract a pressing, current public health needs.471 new generation of experts and retain l T he public health workforce experienced expert professionals. Only 17 percent significant job losses during the Great of the public health workforce has any Recession, resulting in more than 51,000 kind of degree in public health; and job losses from 2008 to 2014;472 l A need to expand training related to l F rom 1980 to 2000, the ratio of and strategies for how to effectively public health workforce to the U.S. address principal factors that population has decreased dramatically influence health — such as for systems from 220 per 100,000 population to changes that incorporate health into 158 per 100,000 population; housing and economic development and working effectively across diverse l 3 8 percent of state and local public populations. health professionals plan to leave governmental public health by 2020 Public health departments need to — 25 percent of state public health recruit and retain appropriately trained employees plan on retiring and 13 and experienced public health and percent plan on leaving their job;473 and health professionals with the abilities to detect, diagnose and track health l 4 8 percent of state and local public problems — but also need to build a health professionals are over 50 years workforce that can develop strategies old; 15 percent are over 60. to improve health and reduce chronic Some key issues raised in the Public and persistent problems, which requires Health Workforce Interests and being able to work with a wide range of 104 TFAH • healthyamericans.org partners and sectors to implement the a regular basis based on training needs strategies. Some priorities for workforce assessments and changing agency and development include: systems thinking; community needs.476 Assessing optimal communicating persuasively within and public health workforce needs should outside of public health; influencing be considered as part of Community and developing policy; business and Health Needs Assessment reviews. financial management; the ability to A 2013 CDC Public Health Workforce be flexible and manage a changing Summit Report identified multiple factors environment; analytic and technical that lead to the public health workforce skills and informatics; information crisis, including the insufficient number technology and computer science of current workers across public health experts of various levels; and being able disciplines and insufficient investment to work with diverse populations.475 As in training and training evaluations.477 technological and informatics needs of Summit leaders called for public health departments increase, it will be health agencies to develop a plan to especially challenging to sustain a public recruit professionals to enter the public health workforce when public health health workforce, including those with funding remains unstable. backgrounds in informatics, business To help better train and maintain the and finance management and law; and workforce, NACCHO and ASTHO have for agencies to encourage mentorship recommended the implementation of between those in supervisory and non- a workforce development plan tied into supervisory positions to prepare mid- quality improvement that is updated on level staff for leadership positions. TFAH • healthyamericans.org 105 l Rebooting and Developing a New Strategy for Hospital and Healthcare Emergency Preparedness — Surge Capacity for Major Emergencies; Healthcare Associated Infections; and Integrated Public Health and Healthcare Response One of the major persistent gaps in public health emergency preparedness is the ability of the healthcare system to rapidly respond to a mass influx of patients or to contain a serious new outbreak. The healthcare system is structured to including hospitals, long-term care emergency health plans and strategies. match regular demands in a community, facilities, outpatient facilities, emergency One potential lever is the recently and does not maintain a “surge” capacity medical services, local health departments finalized CMS emergency preparedness to quickly ramp up the additional staff, and others.481 These coalitions vary in requirements for all Medicare and medicine, equipment, beds and other size and capacity. HHS has identified Medicaid providers.484 Facilities that may types of resources that may be needed capabilities these coalitions should have never prepared for disaster could — and needed quickly — to respond to achieve, such as medical surge planning, now have an incentive to participate a major emergency. In addition, many emergency operations coordination and in healthcare coalitions and to ensure supplies are ordered on a “just-in-time” information sharing.482 There is wide their staff is well-trained for a crisis. basis, so most healthcare facilities and variation and limited transparency in how CMS and ASPR should work together to hospitals do not have extra equipment well states and the coalitions within them ensure coordination between healthcare or large quantities of supplies on hand are doing in achieving capabilities defined coalitions and facilities within the when mass casualty events occur. Many by HHS. While some have achieved coalition’s region in order to meet both outpatient facilities, emergency medical notable successes, other coalitions are CMS requirements and HPP capabilities. services (EMS), and long-term care in nascent stages or lack buy-in from CMS could also pilot bonus incentive organizations have also been left behind healthcare administration within the payments for performance outcomes in planning for disasters, both for their region.483 HPP must receive stable, robust around preparedness. own patients and to help community funding to ensure the program can Another important preparedness coordination efforts. Rebooting achieve its goals. HPP should prioritize asset could be value-based healthcare healthcare preparedness will require performance measures and focus funding models, such as Accountable Care collaboration and planning between the and technical assistance on meeting gaps Organizations.485 Healthcare Ready public health, healthcare delivery and identified in those measures. Coalitions has proposed ACOs — collaboratives of payment systems. should also ensure they are formulated to doctors, hospitals and other healthcare reflect how healthcare is really delivered The Hospital Preparedness Program providers that join together and in their region, leveraging existing (HPP), administered by ASPR, was coordinate high quality care to Medicare affiliations and assets among facilities and created after September 11, 2001, to patients — have a preparedness function providers. help build capabilities in health system by directing and providing some care preparedness for major emergencies.478, 479 With its limited funding base (current away from a centralized location (thus The program’s peak funding was $515 total hospital spending is around reducing surge in a disaster), promoting million in 2004 and has been cut over $971 billion per year), HPP cannot wellness and helping in coordinating time to about $255 million in 2016. The be the only driver of health system care and tracking of vulnerable patients program originally provided small grants preparedness. While HPP should in an emergency.486 to individual hospitals — which were continue to play an important A number of additional levers can be often not sufficient to cover much beyond leadership, coordination and standard further explored for engaging the the cost of maintaining the grant — and setting role, there needs to be new health system — such as tax incentives, shifted over time to provide some support models and additional resources to Medicare shared savings program for the coordination and management of support and augment the program’s and Merit-Based Incentive Payment regional healthcare coalitions (HCCs).480 basic functions and to engage the health System, Joint Commission standards There are currently nearly 500 HCCs delivery system and broader community and National Quality Forum measures nationwide, with over 26,000 members, in building and investing in better 106 TFAH • healthyamericans.org to help support preparedness and planning efforts to ensure health needs the U.S. Department of Health and healthcare coalition participation. and assets of communities are being Human Services Ebola Response also Potential support mechanisms from considered in disaster planning. recommends HHS maintain a national broader community institutions, network of identified treatment centers Not every individual hospital or facility such as universities, economic and for urgent public health threats, requires the same preparedness community development agencies including standardized requirements capabilities, but a community should and other prominent partners that and protocols.490 A standing system of know its health needs will be met during benefit from stability and vitality of regionalization could help to overcome a major emergency. The tiered Ebola their neighborhoods can also serve as barriers to meaningful preparedness response system demonstrated one levers.487 Non-profit hospitals should planning — such as concerns over model of creating regional hubs for consider incorporating community- liability, loss of profit and competition care, although that has proven to be a wide disaster planning participation between healthcare systems. difficult system to maintain over time into their community benefit efforts with only initial start-up funding.489 A A number of examples of health to reflect a recent change in Internal standing regional network system emergencies have shown the importance Revenue Service rules that allows would require continuous incentives of developing better collaborations community resilience to count and reimbursement to maintain between the private sector, including for community benefit.488 And, supplies, workforce and ensure hospitals, pharmacies, health systems communities could also investigate buy-in of hospital leadership. The and public health agencies. For incorporating local health improvement Report of the Independent Panel on instance, during the H1N1 pandemic partnerships into healthcare coalition TFAH • healthyamericans.org 107 flu outbreak, the distribution and that when new serious outbreaks occur, administration of the vaccine and they are able to safely diagnose and the antiviral Tamiflu medication treat patients, and to ensure that other were through combinations of public patients and the healthcare workers and private distribution, insurer and themselves are protected from exposure. provider systems. Often the private For instance, the lack of adherence to sector — such as large or community- best practices led to initial mistakes in based pharmacies — will better be able not admitting the first initial presenting to distribute medical countermeasures Ebola patient in the United States. in some communities in the midst of a Every hospital should have: minimum crisis than overstretched public health baseline screening, including travel agencies, but collaboration is key to history; isolation capabilities to ensure ensuring equity of distribution and patients and healthcare workers are safe reach into underserved communities. from a potential threat; regular training on infectious control practices and use For instance, since 2012, ASTHO and of protective gear; and procedures for CDC have been assessing best practices removal and disposal of protective gear for coordinating pandemic vaccination and waste. preparedness activities between public health programs and pharmacies. Another example of the need for public Successful strategies, tactics and health and healthcare collaboration operational components, identified is in the area of healthcare-associated through stakeholder interviews infections. One out of every 25 and workshops, were incorporated people who are hospitalized each into a template memorandum of year contracts a healthcare-associated understanding (MOU). The MOU is infection (HAI), leading to around intended to formalize responsibilities 75,000 deaths a year.491 But each between state-level public health healthcare facility working alone cannot programs and pharmacies during prevent, track or contain the spread of pandemic vaccination planning and Superbugs. Public health needs to be response. ASTHO is now working the backbone organization in a state or to implement this MOU template in region to coordinate prevention among pilot states (Tennessee, Arkansas and competing or disparate healthcare Georgia). The best practices from these systems and contain potential states will be incorporated into a toolkit. outbreaks.492 And healthcare facilities — ranging from large hospitals to Both public and private sector health long-term care and outpatient facilities organizations are also exploring the — must have effective antibiotic use of nurse triage lines to reduce the stewardship programs in place to tamp strain on the healthcare system during down on inappropriate antibiotic a pandemic or other event. Public prescribing and share information with health, healthcare and insurers should CDC, local public health and laboratory collaborate on these models before networks. HAIs and antibiotic resistance the next event to ensure questions constitute an ongoing health emergency of credentialing, payment and risk — and efforts should be made to fully communications are addressed. and swiftly implement and fund the In addition, healthcare facilities still do National Action Plan for Combating not routinely carry out standard infection Antibiotic-Resistant Bacteria.493 control procedures on every patient so 108 TFAH • healthyamericans.org l Supporting Community Resilience — for Communities to Better Cope and Recover from Emergencies — With Better Behavioral Health Infrastructure and Capacity Another of the most difficult challenges in emergency health readiness is how to better prepare communities to mitigate impact and more quickly be able to recover when a disease outbreak, natural disaster or other emergency strikes. Hurricane Katrina provided one of in multiple languages via trusted the most enduring examples of how sources respecting different cultural vulnerable members of a community perspectives — and delivered via — such as children, the elderly, people multiple media, beyond the Internet, with underlying health conditions or such as radio, racial and ethnic who are lower-income and those with publications and television; limited-English proficiency — are often l D eveloping ongoing relationships the most impacted and least prepared between health officials and members of and protected during emergencies.494 the community so they are trusted and The next phase of preparedness efforts understood when emergencies arise; must prioritize how to improve the l I n addition to building ongoing resilience of all communities. While behavioral health resources for building resilience is one of two communities, both mental health overarching goals identified by HHS first aid and long term mental health in the Biennial Implementation Plan treatment should be integrated for the National Health Security Strategy into disaster response and recovery — there is not sufficient funding or strategies; and other resources available to provide broad support for efforts.495 Local l E ngaging members of the community health improvement partnerships and community-based organizations could be one mechanism for helping directly in emergency planning efforts. to scale and diffuse strategies — and In addition, community resilience engage additional funding support considerations should be incorporated from the broader health, business and into other resilience efforts at the local community sectors themselves. Experts level — such as climate change adaptation, recommend some key components to infrastructure resilience and transportation improving resilience, including:496, 497 and housing planning following a Health l I mproving the overall health status in All Policies Approach. Communities of communities so they are in better should leverage various funding streams, condition to weather and respond to such as from the Federal Emergency emergencies. Initiatives and programs Management Agency, HUD, EPA and supported by the Prevention and Public private grants to ensure resilience and Health Fund can assist in these efforts planning efforts consider the health equity by promoting health and addressing needs of the most vulnerable residents. underlying causes of health disparities; For example, New York City held a competition with HUD disaster recovery l P roviding clear, accurate, funds to make the city more capable straightforward guidance to the public TFAH • healthyamericans.org 109 of withstanding future storm surges Supporting health improvement efforts and sea level rises.498, 499 The winning around the country — such as through designs would not only protect against local health partnerships and other flooding but would provide health and approaches (discussed in Section I environmental benefits to the community of the Blueprint document) would with green, social and recreational help advance the underlying health spaces.500 These kinds of cross-sector of communities to be more resilient collaborations are a model for creating during times of emergencies. resilience for people and communities. SAVE THE CHILDREN: GET READY GET SAFE Save the Children launched the Get In addition, in their 2015 report, Still Ready Get Safe initiative to help U.S. at Risk: U.S. Children 10 Years After communities and families prepare to Hurricane Katrina, they found that only protect and care for children in times 17 of the 81 the recommendations in the of crisis. They help generate child- 2010 report by the National Commission focused emergency plans, provide on Children and Disasters have been emergency training and ensure fully implemented; 44 are in progress; emergency resources are in place and 20 have not been addressed at all, before crisis strikes.501 and only 32 states have met minimum recommended emergency planning standards at schools and childcare.502 Source: Save the Children, Still at Risk: U.S. Children 10 Years After Hurricane Katrina 110 TFAH • healthyamericans.org Prioritizing Major Health Topics SECTION 3 SECTION 3 SECTI O N 3 Blueprint for SECTION 3: PRIORITIZING MAJOR HEALTH TOPICS Prioritizing Major Health Topics A HEALTHY EARLY CHILDHOOD a Healthier Death America Early Death Disease, Disability and Social Problems Scientific Adoption of gaps Health-risk Behaviors Social, Emotional, and Cognitive Impairment Disrupted Neurodevelopment Adverse Childhood Experiences Conception Mechanisms by Which Adverse Childhod Experiences Influence Health and Well-being Throughout the Lifespan SOURCE: Centers for Disease Control and Prevention503 More than half of U.S. children — across the economic spectrum — experience an adverse event during their childhood, such as physical or sexual abuse or substance abuse in the household.504, 505, 506 In addition, 21 percent of children live below the poverty line and 44 percent live in low-income families — which can increase their risk for living in unhealthy conditions or experiencing severe or prolonged periods of stress, often called “toxic stress.”507, 508 When young children, whose bodies neighborhood and environments can and brains are rapidly developing, mitigate against these factors. experience adverse childhood Investing in good health and well-being experiences (ACEs) and toxic stress, for young children can yield lifelong they are at increased risk for cognitive benefits. For instance: and developmental delays, depression, anxiety, aggression and other mental l Q uality early childhood education can and behavioral health problems — provide a 7 percent to 10 percent per OCTOBER 2016 along with higher risk for hypertension, year return on investment based on diabetes, heart disease, stroke and increased school and career achievement many other forms of chronic diseases and reduced costs in remedial as they age.509, 510, 511 education, health and criminal justice system expenditures; and nurse family Nurturing, stable caretakers and home visits for high-risk families with relationships; positive learning young children has shown a return of experiences; and safe homes, $5.70 for every $1 invested.512, 513, 514, 515, 516 l E very $1 spent to support good lives, obesity and eating disorders, nutrition and early health for difficulty in maintaining healthy infants in the two months after birth relationships, poor school performance, through the Supplemental Nutrition behavioral problems in school, dropping Program for Women, Infants, and out of high school, the need for special Children has been shown to lead to a education and child welfare services, reduction in healthcare costs of $1.77 mental and behavioral health problems to $3.13 in the two months after birth like depression and anxiety, alcohol (a 2:1 to 3:1 ROI).517 and drug abuse, exposure to harmful environmental hazards, suicidal thoughts l B abies born into food-insecure and attempts, teen pregnancy, sexually families who had been receiving rental transmitted diseases (STDs), aggression assistance during pregnancy were 43 and violence, domestic abuse and rape, percent less likely to be hospitalized not acquiring key parenting skills or after birth compared to infants in support for when they have children families of similar status not receiving themselves and difficulty in securing and rental assistance.518 maintaining a job.519, 520, 521, 522 These types of investments in early However, currently few of these proven childhood health and well-being have strategies are sufficiently supported at been shown to reduce the risk for: the level needed to deliver them broadly. chronic illnesses, shorter and less healthy 114 TFAH • healthyamericans.org RECOMMENDATIONS l nsure required routine screenings E can all help build protective factors, children. In addition, Medicaid can — and follow up services — are reduce the future risk of substance be used to support services that meet delivered for health problems and misuse and other risky behaviors, and children’s trauma-related behavioral other risks. Even though most public improve educational achievement health needs, including cognitive and private insurers require all covered outcomes, particularly among low- behavior therapy, crisis management children to receive regular screenings, income children. For instance, states services, alternative benefit plans, many children do not receive them. can strengthen licensing requirements home and community-based services, Increased incentives and penalties for for child care settings and utilize new health homes, managed care, improving screenings and referrals to opportunities available through the integrated care models and research follow up care and services; along with Every Student Succeeds Act of 2015 to and demonstration projects.527, 528 building regular, coordinated care and use a portion of Title I funds for early l educe infant mortality, preterm R case worker systems can help ensure childhood education and the transition births and low-birthweight babies by children and their families access from pre-kindergarten to elementary expanding and improving prenatal and and receive the care and services they school. In 2016, the Aspen Institute preconception care. Preconception need. Pediatricians should screen launched the National Commission care can help address the stagnant rate children for poverty and related risk on Social, Emotional and Academic of infant death (about 23,440 infant factors as well as for adverse childhood Development with support from the deaths per year or 5.96 per 1,000 experiences, as recommended by the Robert Wood Johnson Foundation live births) and troubling premature American Academy of Pediatrics. to outline and widely promote an birth rate (one in ten children in the evidenced-based action plan to l ncrease support for families with young I United States.)529, 530, 531, 532 Potential accelerate efforts to integrate the children through expansion of home policy levers include expanding social and emotional development of visiting programs. Evidence-based home Medicaid coverage to more women children into educational settings and visiting programs have demonstrated of childbearing age, supporting facilitate alignment and coordination of strong results in improving health and community-based programs to support education stakeholders toward a shared broader support for low-income families better health and increasing public vision of change in policy and practice. with young children — to ensure education outreach, particularly in their needs are identified and they are l mprove services and care coordination I underserved communities. connected with healthcare, mental for children and youth with special l upport financial, food and housing S health and social services, including healthcare needs. There should be assistance and family and medical financial, employment and food extra emphasis on addressing the leave. Research supports that assistance services. challenge of navigating the range of increased financial, food and housing healthcare, social services, mental l upport health and social-emotional S assistance can help many families health, education and other systems learning in child care and early move out of poverty and help lower for families with children with special education programs. Federal, state the risk and impact of toxic stress. In needs (approximately 15.1 percent of and local policies should focus on addition, policies to increase access U.S. children).523, 524, 525, 526 promoting good health in safe and to family and medical leave can healthy environments in all child l xpand a trauma-informed approach E positively impact the early childhood care, daycare and early childhood across federal, state and locally environment by promoting nurturing education programs. This should supported services for children and caregiver relationships that improve include an emphasis on good nutrition, families. Policies should promote a child’s social, emotional and opportunities to be physically active, the use of trauma-focused screening, cognitive development and reducing positive cognitive experiences and the functional assessments and evidence- toxic stress produced from economic implementation of evidence-based based practices to improve social- hardships (e.g., unpaid leave or social-emotional programs, which emotional-behavioral health among unpaid sick days).533 TFAH • healthyamericans.org 115 HEALTHY STUDENTS AND HEALTHY SCHOOLS Educators and parents know that healthy students are better prepared to learn and succeed in school. Healthy students are more likely to attend school, are better able to focus and are more ready to learn. Good nutrition, physical activity, basic experiencing toxic stress or other safety, clean air and water, education adverse childhood experiences, about making healthy choices, a including more effective and supportive school environment and supportive discipline approaches; access to physical, behavioral and l E arly identification of children’s needs mental healthcare services allow — and connecting and providing children to thrive. The long-term students with programs and services success of children requires that they to help them thrive (e.g., physical, are healthy, safe, engaged, supported mental and behavioral health, special and challenged. education, oral health, optometry, Currently, however, health and social services and others); education policies often miss key l O pportunities to be physically active strategies that can help improve both throughout the day and having the academic achievement and health of attractive, accessible and sufficient the nation’s 55 million children who are spaces and facilities to engage in activity in kindergarten through high school. and encourage physical education; While there has been a sea change in the l P romoting good nutrition — making past several years toward recognizing that safe drinking water and healthy school health is central to helping students thrive, meals and snacks readily available there is still much more that must be done to all students regardless of family to build on this momentum. Helping income or school location; every student succeed will require acting on important opportunities to advance the l B roadening parent- and community- vision for healthier students at heathier engagement to better understand schools, which includes: assets, concerns and obstacles promoting academic performance l A safe, healthy environment in which and health — and developing effective to learn — where parents can feel strategies that engage all stakeholders, confident their children will be safe including local youth advocates and and supported every day; community leaders who contribute l A positive culture and climate to children’s success — inside and where students and educators are outside school and at home; and encouraged to do well and are given l S trong, ongoing professional devel- the tools they need to succeed; opment and support for educators in l P romoting social and emotional ways to promote health and positive learning as well as academic instruction; conditions for learning — and providing a healthy and respectful work environ- l T aking a “trauma-informed” approach ment for educators and other staff. supporting students who may be 116 TFAH • healthyamericans.org WHOLE SCHOOL, WHOLE COMMUNITY, WHOLE CHILD U.S. Students — Some Pressing Health Concerns l P overty, Toxic Stress and Food Inse- l T reatment for Substance Use curity: More than half of U.S. public Disorders: Only around one in ten school students live in poverty.534 teens with a substance use problem Three out of four public school students gets recommended professional regularly come to school hungry.535 treatment.552 l dverse Childhood Experiences: More A l B ullying: Around 20 percent of high than half of children experience an school students report being bullied adverse childhood experience — such on school property and 15.5 percent as physical abuse (28.3 percent), report being bullied through electronic substance abuse in the household (26.9 or social media.553 percent), sexual abuse (24.7 percent for l E xpulsions/Suspensions: More than girls and 16 percent for boys) and parent Source: U.S. Centers for Disease Control and 3.3 million students are suspended divorce or separation (23.3 percent).536, Prevention or expelled from U.S. public schools 537, 538 One-quarter of children experience annually, even though these practices two or more ACEs, 14 percent l T een Pregnancies: Around 249,000 are tied to lower school achievement, experience three or more and 7 percent teens (15 to 19 years old) give birth higher truancy and dropout rates, experience four or more. The more ACEs annually (as of 2014).544 behavior problems and more negative experienced, the higher likelihood for a l O ral Health: 17.5 million children school climate.554 Black students range of health and behavioral risks and and teens experience untreated tooth (kindergarten to high school) are negative consequences. decay or cavities. 545 almost four times as likely to l O besity: One third of children and receive one or more out-of-school l M ental Health Disorders: As many as teens are obese or overweight.539 suspensions as White students.555 one in five children and teens, either l S pecial Education: Around 13 percent currently or at some point in the past, l C hronic Absenteeism: Chronic of students receive special education have had a serious debilitating mental absenteeism rates — where students services; 20 percent of education disorder. 546 More than 25 percent of missed more than 10 percent of the spending is for special education teens are impacted by at least mild school year — are often a warning needs. 540 symptoms of depression. sign of health, family, financial or other concerns. Thirteen percent l L GB Youth: More than 40 percent l A DHD: Around 10.2 percent of children of U.S. public school students (6.5 of lesbian, gay and bisexual youth and teens have diagnosed Attention million) missed 15 or more school consider suicide, 34 percent Deficit Hyperactivity Disorder (ADHD).547 days in the 2013-2014 school year. experience bullying and 18 percent l S ubstance Use: More than 7.4 percent Eighteen percent of high school experience physical dating violence.541 of teens report regular marijuana use, 4.7 students (3 million) and 11 percent l A sthma: More than 8.6 percent of percent of teens misuse prescription drugs, of elementary students (3.5 million) children have asthma. 542 10.8 percent smoke cigarettes, 16.0 per- are chronically absent.556 Rates vary cent use e-cigarettes, 32.8 percent of high significantly across communities — l S exually-Transmitted Diseases: schoolers drink alcohol and 17.7 percent for instance, ranging from 6 percent Nearly half of the 20 million new cases report binge drinking. 548, 549, 550 to 23 percent in six states — with of sexually transmitted diseases each More than 90 percent of adults who high poverty urban schools reporting year are among teen and young adults develop a substance use disorder began up to one-third of students as (ages 15 to 24).543 using before they were 18 years old. 551 chronically absent.557 TFAH • healthyamericans.org 117 RECOMMENDATIONS l rioritize a healthy, positive school P special education needs via tools from climate. State and local school districts the American Academy of Pediatrics and schools can conduct needs (AAP) and special education assessments and adopt wellness plans to programs. In addition, tracking identify school or community specific chronic absenteeism is an important concerns and the best strategies way to help identify physical, for addressing them. Many schools emotional or behavioral health or are also adopting Positive Behavior family concerns. Interventions and Supports (PBIS) l revent and reduce health risks. P models that emphasize strategies State-based expert institutes can to support social and behavioral help districts and schools by 1) improvement, such as character conducting needs assessments to education, social skill instruction, match effective, evidence-based bullying prevention, behavior support policy and program choices to and building consultation teams.558, specific community needs; 2) 559 The 2015 Every Student Succeeds ensuring programs are implemented Act also provides a number of new successfully by providing technical opportunities to support district assistance and access to learning and/or school wide health networks; 3) training and supporting improvement and to support professionals from different sectors; more health-related professional 4) conducting regular evaluations development. — measuring results and ensuring l upport safe, clean and health- S accountability; 5) supporting promoting physical facilities. sustainability; and 6) enhancing Ensuring schools are well maintained; continuous quality improvement. regularly cleaned in ways that promote l xpand obesity prevention by E health and reduce spread of germs; promoting better nutrition and have quality air quality control systems; increasing physical activity before, have good lighting; have quality during and after school. This includes outdoor play areas, sports areas, improving access to healthy, affordable indoor gyms and recreation spaces can breakfast, lunch and snacks and all help improve student achievement, providing increased opportunities to reduce truancy and suspensions, be physically active during the school improve staff satisfaction and day — including by implementing retention and raise property values. nutrition standards in line with the l ncrease early identification and I Dietary Guidelines for Americans. provide support for concerns. School district wellness programs can Identifying concerns early and ensure children are more engaged connecting children with care or in the classroom and ready to learn. support can help prevent, mitigate There are a number of innovative or effectively manage issues. School programs to promote improved systems can ensure at-risk students nutrition and activity, such as reducing are screened for physical, behavioral red tape and increasing access to free- and mental health concerns and and reduced-meals for all students at 118 TFAH • healthyamericans.org low-income schools, flexible breakfast care.561 Efforts range from increasing offerings to promote uptake, increased the number and functions of school access to summer meals, having shared- nurses to full on-site school-based use policies making school recreation health centers to mobile health spaces available to the community centers to designated case workers during non-school hours and ensuring to creating strong partnerships with facilities are safe and clean. local providers such as hospitals, Community Health Centers, behavioral l nsure availability of safe, free E health centers and social service drinking water. Only around 10 providers.562 In addition, there are percent of schools with their own increasing efforts to increase the water systems are required to test for availability and scope of mental health lead (350 of which failed lead tests and behavioral health professionals from 2012 to 2015), and federal law within schools and/or referrals to does not require schools using local systems of support. public water suppliers to test the water.560 Policies are needed to fill l upport and increase funding for Full S these lead-testing gaps to ensure all Service Community Schools. A growing students are drinking safe, clean water. number of states and communities are deploying the community school l ncrease school health services — I model, effectively using public schools including mental, behavioral and oral as hubs for community partners to health — and improve coordination offer a range of services and supports across education, health and other to students, families and communities. social services. A number of models The U.S. Department of Education — including increased ability for currently funds 21 grantees with $10 Medicaid to pay for health services million in FY16. Expanded funding in schools under the new free care would help improve and scale this policy — are emerging to better proven model to additional school sites support children’s health needs in across the country. schools and/or to connect them to TFAH • healthyamericans.org 119 AGING WELL AND INDEPENDENTLY Source: Goldman & Gaudette, 2015563 By 2030, almost 20 percent of Americans (72 million) will be 65 years or older — up from the current 14.5 percent — due to longer lifespans and the aging Baby Boomer population.564,565 As people are living longer, the age — including supporting prevention number of older seniors is also growing efforts before people reach their senior exponentially. Currently, around 6.2 years. Many health problems could be million people are ages 85 or older prevented, mitigated or delayed with in the United States — by 2040, the a stronger focus on improving health number will grow to around 14.6 million throughout a person’s lifetime. (a 135 percent increase).566 l hronic Disease: By 2030, estimates C The aging population has a major impact are that 79 percent of seniors will on healthcare spending — which is have hypertension, 43 percent heart projected to grow by 25 percent by 2030 disease, 47 percent obesity and 39 — as Baby Boomers age into increased percent type 2 diabetes.573 numbers of diseases and disabilities and l rthritis: More than 50 percent A new treatments and technologies expand of seniors have doctor-diagnosed to meet those needs.567, 568, 569 The arthritis.574 healthcare costs of an individual over age 65 are three to five times as high as those l alls: One in three seniors experience F for someone under age 65 years.570 a serious fall each year — which often leads to other complications and Medicare spending is expected to reach deterioration of health. Falls are the $903 billion by 2020 and more than leading cause of injury death in adults double — to $1.2 trillion — by 2030.571, 572 ages 65 and older (more than 27,000 It is important to develop strategies deaths), and contribute to around that support improved health and 250,000 hip fractures a year and over $31 quality of life for Americans as they billion in Medicare spending.575, 576, 577 120 TFAH • healthyamericans.org l ementia: One in three seniors die D Currently, an estimated 67 percent to with Alzheimer’s or some other form 86 percent of adults who may benefit of dementia.578 Nearly one in five from hearing aids do not have or are Medicare dollars is spent on dementia not using them. 583 — which is expected to grow to one Fewer than 50 percent of seniors ages in three by 2050. Medicare spending 65 and older receive recommended for individuals with dementia is three clinical preventive services.584 Less times higher than for those without, than 1 percent of Medicare enrollees and Medicaid costs are 19 times higher. had participated in obesity counseling l A lzheimer’s Disease: 5.2 million between 2011 (when it became available) seniors have Alzheimer’s Disease and 2014.585 Moreover, around one- (nearly two-thirds of cases are third of seniors do not receive a flu shot women); the rates are expected to and nearly a third have not received a reach 7.1 million by 2025 and 13.8 one-time vaccine against pneumonia — million by 2050.579 Alzheimer’s is despite the fact that roughly 71 percent the sixth leading cause of death, and to 85 percent of flu and pneumonia costs $236 billion in medical costs, deaths are among seniors.586, 587, 588 half of which is paid by Medicare.580 Eighty-eight percent of seniors want to l ental/Oral Health: One in four D remain in their homes and 80 percent Medicare beneficiaries has no natural want to remain in their communities as teeth — and around one in four adults along as possible, according to a 2014 ages 65 to 74 have gum disease.581, 582 survey by the American Association for Medicare does not cover routine Retired Persons (AARP).589 However, dental care, many restorative dental approximately one in every three seniors services, dentures or tooth extractions. will enter a nursing home before they die.590 A growing population of seniors l earing Loss: 45.6 percent of those H will increase demands for caregivers and ages 70 to 74 and 80.6 percent of those nursing home and long-term assisted care. 85 or older suffer from hearing loss. TFAH • healthyamericans.org 121 RECOMMENDATIONS l ncrease coverage and delivery I l upport mental health and healthy S of prevention services to seniors. brain initiatives. Support should be Medicare should encourage greater given to community programs and clinical-community coordination services that improve prevention, early by covering a range of supportive intervention and treatment and long- services. This can be supported term care support for Alzheimer’s and through models like patient-centered other dementias. Policymakers should care, increased use and coordination support states in developing state of Electronic Health Records and plans for Alzheimer’s that include improvements in provider education components of the Healthy Brain and patient outreach programs. In Initiative’s Public Health Road Map for addition, Medicare policy changes State and National Partnerships.593 are needed to increase coverage for l nable aging in place. Potential policy E high-need services among seniors, recommendations include increasing such as better dental care and and preserving affordable housing hearing aids, which improve quality for older people through housing of life and also can help prevent trust funds, rental subsidies or tax or mitigate escalation of some incentives; and incorporating universal additional health problems. design into community planning to l xpand senior-focused local health E make the built environment accessible improvement initiatives. Assessments to aging adults.594 Policymakers need are needed to measure the aging- to consider the underlying systematic friendliness of communities and track and environmental barriers — such outcomes of community-based services as unsupportive community design, and programs.591 Policymakers should unaffordable and inaccessible housing also support cross-sector collaborations and a lack of services — when between aging, health, transportation designing policy solutions and using and other social support agencies to technologies to support aging in place. promote planning for senior-focused l romote strategies to encourage P local health initiatives. healthy aging before age 65. CDC, l xpand community-based prevention E AARP and the American Medical programs. Many community-based Association issued a guide to Promoting programs can help provide increased Preventive Services for Adults 50-64: support for seniors to stay active, Community and Clinical Partnerships, improve nutrition and be healthier at which identifies a range of successful any age and help them stay well and strategies — focusing on early detection independent for as long as possible. and lowering risk factors for health One of the most effective community- problems.595 CMMI should also explore based health efforts for seniors has options for paying for these services for been fall prevention programs, which the pre-Medicare population — to keep have been shown to help reduce the the cohort healthier and costs downs number of falls by as much as half.592 for when they age into Medicare. 122 TFAH • healthyamericans.org STOPPING THE PRESCRIPTION PAINKILLER MISUSE AND HEROIN EPIDEMICS America is in the midst of an opioid misuse epidemic. In 2014, more than 24,000 individuals died from prescription painkillers and heroin, representing the deadliest year on record.597 Drug overdoses have surpassed motor vehicle crashes as the leading cause of injury deaths. In the past 15 years, prescription painkiller overdoses more than quadrupled.598 Every day, 3,900 Americans initiate nonmedical Age-adjusted rate of drug overdose deaths and drug overdose deaths use of prescription opioids, contributing to involving opioids— United States, 2000–2014596 the almost 2 million individuals currently addicted to opioids.599, 600, 601 Since 2000, the number of prescription painkillers sold has nearly quadrupled.602, 603 Currently, approximately 650,000 opioid prescriptions are dispensed every day.604, 605 Medicaid beneficiaries are prescribed opioid painkillers at twice the rate of non-beneficiaries, and are three to six times more likely to suffer an opioid overdose.606, 607, 608 The rate of pain reported by Americans, however, has remained constant during this same time period.609, 610, 611 Only about one in ten individuals with a substance use disorder receive Source: CDC National Vital Statistics System recommended treatment.612 The use of prescription painkillers is also driving the rise in heroin use, since Prescription opioid misuse costs it is often cheaper and easier to access the United States over $55.7 billion in some places in the country. Heroin annually. Healthcare costs related initiation is 19 times higher among to opioid abuse make up $25 billion people with a history of prescription of the sum.619 Workplace costs painkiller misuse.613, 614 Heroin overdoses associated with prescription painkiller have increased six-fold since 2001 and misuse total $25.6 billion—including have more than tripled since 2010.615, 616 $11.2 billion in lost earnings due to Each day, 580 individuals try heroin for premature death and $7.9 billion the first time.617 Over the last decade, in lost employment/reduced heroin use doubled among adults aged compensation.620 18-25 years and women.618 TFAH • healthyamericans.org 123 RECOMMENDATIONS l xpand prevention efforts. Evidence- E for pain management, responsible and generic products, ensuring based approaches to reducing prescribing of pain medication, doctors and patients have the widest substance misuse should be expanded methods of diagnosing, treating and array of abuse deterrent options. across communities and in schools managing substance use and the use l ake “rescue drugs” regularly available M — focused on programs that have of management and diversion tools, and provide legal immunity to those demonstrated effective results in such as Prescription Drug Monitoring experiencing overdose, bystanders and reducing risk factors. Each state Programs (PDMPs). providers who prescribe naloxone. should have an end-to-end network of l xpand the use of Prescription Drug E Naloxone should be available over the experts and resources to support the Monitoring Programs. States that counter or co-prescribed to high risk effective community-based selection, mandate providers to use PDMPs see patients and/or their family, friends and adoption, implementation and reductions in opioid prescriptions.622 caregivers and should be commonly evaluation of evidence-based programs. Medical providers should be required available to first responders, in schools The National Institutes of Health, to enroll and participate in their PDMPs and other targeted locations. Liability Communities that Care (CTC) network in order to maximize the benefits of the and legal concerns serve as prominent and other experts have identified a system. PDMPs should be fully funded barriers to effective naloxone use and strong set of evidence-based school and to allow real-time communication distribution. States should amend community prevention programs that across providers and incorporation into current naloxone distribution laws have shown strong returns in reducing electric heath records. to 1) include “Good Samaritan” drug misuse, but have not been widely provisions to allow timely summons of implemented throughout the country. l ncourage evaluation of prescription E emergency responders without fear of Efforts should be integrated across opioid misuse interventions. Additional negative legal consequences, and 2) school-based and wider community emphasis and federal funding is needed allow prescribers to distribute naloxone efforts, via multisector collaborations. to support rigorous evaluations of in good faith to those other than Screening, Brief Intervention and practices and interventions addressing the person to whom the drug will be Referral to Treatment (SBIRT) should prescription opioid misuse—including administered (i.e. friends, family).623 be routine practice in middle and high overdose education and naloxone schools and healthcare settings — since distribution programs, pharmacy l xpand access to treatment and E even brief counseling and interventions benefit managers and community-based prevention programs: Core programs can have a positive impact. prevention strategies. to treat and prevent substance misuse disorders have been underfunded l mprove opioid prescription and I l mproving guidance from FDA. It I for years and have not kept up with dispensing practices through is critical that prescribers have the inflation, let alone the growing need for provider education. Several states information they need to reduce services. The Comprehensive Addiction have implemented requirements the risk of opioid misuse while still and Recovery Act, passed by Congress for physicians to receive Continuing safely and effectively treating patients in July 2016, authorized $181 million in Medical Education (CME) credits suffering from chronic pain. FDA new federal money to address this crisis. in pain management.621 Additional recently acted to require stronger To be effective, this money must be fully action is needed to mandate physician warnings on the dangers of combining appropriated and also expanded to training on the risks of prescription opioids and benzodiazepines, and support existing core programs to treat opioids and to disseminate CDC they should continue to aggressively and prevent substance misuse, such as guidelines for prescribing opioids for implement their Opioids Action the Substance Abuse Prevention and chronic pain. Training for all medical Plan. FDA should establish clear and Treatment Block Grant. providers should include best practices reasonable pathways for both branded 124 TFAH • healthyamericans.org PREVENTING OBESITY, IMPROVING NUTRITION AND INCREASING PHYSICAL ACTIVITY Nearly 38 percent of adults and 17 percent of children in the United States are obese.624, 625 Over the past 25 years, rates have more than doubled among adults and more than tripled among children. Obesity is one of the biggest health threats in the country, putting Adult Obesity Rate by State, 2015 Americans at increased risk for type 2 diabetes, heart disease, high blood WA MT ND pressure, some forms of cancer and a MN VT ME range of other health problems. 626, 627, 628 OR SD WI ID NH And it contributes to more than $147 WY IA MI NY MA billion to $210 billion in preventable NE PA RI IL IN OH CT healthcare spending.629 NV UT CO DE NJ KS MO WV KY VA MD DC Through increased awareness and policy CA OK TN NC efforts, rates have begun to stabilize in the AZ NM AR SC past decade, but remain high. In some MS AL GA LA communities, there have been signs of TX progress — where childhood rates have decreased in more than 30 communities — FL n <25% AK and overall they have significantly declined HI n >25% & <30% among 2- to 5-year-olds.630 And the rate of n >30% & <35% increase among adults has slowed.631 n >35% Source: CDC, BRFSS Reversing the epidemic — and ensuring that all children have the opportunity scarce and more expensive, while cheap overweight or obese is the leading to grow up at a healthy weight — will processed foods are widely available and medical reason why young adults require intensifying investments in the heavily marketed. And, finding safe, cannot enlist.635, 636 The military spends most effective programs and policies. accessible places to be physically active more than $1.5 billion on healthcare Evidence about what works to help curb can be a challenge for many. costs and on recruiting replacements the epidemic is growing and some key for those who are too unfit to serve. Third, it is essential to target more intense lessons have emerged. efforts in areas where there are the greatest l T here are significant regional and First, prevention should be a top priority, challenges. Obesity rates are highest socioeconomic inequities: especially among young children and among racial and ethnic minorities, people l A dult obesity rates are higher among pregnant women. It is easier and who live in low-income communities and Blacks (48.4 percent) and Latinos more effective to prevent unhealthy those living in the South. These groups (42.6 percent) than among Whites weight gain than it is to reverse it later. are more likely to have limited access to (36.4 percent) and Asian Americans Strategies that focus on helping every healthy options, and progress in addressing (12.6 percent).637 child maintain a healthy weight are the inequities has been limited. l C hildhood rates are higher among critical. By giving children a healthy l M ore than 29 million Americans Latino (21.9 percent) and Black start, they will be on a much better have diabetes, and if current trends (19.5 percent) children than among trajectory for lifelong health as they age. continue, by 2050, one in three will White (14.7 percent) and Asian (8.6 Second, making healthy choices an have type 2 diabetes.632 percent) children (ages 2 to 19) — easier part of people’s daily lives is and the rates are higher starting at l O ne in four Americans has some form essential. While personal responsibility earlier ages and increase faster.638 of heart disease and one in three have is an important consideration in obesity hypertension.633, 634 l M ore than 33 percent of adults who prevention, the choices families and earn less than $15,000 per year are youth make are impacted by where l A pproximately one in four young obese compared with 24.6 percent they live, learn, work and play. In many adults — ages 17 to 24 — are too of those who earned at least $50,000 neighborhoods, healthy foods are overweight to join the military. Being per year.639 TFAH • healthyamericans.org 125 RECOMMENDATIONS be supported starting pre-birth and continued throughout childhood. l xtend school-based policies and E programs. School meals have been transformed in the past several years — bringing them up-to-date with the current nutrition standards in Dietary Guidelines for Americans. Efforts should be continued to support better nutrition and increased activity in schools, such as through wellness policies; expanding options for flexible breakfasts and community eligibility programs; implementing the final “Smart Snacks” rule for improved nutrition for snacks and beverages sold in schools; eliminating in-school marketing of foods that do not meet Smart Snacks nutrition l nvest in healthier eating and safe I standards; and leveraging opportunities physical activity initiatives and obesity to support health, physical education prevention. Providing adequate and activity under ESSA. funding for the Prevention and Public Health Fund and for CDC’s National l xpand community-based policies and E Center for Chronic Disease Prevention programs. This includes prioritizing and Health Promotion/Division of health in transportation planning to Nutrition, Physical Activity, and Obesity help communities ensure residents (DNAPO) would increase support to have access to walking, biking, and state, local health departments, tribal other forms of active transportation and organizations and community partners. promoting innovative strategies, such DNAPO’s annual budget is only around as tax credits, zoning incentives, U.S. $50 million annually, in contrast to the Department of Transportation grants, $147 to $210 billion spent each year on improved transportation planning, obesity-related healthcare costs. low-interest loans and public-private partnerships to increase access to l ocus on early childhood policies and F healthy, affordable foods. programs. This includes supporting better health among young children l upport integrated community health S through healthier meals, physical and healthcare approaches to obesity. activity, limiting screen time and This includes covering the full range connecting families to community of obesity prevention, treatment and services through Head Start; management services under all public prioritizing early childhood education and private health plans, including opportunities under the Every Student nutrition counseling, medications and Succeeds Act; and implementing behavioral health consultation, along the updated nutrition standards with encouraging an uptake in services covering the Child and Adult Care for all eligible beneficiaries. Food Program. Programs should 126 TFAH • healthyamericans.org ELIMINATING TOBACCO USE Tobacco remains the leading cause of preventable diseases, disability and death in the United States, killing more people each year then alcohol, AIDS, car accidents, illegal drugs, murders and suicides combined.641 It is responsible for one in five deaths and nearly one-third of cancer deaths in the country.642 Approximately 40 million adults — roughly one in six — are current High School Students Reporting Using Tobacco Products at Least 1 Day smokers.643 High school cigarette smoking During the Past 30 Days, United States 2015 rates are at historic lows, at around 9 percent, but overall rates of teens using any form of tobacco remain around 25 percent.644 In addition, there has been a dramatic rise in the use of e-cigarettes — around 16 percent of high school students now report using e-cigarettes, up from 1.5 percent in 2011.645, 646, 647 Tobacco-related health problems cost the country approximately $170 billion per year, including $39.6 billion by Medicaid and $45 billion by Medicare, and another $151 billion in lost productivity.648 l N early 90 percent of adult smokers began SOURCE: Centers for Disease Control and Prevention, 2016640 smoking as teenagers.649 At current rates, 5.6 million children alive today will die from smoking-related illnesses.650 l N early one-third (31.8 percent) of teens l A dults with mental health or other do not perceive smoking one or more substance use disorders smoke cigarettes packs of cigarettes per day as risky.651 more than adults without these l E ach year, more than 41,000 deaths disorders; approximately 25 percent of result from secondhand smoke U.S. adults have some form of mental exposure.652 Annual healthcare health or substance use disorder, and expenditure on secondhand smoke these adults consume almost 40 percent exposure alone is over $6 billion.653 of all cigarettes smoked by adults.655 l E ach one percentage point decline in l S moking among lesbian, gay, adult and youth smoking rates in the and bisexual adults in the United country results in 2.4 million fewer States is much higher than among adult smokers, over $1.3 billion in heterosexual/straight adults. Nearly 1 in savings from heart attack and stroke 4 lesbian, gay or bisexual adults smokes reductions over 5 years, and $393.2 cigarettes compared with roughly 1 in 6 million in savings from reductions in heterosexual/straight adults.656 smoking-affected births over 5 years.654 TFAH • healthyamericans.org 127 RECOMMENDATIONS l upport increases in taxes on tobacco S l ustain investments in tobacco S and implement smoke-free policies products. Tobacco tax increases are prevention and cessation programs. and practices and has proposed effective ways to reduce smoking rates Federal, state and local funding for rulemaking to make public housing among adults and prevent children preventing tobacco use and tobacco smoke-free.661 CDC estimates nearly from beginning smoking, while also cessation should be preserved, $497 billion could be saved each year providing revenue to fund tobacco including protecting the Prevention if smoking was universally banned in control programs. Nationally, every and Public Health Fund, which subsidized and public housing.662 10 percent increase in the price enables communities around the l ffectively regulate tobacco E of cigarettes results in a 4 percent country to invest in proven strategies products. In 2009, Congress gave reduction in overall consumption and to improve health, including those FDA the authority to regulate the reduces smoking among young adults targeted at the reduction of tobacco manufacturing, marketing and sale by 3.5 percent and among youth by 6 use. These funds should also support of tobacco products in order to to 7 percent.657 continuation and expansion of Tips protect public health and protect from Former Smokers, the Centers l upport raising the minimum legal S youth from tobacco-caused disease for Disease Control and Prevention’s sales age for tobacco products to and premature death. FDA, for highly effective media campaign to 21. Roughly half (47 percent) of example, can require changes in reduce tobacco use. adult smokers become daily smokers tobacco products to make them less before the age of 18; however, four l xpand access to and use of evidence- E addictive, less appealing to youth and out of five adult smokers become daily based tobacco cessation services. Use less harmful; review new products to smokers before the age of 21.658 A of FDA-approved tobacco cessation ensure they are not detrimental to 2015 study from the National Academy medications and counseling are public health; and improve public of Medicine shows that raising the effective ways for tobacco users to awareness of health risks such as by tobacco sale age would significantly increase their ability to quit successfully. implementing graphic warning labels reduce smoking initiation among Expanding coverage of tobacco and preventing manufacturers from youth, resulting in reductions in cessation services in Medicaid and making misleading health claims. smoking-related deaths.659 Currently, increasing awareness of this coverage l -cigarettes should be regulated by E two states (California and Hawaii) and among enrollees and providers would FDA and included in smoke-free laws. 200 localities have raised the tobacco help reduce tobacco use in a high-risk FDA finalized a rule in August 2016 sale age to 21.660 population. Ensuring that private to extend its regulatory authority health insurers cover evidence-based l xpand comprehensive smoke-free E to all tobacco products, including tobacco cessation services would also laws to all 50 states. Currently 25 e-cigarettes. This authority should help more tobacco users to quit. states, Washington, DC, Puerto Rico not be infringed, as it gives FDA the and the U.S. Virgin Islands have l ake public and subsidized housing M opportunity to evaluate the safety of enacted smoke-free laws that include smoke-free. Banning smoking in e-cigarettes by reviewing ingredients, all workplaces, including restaurants subsidized or public housing is a product design, health risks and appeal and bars. Five more states have smoke- key strategy for reducing children’s to youth and non-tobacco users.663 free laws that include restaurants and exposure to secondhand smoke. Studies have shown that e-cigarettes bars, but not all other workplaces. The U.S. Department of Housing emit probable carcinogens, and To eliminate secondhand smoke in and Urban Development and a set not simply water vapor. As a result, all workplaces and public places, of partners issued a guidance and e-cigarettes should be included in state comprehensive smoke-free laws should toolkits for public housing and multi- and local smoke free laws in order to be adopted in the remaining states. unit family housing owners, managers protect the public’s health. and residents for ways to establish 128 TFAH • healthyamericans.org PREVENTION AS A PRIORITY OF THE NATIONAL CANCER MOONSHOT INITIATIVE Cancer is responsible for one in every four deaths in the United States, roughly 1,630 per day.665 In addition, around 14.5 million Americans have a history of cancer666 — roughly equivalent to the populations of New York City, Houston and Los Angeles combined.667 In 2016, more than 1.6 million more Americans are expected to be diagnosed with cancer.668 By 2025, the number of new annual cancer diagnoses is predicted to grow by 31 percent and cancer deaths are expected to grow by 37 percent.669 By 2020 medical expenditures related to cancer Source: American Cancer Society664 are expected to increase 27 percent to approximately $158 billion a year.670 According to researchers, however, Preventive measures can drastically a majority of cancer cases could be help lessen the health and economic prevented. For instance, this year, burden of cancers. Reducing risk cigarette smoking will be responsible for factors for colorectal cancer, such as by nearly one-third of all cancer deaths.671 reducing smoking, obesity and red-meat One in five cancer deaths will be consumption, could contribute $12.4 attributable to other health behaviors billion in savings by 2020.678 such as physical inactivity, excess alcohol In 2016, President Obama announced a $1 consumption and/or poor nutrition.672 billion initiative to eliminate cancer known Cancer prevention initiatives such as as the National Moonshot Initiative. targeted behavior changes, screenings or Headed by Vice President Joe Biden, the vaccinations serve as a key component for Cancer Moonshot Task Force examines reducing cancer rates and mortality.673 mechanisms to support cancer research For example, by 2030, obesity is and enable progress in treatment that expected to lead to an additional makes the most of federal dollars.679 While 500,000 cases of cancer in the United much of the Moonshot effort is focused States.674, 675 A one percent decrease on cures and treatment, an increased in individual BMI among all American emphasis on prevention would provide a adults, however, would prevent about cost-effective, evidence-based means for 100,000 new cases of cancer.676, 677 advancing the Task Force’s goals. TFAH • healthyamericans.org 129 RECOMMENDATIONS l upport investments in tobacco S the existing literature and developing prevention and cessation. Tobacco new strategies for addressing these is responsible for nearly one-third determinants of cancer though policy, of all cancer deaths.680 To achieve system and environmental changes. significant progress, an initiative to l nvest in research and interventions I reduce cancer must include increased addressing health, disease and investment in tobacco control. More mortality disparities among population funding and research resources should groups. Additional funding is be devoted to reducing disparities needed to ensure preventive in tobacco use and identifying and cancer initiatives are implemented implementing innovative local, state, within populations with the highest federal and private sector policy documented disparities. National approaches to tobacco control.681 Moonshot priorities should include l upport investments in interventions S increased funding for interventions that work to increase physical activity, already rooted in the evidence-base, improve nutrition and prevent such as preventive screenings, as well obesity. Given the high impact that as funding for intensified research increasing physical activity and good specifically related to exploring causes nutrition can have on preventing or of existing cancer disparities. reducing the risk for a number of l mprove existing preventive I types of cancer, there should be a vaccination initiatives through high and deliberate priority placed provision of communication strategies on developing programs that address for providers. While research strongly these factors explicitly. supports HPV vaccines’ effectiveness l xpand research and development E in reducing the roughly 39,000 of additional interventions to address annual HPV-associated cancer cases,682 environmental and behavioral factors vaccination rates remain low, with related to the major noncommunicable only about 40 percent of adolescent diseases including cancer, girls and 30 percent of adolescent cardiovascular diseases and diabetes. boys receiving all doses.683 Missed In addition to obesity and tobacco clinical opportunities to discuss and related prevention programs and recommend the HPV vaccine serve as policies, there should be an increased a driving force for low vaccination.684 investment in additional research into As a part of its prevention efforts, strategies to address the relationship the National Moonshot Initiative between cancer risk and key health should develop, test and disseminate behaviors and environmental comprehensive communication exposures. The Moonshot Task Force strategies for providers to encourage should dedicate resources to reviewing HPV vaccination for all adolescents. 130 TFAH • healthyamericans.org ENDING THE HIV/AIDS EPIDEMIC Successful treatment regimens have led to complacency and a belief that HIV/AIDS is under control. But, HIV/AIDS is still a significant health concern — with more than 1.2 million Americans living with HIV, and around 44,000 new HIV diagnoses a year.686 A number of promising policies and practices are renewing efforts in Estimated HIV Diagnoses Among Men Who Have Sex With Men, by communities around the country to Race/Ethnicity and Age at Diagnosis, 2014 — United States685 reach the goal of ending HIV/AIDS. 5,000 An increased focus on preventing White HIV — with particular emphasis on Black Hispanic/Latino prevention in high-risk communities, a 4,000 full continuum of care and treatment as prevention — could help eliminate the epidemic in a generation. Some 3,000 key concerns to help focus efforts include that: 2,000 l N early one in eight people living with HIV do not know they are infected.687 More than 90 percent 1,000 of new infections could be averted through diagnosis, and ensuring people receive prompt, ongoing care 0 13–24 25–34 35–44 45–55 ≥55 and treatment.688 Age in years l T here has been a significant increase Source: CDC, HIV Surveillance Report 2015 in new infections among young gay men — a 6 percent increase between 2012 and 2014 among men who have sex with men (MSM) — (LGBTQ) community. This includes reported cases from 2010 to 2014 with an 87 percent increase among developing supportive and respectful (with nearly 30,500 new infections in young Black and Latino MSM policies that help reduce stigma, 2014), with new cases predominantly between 2005 and 2014.689 discrimination and bullying.690, 691, 692 among young adults and middle aged adults (ages 20 to 39), who are White l F or decades, the country has l A rise in opioid and heroin addiction and live in rural and suburban areas.695 approached the HIV/AIDS epidemic is contributing to a major rise in In Kentucky, Tennessee, Virginia and focused on individual behavioral hepatitis C virus (HCV) infections, West Virginia, acute HCV infections risk, but the research shows that is and there is concern this will also increased by 364 percent from 2006 only one part of the equation. More lead to an escalation in HIV rates, to 2012 — a majority of those infected effective strategies include focusing on particularly in places where HIV rates have been White adolescents and prevention and improving the overall have traditionally been low, such as adults under 30 who inject drugs.696 well-being and health of members of the in Appalachia.693, 694 HCV infections lesbian, gay, bisexual, transgender, queer have increased by 158.1 percent in TFAH • healthyamericans.org 131 RECOMMENDATIONS l mplement a full continuum I policies to ensure that all students are syringe exchange programs lowered approach to eliminating AIDS — safe from violence (such as S.A.F.E the incidence of HIV/AIDS among including prevention, reducing HIV Classrooms) and training for teachers people who inject drugs by 80 percent risk behaviors, ensuring access to and administrators to support LGBTQ in the last decade.704, 705 There should sustained treatment (and treatment as students and to discern harassment or be increased state, local and private prevention) and supporting access to abuse.699 Supportive programs during support for syringe exchange programs pre-exposure prophylaxis (PrEP).697 youth have shown strong results in and campaigns to inform the public There should be increased focus on helping to build protective factors and about the effectiveness of syringe prevention programs, support and resiliency that reduce risk for a wide exchange programs for limiting education among young MSM — with range of health and social concerns. the spread of disease — including particular emphasis on young Black for protecting first-responders and l oordinate prevention strategies and C MSM. In addition, there should be a healthcare workers. While action treatment when appropriate for strong emphasis on “test and treat” and has been taken recently to lessen HIV/AIDS, hepatitis and tuberculosis. “treatment as prevention” initiatives. restriction on syringe exchange Since the at-risk populations often Expanded screening initiatives are programs at the federal level and in overlap for these conditions, it is important to help individuals know their some states as part of addressing the important to coordinate strategies, status since HIV-positive individuals rising heroin and prescription drug surveillance and treatment programs with full viral suppression are unlikely epidemics to limit the spread of for these conditions, which also helps to transmit infections. Finally, PrEP HIV/AIDS and HCV infections, it is to efficiently use available resources. therapy can also help prevent non- not at a level that is sufficient. infected individuals from infection.698 l xpand Medicaid coverage of routine E l mprove real-time surveillance I HIV screening. All state Medicaid l educe the impact of social R to monitor and contain hepatitis programs should cover routine determinants of HIV among outbreaks. Recent clusters of screening of HIV, regardless of risk adolescent MSM — including stigma outbreaks show the urgent need for (consistent with CDC guidelines).700 and discrimination — through the improved and real-time measurement Providing screening services for creation of a culture of acceptance of infections to allow for interventions Medicaid beneficiaries is particularly and integration in families, schools to prevent the spread of HCV. Disease important since these Americans and communities. Federal, state surveillance needs to be dramatically include many of the lowest-income and and local policies should prioritize improved to become a true real-time, most vulnerable in terms of quality of support for education and programs interoperable system, able to quickly health and risk for HIV infection. for parents and families of youth who identify outbreaks and threats and are sexual minorities and gender non- l emove all restrictions on syringe R implement containment and treatment conforming; school environments exchange programs — and support strategies. The federal government that are supportive of all students; public safety campaigns and syringe should work to upgrade systems to the and community-based services for exchange programs to help prevent latest technologies to allow for real- LGBTQ youth. To reduce stigma HIV and viral hepatitis. One of the time and interoperable tracking of experienced by adolescent MSM, most effective, scientifically-based diseases — to more efficiently collect local and state policymakers should methods for reducing HIV/AIDS and and analyze data, to better identify provide comprehensive sexuality viral hepatitis is syringe exchange threats and to understand how threats education in schools, implement programs.701, 702, 703 CDC has found can be interrelated. 132 TFAH • healthyamericans.org STOPPING SUPERBUGS AND ANTIBIOTIC RESISTANCE Overuse of antibiotics has contributed to one of the biggest threats to public health: antibiotic resistant pathogens or “superbugs.”706 Superbugs are turning infections that were once easily treated — like E. coli and salmonella — into deadly pathogens. More than 2 million people in the United States are annually infected by superbugs and at least 23,000 die.707 Superbugs cause $20 billion in annual direct costs and an additional $35 billion in productivity losses.708 CDC has warned that superbugs are expected to continue to grow dramatically — and has prioritized 18 organisms that are an urgent, serious or concerning antibiotic resistant threat — ranging from Methicillin- resistant Staphylococcus aureus (MRSA) to antibiotic-resistant gonorrhea. Six of those urgent or serious antibiotic- resistant threats, plus C.difficile, can cause healthcare-associated infections.709 l E xperts have found that nearly one-third of the 154 million annual antibiotic prescriptions written in doctor’s offices and emergency departments are unnecessary. Many are prescribed for viral respiratory illnesses that inherently will not respond to antibiotics.710 l I n addition, more than 80 percent of antibiotics sold in the United States are used in agriculture (including Another factor contributing to the rise ionophores not used in human is that there are few market incentives medicine).711 Pathogens can develop for pharmaceutical companies to antibiotic resistance when food invest in new antibiotic research animals — such as poultry, cattle or and development. As of March swine — are exposed to antibiotics.712 2016, only 37 new antibiotics were in They can spread to humans through development, 13 of which had reached consumption of food animal products, phase 3 testing.714 Historically, only direct contact with infected animals or 60 percent of phase 3 drugs will be contact environmental sources, such approved by the FDA.715 as water and soil contaminated by animal waste runoff.713 TFAH • healthyamericans.org 133 RECOMMENDATIONS l ully fund and implement CDC’s F requirements for all CMS-enrolled U.S. and inform new interventions. Antibiotic Resistance Solutions facilities to have effective antibiotic Sustained funding and continued Initiative. The initiative is designed stewardship programs and work support to state and local health to fully implement the priority actions with public health to track progress departments implementing CDC’s identified in the National Action Plan for in prescribing rates and resistance Antibiotic Resistance Laboratory Combating Antibiotic Resistant Bacteria. patterns. The U.S. Department of Network (AR Lab Network), next Health and Human Services should generation surveillance in PulseNet l ncentivize development of new I help develop quality measures that laboratories and whole genome antibiotics and new diagnostic tests for assure appropriate prescribing of sequencing to rapidly uncover resistant bacteria. The FDA should antibiotics. HHS, CMS, accrediting foodborne drug-resistant bacteria as be able to approve drugs for a limited organizations, healthcare facilities, well as effective dissemination of data population of patients with serious medical schools and others should collected will be critical for realizing or life-threatening infections and for educate providers and patients about the impacts of this initial federal drugs that fill an unmet need based the harm of inappropriate prescribing. investment in antibiotic resistance upon more limited data (e.g. smaller surveillance. clinical trials). Limited Population l revent and stop the spread of P Antibacterial Drug (LPAD) approval infections and improve antibiotic use l revent infection by improving P provides a mechanism to do so. in every state. CDC should continue vaccination rates for children and expanding implementation of public adults. Despite their effectiveness, l educe overuse of medically- R health-healthcare prevention networks vaccination rates remain low in many important antibiotics in agriculture. in every state to improve identification communities across the U.S. — even The FDA should fully implement and response to all emerging threats among adult populations.716 In and strengthen guidance to industry and implement proven strategies 2014, 80 percent of U.S. adults did regarding the nontherapeutic in healthcare facilities to prevent not receive recommended tetanus, use of antibiotics in food animals. infections and transmission across diphtheria and pertussis (whooping Important measures include enforcing healthcare settings. cough) vaccinations.717 Federal, requirements for the collection and state and local health officials, in publishing of species-specific use data, l trengthen surveillance and tracking S partnership with medical providers requiring valid veterinary oversight of resistant bacteria. Congress and and community organizations, should on the farm, promoting antibiotic CDC must continue to invest in conduct assertive campaigns about stewardship programs and tracking the our public health infrastructure to the importance of vaccines. Targeted impact of these policies on resistance. enable the detection and control of outreach should be made to high- drug resistant outbreaks. National l educe over-prescription of R risk groups and to racial and ethnic programs to identify emerging antibiotics through implementation of minority populations where the patterns of both resistance and antibiotic stewardship. The Centers misperceptions about vaccines are antibiotic use will quantify the for Medicare and Medicaid Services particularly high.718 magnitude of antibiotic use in the should finalize and implement 134 TFAH • healthyamericans.org ENVIRONMENTAL HEALTH AND JUSTICE719 From the food and water people consume to the air they breathe, the physical environment can have profound effects on individual health. An estimated 13 percent of diseases could be prevented through improvements in the environment.720 The economic impact of the health effects of Biomonitoring | Lead environmental factors among children alone is more than $76.6 billion per year.721 The recent contaminated water crisis in Flint, Michigan helped highlight the continued environmental health threats in homes and communities around the country — and threats are significantly higher in low-income and minority communities. Young children also have higher risk due to harmful environmental elements — including pollution, toxic chemicals, contaminated water or food and waste from landfills. Even relatively low levels of exposure to pollution and environmental hazards can adversely impact the health of children — contributing to lower birth weights, lower test scores and lower earning potential as adults. 722, 723 A vast majority of environmental health threats could be prevented — and renewed strategies should focus on promoting environmental justice. Renewed efforts should be made to ensure every community has safe and clean water, air and food — and every American can live in a healthy, safe home and neighborhood. *The estimate should be interpreted with caution because the standard error of the estimate is relatively large: the relative standard error, RSE, is at least 30% but is less than 40% (RSE = standard error divided by the estimate), or the RSE may be underestimated. l M ore than half a million children ages 1 to 5 still suffer from increased level of exposure to secondhand smoke.735, 736 Data characterization lead poisoning.724 Rates of lead poisoning are highest among Secondhand smoke has been known to cause asthma attacks, - Data for this indicator are obtained from an ongoing continuous survey conducted by the National Center for Health Statistics. children living in poverty (4.4 percent) and Black children bronchitis and pneumonia, ear infections among children, - Survey data are representative of the U.S. civilian noninstitutionalized population. - Lead is measured in blood samples obtained from individual survey participants. (5.6 percent). 725, 726, 727 A majority of cases are from exposure and has been linked to sudden infant death syndrome. 737 to lead paint in older homes: around 4 million homes with  The median blood lead level in children ages 1 to 5 years in 2007–2010 was 1.3 µg/dL. The l Lower-income housing is more likely to 1 to 5 years in close to median blood lead level in Black non-Hispanic children agesbe located2007–2010 was young children are estimated to still contain lead threats; but sources of pollution and toxins. For instance, Black and less there are also cases of exposure through contaminated water America’s Children and theare more likely Edition within 200 meters 125 educated women Environment | Third to live and exposure to lead paint through schools or commercial of Superfund hazardous waste sites or factories emitting buildings. Medical and special education needs per year per toxic releases.738 In addition, the highest concentration child with lead poisoning are around $5,600.728 of brownfields — lands formerly used for commercial l M ore than 12 percent of children in families living in poverty or industrial purposes but are no longer in use — are have asthma, compared to 8.2 percent of middle and higher disproportionately in low-income communities.739 income families. In the past decade, asthma rates have The return on investment for many environmental health increased by nearly 15 percent overall and by more than 50 interventions can be significant. For lead control programs, percent among Black children. Children living in low-income for example, for every dollar spent, $17 to $221 is returned in housing have higher exposure to indoor environmental triggers health benefits, increased intelligence quotient (IQ), higher such as pollen, mold, animal dander, cockroaches, rodents lifetime earnings, tax revenue, reduced spending on special and dust mites.729, 730, 731, 732, 733 Asthma is the second most costly education and reduced criminal activity — resulting in a medical condition among children, at more than $8 billion.734 potential net benefit of $181 billion to $269 billion.740 And, a l M any children and pregnant women living in multi-unit Boston Community Asthma Initiative led to a return of $1.46 housing (such as apartment complexes) have a 45 percent to insurers/society for every $1 invested.741 TFAH • healthyamericans.org 135 RECOMMENDATIONS l rioritize environmental health and P between local and state housing and exposure to secondhand smoke. justice efforts. Federal, state and health authorities, prenatal parental The U.S. Department of Housing local governments should place a high counseling, enforcement of lead-safe and Urban Development and a set priority on programs to eliminate housing standards and identification of of partners issued a guidance and and reduce environmental threats to funding for lead hazard remediation.742 toolkits for public housing and multi- the nation’s health, with a particular The American Academy of Pediatrics unit family housing owners, managers emphasis on addressing inequities. identifies roles and recommendations and residents for ways to establish and Efforts like CDC’s environmental for EPA, CDC, HUD, CMS, providers, implement smoke-free policies and health services programs and the public health officials and other practices.745 CDC estimates nearly Federal Interagency Working Group stakeholders.743 $497 billion could be saved each year on Environmental Justice — which if smoking was universally banned in l educe asthma through expansion R works to improve access to affordable, subsidized and public housing.746 of the National Asthma Control safe, housing while safeguarding the Program and environmental l xpand actionable research on the E environment — should be extended. trigger management: Home-Based connection between the environment l liminate lead poisoning in children E Multi-Trigger, Multicomponent and health, including a Nationwide through primary prevention. Public Environmental Interventions can Health Tracking Network (NHTN).747 health efforts — including improving greatly reduce the number of asthma While there are clear connections water systems, lead paint remediation attacks and recurring emergency showing the negative impact of lead, and required screening of lead room visits among children and mercury and many other toxins on exposure in children — have helped adolescents.744 In order to expand health, more research and surveillance reduce lead poisoning levels by 70 access to these evidence-based is needed to better understand percent since 1990. Policies that interventions, the CDC’s National and locate the impact and scope of provide much-needed services after Asthma Control Program should different environmental factors on a child screens positive for elevated be further expanded to all 50 states health. A better tracking system could blood lead levels are addressing a and Washington, D.C. In addition, provide “early warning” information serious problem too late. Instead, local Medicaid programs in every state about environmental-exposure and state policies need to implement should support and prioritize emergencies, such as the lead water primary prevention strategies to recommended asthma home visiting crisis in Flint, Michigan. Additional eliminate childhood exposure to support and remediation programs. resources are needed to build out lead. The strategies recommended the NHTN system to better identify l ake public and subsidized housing M by the CDC’s Advisory Committee connections and causes of many smoke-free. Banning smoking in on Childhood Lead Poisoning diseases, and to expand to all 50 states. subsidized or public housing is a Prevention include data-sharing key strategy for reducing children’s 136 TFAH • healthyamericans.org HEALTH, CLIMATE CHANGE AND EXTREME WEATHER Climate change and extreme weather events have health consequences in the United States.749 Shifts in temperatures, storms, sea level rise, flooding, droughts, air quality and pollution, insect control and other climate and weather changes can lead to: l A rise in new insect and other vector- borne disease threats, ranging from Zika to dengue fever; 750,751 l I ncreased heat-related deaths and sicknesses, particularly among the elderly and children; 752 l A ggravating triggers for asthma; 753,754 l I ncreased allergens and extended allergy seasons; 755 l M ore injuries and difficulties accessing medical care during major storms;756 l W ater shortages because of droughts and/or water contamination after SOURCE: CDC Climate and Health Program748 heavy rainfall;757 l M ental health impacts such as Health departments have an important depression and post-traumatic stress role to play in helping communities disorder (PTSD);758 and prepare for the adverse effects of climate change, given their role in l M alnutrition due to extreme weather building healthy communities. Public affecting agricultural yields and crop health workers are trained to develop production.759 communication campaigns that both Experts estimate that ozone and particle inform and educate the public about health effects associated with climate health threats and can use these skills change could contribute to 1,000 to 4,300 to educate the public about climate additional premature deaths nationally change-related disease prevention and per year by 2050.760,761,762 Climate change preparedness. In addition, public health is expected to have a growing adverse departments are also on the frontlines economic impact. A recent study found when there is an emergency, whether between 2002 and 2009, climate change- it is a natural disaster or an infectious related factors, such as flooding, vector- disease outbreak. These types of borne illnesses, and extreme weather emergency preparedness and response events resulted in about $14.1 billion in skills are essential as extreme weather health costs, including the value of lives events and other effects of climate lost prematurely.763,764 change become more common. TFAH • healthyamericans.org 137 RECOMMENDATIONS l revent and prepare for the P the underlying causes of climate l mplement the Clean Air Act (CAA) I adverse impact of climate change change can simultaneously provide in an effective and timely manner. on infectious disease outbreaks, important health equity benefits to The CAA protects American health including Zika. Every state should vulnerable populations. Projects against dangerous levels of air have a comprehensive climate aimed at reducing greenhouse gas pollutants, and investments to comply change adaptation plan that includes emissions through city planning with the CAA have provided $4 to a public health assessment and initiatives promoting active $8 of economic benefits for every $1 response, including developing transportation options, for example, spent on compliance.768 Four major sustainable state and local mosquito can play an important role in reducing rules of the CAA alone would yield control programs. Public health and existing health inequities by increasing more than $82 billion in Medicare, environmental agencies should work resilience, physical activity levels and Medicaid and other healthcare together to implement strategies that social cohesion in communities most savings for America through 2021.769 help track concerns, coordinate risk at-risk.765 Urban planning policies can l evelop sustainable state and local D management and communications also help vulnerable populations adapt mosquito and other vector control and prioritize key public health to the predicted impacts of climate programs. A review by ASTHO capabilities needed to address change. Policies ensuring buildings found that many states and local environmental health concerns. are constructed to resist extreme communities are challenged to Climate change needs assessments weather events, for example, could develop and maintain vector control should include an examination of help mitigate the negative impacts programs, especially in tight budgetary what additional capacities are needed for vulnerable populations located in times and when emergency situations and identify vulnerable populations areas heavily impacted by hurricanes have quieted, but that these programs and communities. or heavy rain.766 are a vital public health strategy to l uild resilience to climate-related B l estore funding for the CDC’s R help control vector-borne diseases.770 health effects at the federal, state Climate and Health Program at the l ncrease funding for the National I and local level. Climate change National Center for Environmental Environmental Public Health Tracking preparedness should be a required Health. The program was created Program at the National Center for element of Public Health Emergency in 2009 to translate climate change Environmental Health at the CDC. Preparedness (PHEP) and Hospital science to inform states and Health tracking is important to identify Preparedness Program plans communities, create tools to build the link between environmental factors and grants. Funding should be state and local capacity to handle and their impact on health. The significantly increased to expand extreme events happening today program should be expanded and fully CDC’s Climate Ready States and Cities and in the future and lead efforts to funded to cover every state. Initiative nationwide and to build mitigate the public health impacts capacity at the federal, state and local of climate change and extreme l mprove coordination and move to I level to understand the impact of weather. For each additional $1 integration across medical care, public climate change and apply this to long- million in funds, CDC would be health and environmental agencies. range health planning. able to fund approximately three Public health agencies at all levels must additional states or cities under work with environmental, homeland l ncrease funding for prevention and I their Climate Ready States and Cities security and other agencies to undertake preparedness measures that promote Initiative.767 A larger, long-term initiatives to reduce known health health equity and help protect investment will be critical to building threats from extreme weather, food, vulnerable populations from adverse nationwide resilience. water and air and educate the public climate effects. Initiatives addressing about ways to avoid potential risks. 138 TFAH • healthyamericans.org Investing in a Robust Environmental Health System Background and Need for Action Environmental Health is the branch of public health that focuses on the interrelaƟonships between people and their environment, promotes human health and well-being, and fosters healthy and safe communiƟes. As a fundamental component of a comprehensive public health system, environmental health works to advance policies and programs to reduce chemical and other environmental exposures in air, water, soil and food to protect residents and provide communiƟes with healthier environments. PARTNERS: Environmental health protects the public by tracking environmental exposures in communiƟes across the United States and potenƟal links with disease outcomes. To achieve a healthy community, homes should be safe, affordable, and healthy places for families to gather. Workplaces, schools, and child care centers should be free of exposures that negaƟvely impact the health of workers or children. NutriƟous, affordable foods should be safe for all community members. Access to safe and affordable mulƟmodal transportaƟon opƟons, including biking and public transit, improves the environment and drives down obesity and other chronic illnesses. Outdoor and indoor air quality in all communiƟes should be healthy and safe to breathe for everyone. Children and adults alike should have access to safe and clean public spaces such as parks. When a disaster strikes, a community needs to be prepared and should have the tools and resources to be resilient against physical (infrastructure and human) and emoƟonal damage. All these acƟviƟes require the participaƟon of federal, state, local, and tribal governments. Building a Robust Environmental Health System InvesƟng in essenƟal governmental environmental health services through dedicated resources will create an effecƟve environmental health system that proacƟvely protects communiƟes and helps everyone aƩain good health. Federal, state, local, and tribal governments should adopt standard approaches to ensuring environmental health equity, protecƟons and access for all, parƟcularly vulnerable and at-risk populaƟons. The federal government can help build an effecƟve and strong environmental health system by: • CREATING AN INTEGRATED INFRASTRUCTURE TO COLLECT AND TRACK CRUCIAL INFORMATION . • DEVELOPING A WELL -TRAINED AND HIGHLY SKILLED WORKFORCE . • PROVIDING AMPLE AND SUSTAINABLE FUNDING FROM DIVERSE SOURCES . • ENSURING THAT POLICY AND PROGRAMS ARE GROUNDED IN EXISTING AND UP - TO -DATE EVIDENCE -BASED RESEARCH . Top 10 Focus Areas • ENCOURAGING/INCENTIVIZING CROSS - SECTORAL PARTNERSHIPS TO SUPPORT Safe Drinking Water CONSIDERATION OF HEALTH IMPACTS. Clean Air • ASSURING ENVIRONMENTAL HEALTH SERVICES AR E EQUITABLY ACCESSIBLE. Vector Control Food Safety Chemical Safety A cohesive environmental health system monitors and measures diseases, Healthy Community Design hazards, exposures, and health outcomes; can collect data over Ɵme; and can Healthy Housing Climate Effects present real-Ɵme data to quickly respond to emergencies and to idenƟfy Emergency Preparedness problems for program planning. All government agencies should assess the Environmental Equity environmental health impacts of their programs and policies across all sectors to improve health of all communiƟes and people. TFAH • healthyamericans.org 139 Recommendations Governmental environmental health services are not a luxury; they are essenƟal to providing basic needs to the public such as safe drinking water, clean air, lead poisoning prevenƟon, climate change adaptaƟon, and more. Everyone should have the opportunity to achieve the highest possible level of health at all stages of life, which encompasses physical, mental, and social well-being and extends beyond the absence of disease. As such, the following recommendaƟons support the uncomplicated right to environmental health: PREVENTION: Enable federal, state, local, and tribal governments to promote resilient, equitable, and healthy communiƟes for all Americans, especially those who are most vulnerable and most at risk. RESPONSE: Build and support the governmental environmental health system, including workforce needs as well as tracking disease outcomes and environmental exposures. REAL-LIFE SOLUTIONS: Strengthen environmental health protecƟons and support peer-reviewed research to inform environmental health decision making and pracƟce. Case Examples that Demonstrate the Need for a Strong and Equitable System Environmental health professionals work every day to ensure that the air we breathe, the water we drink, and the food we eat are safe and secure. No one would want a person without a medical degree performing surgery, nor should anyone want the safety of their food or water being determined by a person who is not a highly skilled professional. Offering collaboraƟon early on, enhancing their capabiliƟes to detect and respond to threats, grounding policy and acƟons in evidence-based research, and ensuring that their services reach everyone are criƟcal tenets of a system that can create resilient communiƟes aŌer a dis aster. Recent major emergencies demonstrate the need for a strong governmental naƟonwide environmental health system. The Zika virus outbreak, Flint water crisis, and Hurricane Katrina are three examples with stark environmental health implicaƟons. Th ese emergencies will not be the last, so we must prepare by invesƟng in a robust environmental health system. Zika Virus Outbreak Flint Water Crisis Hurricane Katrina & Super Storm Sandy Mosquito-borne diseases have and Due to recent, highly visible events, the conƟnue to threaten the public’s health safety of, and trust in our naƟon’s UnforgeƩably, Hurricane Katrina with such illnesses as EncephaliƟs, West drinking water systems have been called flooded the city of New Orleans in 2005, Nile Virus Disease, Dengue, into quesƟon. The drinking water crisis damaging more than 100,000 homes Chikungunya, and now Zika Virus associated with lead contaminaƟon in and Super Storm Sandy hit New York, Disease. Zika infecƟon - passed from an Flint, MI, sheds a naƟonal spotlight on New Jersey and other neighboring infected pregnant woman to her fetus an issue that is occurring across the states in 2012, also causing devastaƟng and capable of causing devastaƟng birth country. In Flint, due to a change in the damage to homes and businesses, defects - also can have significant source of the city’s drinking water power supply systems, and other criƟcal economic consequences on affected without taking the necessary corrosion infrastructures such as roads. Storms communiƟes. There is no vaccine to control steps, the safety of like these have both acute and longer prevent Zika. The best way to prevent approximately 100,000 people’s term environmental health impacts disease-carrying mosquitoes is through drinking water was threatened. This capable of causing physical, emoƟonal, community-based mosquito control and resulted in the leaching of lead from the and economic harm. Understandably, public educaƟon programs. plumbing causing an increase in the the vicƟms’ focus was on mere survival Environmental health acƟons are blood lead levels in children consuming and not necessarily whether the water mobilized through Integrated Mosquito the water. This was a preventable coming from their kitchen sink was safe Management Programs that provide situaƟon. Strong policy with sufficient to drink, whether residual mold growth mosquito monitoring and surveillance, oversight and accountability supported in their home would impact the health remove places where mosquitos lay by a skilled and resourced of their children, or whether the eggs, and carefully apply pesƟcides to environmental health system is reconstrucƟon of their home would significantly reduce mosquito essenƟal to monitor drinking water cause harmful exposures to lead or populaƟons while protecƟng water systems. The presence of chemical and other building materials or systems and minimizing undue human microbial contaminants must be contaminants. A strong environmental and animal exposure. These acƟons, detected, source waters must be health system provides the necessary coupled with public educaƟon and protected, regulaƟons must be safeguards to measure, track, and promoƟng healthy housing, will enforced, and surveillance systems must respond to such concerns and miƟgate undoubtedly result in reduced illness be in place that monitor and link water the adverse health consequences. and suffering. quality to human health data for rapid detecƟon of potenƟal public health problems. This document was made possible through cooperaƟve agreement 1U38OT000131 between the Centers for Disease Control and PrevenƟon and the American Public Health AssociaƟon. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and PrevenƟon. 140 TFAH • healthyamericans.org ACHIEVING HEALTH EQUITY A person’s health, and ability to make healthy decisions, is impacted dramatically by where they live, their income, their educational attainment and their racial and ethnic status. Americans in the top 1 percent of household income live 10-15 years longer THE RELATIONSHIP BETWEEN LIFE EXPECTANCY AND INCOME BY than those in the bottom 1 percent.772 GENDER, U.S. 2001-2014 771 Adults without a high school diploma are three times more likely to die before the age of 65 than those with a college degree.773 On average, the life expectancy for Black men is 4.5 years shorter than for White men; and 3 years shorter for Black women than White women.774 The causes of health inequities are multifaceted and often intertwined with lower socioeconomic status and differential access to opportunities and factors that influence health, such as quality healthcare, income, education, housing, transportation and others. For instance, access to safe parks, supermarkets and quality housing provide significant opportunities to be healthier.775 Blacks and Latinos have lower median Source: Chetty et al., 2016 household incomes than Whites and are more likely to live in poverty.776 Black men earned 70 cents for every affects respiratory and cardiovascular spending).786, 787 According to CDC, the dollar earned by White men in 2014 health, as well as birth outcomes.783 rate of preventable hospitalizations for and Hispanic men earned 60 cents Blacks is almost double that of Whites — on the dollar.777, 778 People living Health inequities have a high economic which contributes to over a half million in neighborhoods with high levels cost. A study by the Urban Institute hospitalizations and $3.7 billion in of poverty have a higher risk of less found that the differences in rates hospitalization costs annually.788 healthy behaviors — such as smoking, among Blacks, Hispanics and Whites for physical inactivity or poor nutrition a set of preventable diseases (diabetes, Examples of some health inequities — related to inequities in the physical heart disease, high blood pressure, renal include: and social environment.779 Low-income disease and stroke) cost the healthcare l A merican Indians and Alaska Natives neighborhoods, for example, are less system $23.9 billion annually.784 By are twice as likely to have diabetes likely to have places where children can 2050, this is expected to double to $50 as Whites, and diabetes rates among be physically active or have access to billion a year.785 Eliminating health Blacks and Hispanics are over 1.5 times fully-stocked supermarkets with healthy, inequalities could lead to reduced higher than for Whites.789 affordable foods — contributing to medical expenditures of $54-61 billion higher rates of obesity and poor nutrition a year, and recover around $13 billion l B lacks have the highest death rate in these communities.780, 781, 782 Low- annually due to work lost by illness and shortest survival of any racial and income and minority communities also and around $240 billion per year ethnic group in the United States for experience higher air pollution, which due to premature deaths (2003-2006 most cancers.790 TFAH • healthyamericans.org 141 education level.795 American Indian WASHINGTON, D.C. Follow the discussion and Alaska Native infants die from #CloseHealthGaps #CloseHealthGaps Sudden Infant Death Syndrome Short Distances to Large Gaps in Health (SIDS) at about twice the rate of White infants.796 84 YRS l A sthma rates for Black children grew MONTGOMERY COUNTY by 50 percent between 2001 and 2009, while the overall asthma rates increased 15 percent.797 Disparities in asthma rates between Black and White 78 YRS children reached a peak in 2011 (with DISTRICT OF COLUMBIA Black children twice as likely as White children to have asthma).798 And, asthma-related hospitalizations and 86 YRS 86 YRS ARLINGTON COUNTY deaths are over twice as high among FAIRFAX COUNTY Blacks as Whites.799, 800 2 miles 78 YRS l B lack and Latinos have less access to PRINCE GEORGE'S COUNTY regular healthcare and receive lower Life expectancy at birth (years) quality care on about 40 percent of Shorter Longer core healthcare measures.801 © 2016 Robert Wood Johnson Foundation l I n addition, Blacks and Hispanics were more likely than Whites to report poor communication from healthcare providers.802 Some examples of implicit bias in healthcare identified l B lack women with breast cancer are by The Joint Commission, Division of 40 percent more likely to die than Health Care Improvement include: White women with breast cancer, non-White patients receive fewer despite similar incidence rates of cardiovascular interventions and renal the disease.791, 792 transplants; Black women are more l B lack men are about twice as likely to likely to die after being diagnosed die from prostate cancer as Whites. 793 with breast cancer; non-White patients are less likely to be prescribed pain l H ispanic women are more than 1.5 medications; Black men are less times as likely to have cervical cancer likely to receive chemotherapy and as Whites.794 radiation therapy for prostate cancer; l I nfants born to Black women are and patients of color are more likely 1.5 to almost 3 times more likely to to be blamed for being too passive die than infants born to women of about their healthcare.803 other races/ethnicities regardless of 142 TFAH • healthyamericans.org RECOMMENDATIONS l reate strategies to optimize the C taken into account in this process. l rioritize community resiliency in P health of all Americans, regardless Proven, effective programs, such as health emergency preparedness of race, ethnicity, income or REACH (Racial and Ethnic Approaches efforts. Federal, state and local where they live. The country must to Community Health) should be fully- government officials must work with invest in first understanding the funded and expanded. communities and make a concerted systematic disparities that exist and effort to address the needs of l ollect Data on Health and Related C the factors that contribute to these low-income and minority groups Equity Factors by Neighborhood: differences, including poverty, during health emergencies. Public Improving data collection at a very income, racism and environmental health leaders must develop and local level to make connections factors. Resources must then be sustain relationships with trusted between health status and equity devoted to implement community- organizations and stakeholders in concerns can help identify concerns driven approaches to address these diverse communities on an ongoing and inform the development of factors, including using place-based basis—including working to improve strategies to address them. Collecting approaches to target programs, the underlying health of at-risk and reporting data by neighborhood policies and support effectively. communities, so these relationships at a zip code or even more granular are in place before a disaster strikes. l xpand cross-sector collaborations E neighborhood level are essential to Communication and community addressing health equity. Improving understanding inequity concerns. engagement must be ongoing to equity in health will require supporting l upport Medicaid coverage and S understand the disparate needs of and expanding cross-sector efforts to reimbursement of clinical-community various populations. make communities healthy and safe. programs to connect people to Efforts should engage a wide range of l liminate racial bias in healthcare. E services that can help improve health. partners, such as schools and businesses, Policies should incentivize equity Medicaid should reimburse efforts to focus on improving health through and penalize unequal treatment that support improved health beyond better access to high-quality education, in healthcare, and there should be the doctor’s office — programs such jobs, housing, transportation and increased support for programs as asthma and diabetes prevention and economic opportunities.804 to increase diversity across health care management, and community- professions. Some of The Joint l ully fund and implement health F based initiatives, can help better Commission’s recommendations for equity, health promotion and address the root causes that contribute combatting implicit bias include: prevention programs in communities. to inequities. assiduously practicing evidence- Partner with a diverse range of l ommunicate effectively with C based medicine; supporting cultural community members to develop diverse community groups. Federal, understanding and avoiding and implement health improvement state and local officials must design stereotypes; supporting the National strategies. Federal, state and local culturally competent communication Standards for Culturally and governments must engage communities campaigns that use respected, Linguistically Appropriate Services in efforts to address both ongoing and trusted and culturally competent in Health and Health Care; and emergency health threats. The views, messengers to communicate their supporting techniques that de-bias care, concerns and needs of community message. Communication channels including through training, perspective- stakeholders, such as volunteer should reflect the media habits of taking, emotional expression and organizations, religious organizations the target audience. counter-stereotypical exemplars.805 and schools and universities must be TFAH • healthyamericans.org 143 REVERSING RISING DEATH RATES AMONG MIDDLE-AGED WHITE ADULTS Mortality by Cause, White Non-Hispanics Age 45–54 Mortality, Age 45–54 35 1000 Lung Cancer Poisoning 30 800 25 Deaths per 100,000 Deaths per 100,000 Black 600 20 Chronic Suicide Liver disease White non-Hispanic 15 Diabetes 400 Hispanic 10 200 5 0 0 1999 2004 2009 2014 1999 2004 2009 2014 Source: CDC 1999–2014. Source: Centers for Disease Control and Prevention 1999–2014. Note: Figure is adapted from Case and Deaton (2015) figure 2. Chronic liver diseases Note: Mortality data are for all-cause mortality. Figure is adapted from Case and include alcoholic liver diseases and cirrhosis. Poisonings include drug and alcohol Deaton (2015) figure 1. poisoning, both accidental and with undetermined intent. IMAGE SOURCE: Schanzenbach, Nunn & Bauer, The Hamilton Project, 2016806 After decades of increasing life expectancy rates — the death rate for middle-aged (ages 45 to 54) White men and women increased by 10 percent since 1999.807 Key contributing factors have been 2014, the rates of synthetic opioid more often than females in other growths in unintentional injuries (drug deaths and methadone overdose racial and ethnic groups.814 overdoses and alcohol poisonings), liver deaths were highest among Whites Another factor in the increasing death disease and suicide.808 Deaths from compared with other racial or ethnic rates among middle-aged Whites is that these three factors have tripled among groups.811, 812 Between 2013 and mortalities caused by diabetes, heart White working age Americans in the 2014, rates of synthetic opioid deaths disease and other chronic conditions past 15 years.809 increased 170 percent among Whites have remained relatively stagnant in in eight high-burden states, and l D rug overdoses and alcohol poisoning this cohort — particularly among lower- were largely attributable to illicitly passed lung cancer as the leading income middle-aged Whites, since manufactured fentanyl.813 causes of death among middle- 1999.815 Improvements in disease rates aged Whites in 2011. Nationally, l S uicides among White females ages 45 had been a major factor in prolonging prescription painkiller and heroin to 64 have increased 80 percent and, life expectancy from the 1900s, and related deaths have more than tripled among White males ages 45 to 64, they continued progress in these areas are since 1999, and heroin use among have increased by 59 percent since still contributing to longer lifespans middle-aged Whites increased nearly 1999. Middle-aged White females among Blacks and Latinos. 115 percent from 2002 to 2013.810 In commit suicide more than three times 144 TFAH • healthyamericans.org 300 240 180 120 60 0 Percent of total deaths for the 5 leading causes of death for Non-Hispanic, Whites, Both Sexes, 45-54 years: United States, 1999 & 2014819, 820 Change in Percent of Total Cause of Death 1999 2014 Deaths 1999 to 2014 Cancers 32.7 25.8 -6.9 Heart disease 23.2 19.2 -4.0 Unintentional injuries, including 7.9 12.9 +5.0 drug overdoses Suicide 4.2 6.3 +2.1 Chronic liver disease and cirrhosis 4.1 5.1 +1.0 Education and income levels play a role. among those with a college degree; The increases in death rates were only and deaths from chronic liver cirrhosis among middle-aged Whites with less increased by nearly 50 percent than a college education.816 among the high school or less group while those with a college degree l D eath rates among middle-aged experienced decreases. Whites with a high school degree or no degree increased around 20 The increasing death rates were also percent from 1999 to 2013, while highest in a number of states in the Whites with some college or a college South: West Virginia, Mississippi, degree had lower death rates. Oklahoma, Tennessee, Kentucky, Alabama and Arkansas.817 Five of the l F or middle-aged Whites with a high six states (all but Oklahoma) with the school degree or less, death rates highest increases in death rates also had from drug overdoses and alcohol the highest poverty rates among Whites poisonings grew by 4 times compared as of 2015.818 to deaths in 1999 vs. a 2.3 time growth TFAH • healthyamericans.org 145 RECOMMENDATIONS l upport place-based initiatives S or faith-based organizations, have that address the underlying social also been shown to reduce suicidal and environmental determinants behavior and can provide better access of substance misuse in high-risk to formal preventive resources.823 824 populations. The trends of increasing The National Strategy for Suicide middle-aged White deaths are most Prevention report by the Surgeon pronounced among those with General and National Action Alliance lower income and lower educational for Suicide Prevention encourages attainment. To reduce mortality, the development of community- resources must be devoted to broader based services and programs that community-driven approaches promote wellness and resiliency and addressing systematic disparities address the social and environmental driven by poverty, income and risk factors for suicide.825 Local environmental factors. government entities and community- based organizations can enhance l xpand prevention efforts to combat E social connectedness by promoting the prescription opioid epidemic. The collaborative efforts between schools, prescription opioid epidemic plays workplaces, faith- and community- a major role in the rising mortality based organizations, the healthcare trends among middle-aged Whites. sector, law enforcement agencies States need to expand evidence-based and other groups to create targeted approaches to reducing substance prevention programming for middle- misuse, particularly in those states in aged adults in their communities. which the mortality gap is the largest. States should increase prevention l romote positive early learning P programs, strengthen prescription environments through the inclusion of drug monitoring programs, make social and emotional learning in early Screening, Brief Intervention and care and school settings. Research Referral to Treatment a routine shows that the foundations for mental practice for young and middle- health are built during early childhood, aged adults and improve opioid making these early years a critical prescription and dispensing practices intervention period to promote mental through provider education. well-being.826 Social and emotional learning programs have been linked to l upport targeted programs to S reductions in drug and alcohol abuse enhance individual and community and suicide ideation and attempts later social connectedness. Positive in life.827, 828 These programs provide a and supportive relationships with cost-effective prevention tool that on individuals have been shown to help average, can yield an 11:1 return on prevent depression and suicide.821 822 investment.829 Strong social connectedness with community organizations, like schools 146 TFAH • healthyamericans.org PROMOTING POSITIVE MENTAL HEALTH Mental health is as essential to well-being as physical health. Promoting mental health and improved integration of care with other medical health and social services can help promote better health, reduce rates of mental illness and improve management and treatment of mental illness. The United States should invest in a broad strategy to improve mental health — STATE MENTAL HEALTH BUDGETS FISCAL YEAR 2015-2016 stressing prevention, early identification and full support for treatment. First, stronger prevention efforts — such as addressing cycles of toxic stress RI in low-income families and providing evidence-based social-emotional learning programs in child care and schools — are among the most DC important approaches to supporting positive mental health and well-being in the United States. For instance, Increased toxic stress and traumatic experiences Decreased during childhood increase the risk for Maintained mental illness and behavioral problems, Pending risky health behaviors, low academic and career performance and difficulty Source: National Alliance on Mental Illness establishing fulfilling relationships.830, 831 Second, there is a need to improve l E ach year, one in five adults in the United screening and pathways to appropriately States experiences a mental illness.836 identify and address mental health issues and provide ongoing care for individuals. l O ne in five children and/or teens have a history of a serious debilitating And, third, while parity laws and mental disorder.837 Half of all chronic measures in the Affordable Care Act mental illness begins by age 14 and require improved coverage and support three-quarters by age 24.838, 839 for mental health, there are still many barriers to these being carried out in l T hree out of every five adults and practice, including legacy healthcare nearly half of youth ages 8 to 15 with systems and practices, shortages of trained a mental illness receive no mental professionals and ongoing social stigma. health services.840, 841 Mental illness issues are widespread in l U ntreated mental illness contributes the United States and are the fourth to increased rates of homelessness, largest driver of medical expenses (at incarceration, violence and $77.6 billion annually), and are the suicide.842, 843 top medical cost for children ($13.9 l A round 20 percent of Veterans who billion).832, 833 In addition, serious mental severed in Iraq or Afghanistan suffer illness accounts for $193.2 billion in lost from depression or post-traumatic earnings and 217 million lost days of stress disorder, and around 20 Veterans work each year.834, 835 commit suicide each day.844, 845 TFAH • healthyamericans.org 147 l T eens with untreated depression are at which can limit access to care, a higher risk to be aggressive, engage discourage people from pursing in risky behavior, die from suicide, treatment and contribute to self- misuse drugs or alcohol, do poorly in stigmatizing attitudes.856 school or run away.846 Another reason for the gap in care is l S uicide rates have increased 24 there is a shortage of trained mental percent since 1999,847 and 90 percent health professionals. More than half of those who die by suicide have an of U.S counties — all rural — have no underlying mental illness.848 practicing psychiatrists, psychologists or social workers.857 More than three l A pproximately 26 to 30 percent of out of every four counties have a severe homeless adults in shelters live with shortage of mental health workers and serious mental illness.849,850 96 percent of counties do not have l R oughly 15 percent of those below the sufficient numbers of professionals poverty line experience depression, licensed to be able to prescribe mental over twice the rate of those at or above health medications.858 Schools also the poverty line.851 have a shortage of counselors — with an average counselor-to-student l A n estimated 56 percent of state ratio of 1:471 (whereas 1:250 is the prisoners, 45 percent of federal recommended level).859 prisoners and 64 percent of jail inmates have mental health issues.852 Nearly half of all Medicaid spending is Among youth in the juvenile justice on care for the 20 percent of Medicaid systems, 70 percent have at least one beneficiaries who have a behavioral mental health condition.853 health diagnosis (mental illness and/or substance use). Annual expenditures l I ndividuals with serious mental are nearly four times higher for illness also have an increased risk Medicaid patients with a behavioral of experiencing chronic medical health diagnosis than without a conditions, injuries and cancer and diagnosis ($13,303 versus $3,564).860 die on average 25 years earlier than Despite the high amounts spent on others.854,855 mental healthcare, states cut $4.35 Stigma surrounding mental illness billion from the mental healthcare leads to prejudice and discrimination, system from 2013 to 2015.861 148 TFAH • healthyamericans.org Mental Health Facts CHILDREN & TEENS Fact: 1 in 5 children ages 13-18 have, or will have a serious mental illness. 1 20% 11% 10% 8% 20% of youth ages 11% of youth have 10% of youth 8% of youth have 13-18 live a with mental a mood disorder 1 have a behavior or an anxiety disorder 1 health condition1 conduct disorder 1 Impact Suicide 50% 50% of all lifetime cases of mental illness begin by age 14 and 75% by age 24.1 3rd Suicide is the 3rd leading cause of death in youth 10 yrs The average delay between onset of symptoms and intervention is 8-10 years.1 ages 10 - 24.1 37% of students with a mental health condition age 14 and 37% older drop out of school—the highest dropout rate of any disability group.1 90% 90% of those who died by suicide had an underlying 70% of youth in state and local 70% juvenile justice systems have a mental illness.1 mental illness.1 Warning Signs ! Feeling very sad or withdrawn for more than 2 weeks (e.g., crying regularly, feeling ! Severe mood swings that cause problems in relationships. fatigued, feeling unmotivated). Trying to harm or kill oneself or making plans ! Repeated use of drugs or alcohol. ! to do so. Drastic changes in behavior, personality or ! sleeping habits (e.g., waking up early and ! Out-of-control, risk-taking behaviors that can cause harm to self or others. acting agitated). Extreme difficulty in concentrating or ! Sudden overwhelming fear for no reason, sometimes with a racing heart, physical ! staying still that can lead to failure in school. discomfort or fast breathing. Intense worries or fears that get in the way ! Not eating, throwing up or using laxatives to lose weight; significant weight loss or gain. ! of daily activities like hanging out with friends or going to classes. 4 Things Parents Can Do Talk with your Get a referral to a Work with Connect with pediatrician mental health specialist the school other families 1 This document cites statistics provided by the National Institute of Mental Health. www.nimh.nih.gov Source: Us! Follow National Alliance on Mental Illness facebook.com/officialNAMI twitter.com/NAMIcommunicate www.nami.org TFAH • healthyamericans.org 149 RECOMMENDATIONS l upport social and emotional S better enforcing parity laws; covering and guidelines, quality improvement development, especially in early a broader range of mental healthcare approaches and models of care based childhood. Building positive protective services and medications; reducing on interprofessional teams.867 Policies factors and reducing risks can help out-of-pocket costs; and increasing trans- are needed to promote sharing of improve the mental health of all parency, including publishing clinical knowledge and skills, effective team children. Research by the National criteria used to approve or deny care functioning, common standards of care Institutes of Health, National Academy and accurate lists of mental health pro- and consensus on core competencies of Medicine and other experts have viders participating in insurance plans.865 between physical and behavioral health demonstrated that early interventions and within behavioral health disciplines. l romote payment and care models P — including home visits, mental health Policymakers should broaden the to support mental and behavioral consultations and family and parenting behavioral health workforce to include healthcare. Scaling up value-based skills training — can be effective in peer support, social workers, and non- care and payment models that promote preventing or delaying the onset of traditional health workers — and develop flexible, team-based care — including mental, emotional and behavioral the capacity of these providers to identity community-based supports — can disorders, as well as enhancing social and address mental health needs. help expand services and integrate and emotional skills and well-being. with primary care.866 Solutions l mplement effective treatment practices. I Federal and state policies should should include adequate funding for All states should adopt — and all payers encourage integration of these community health centers that have should cover — the latest evidence- interventions into early childhood the capacity to address behavioral based treatment methods, including settings such as schools and childcare. and mental health prevention and cognitive behavioral therapy, peer and l dentify and intervene to address I treatment needs. family support programs and targeted mental and behavioral illness as early approaches for high-intensity patients, l xpand, improve and modernize the E after onset as is feasible. Mental health youth transitioning to adulthood and mental and behavioral health workforce. screenings should be guaranteed to partnerships between law enforcement Federal and state policymakers children — and parents — as part of and mental health services. Currently, should incentivize the training of new well-child exams and to adults as part only limited numbers of states have all of behavioral health providers, including of annual physicals.862 In addition to these policies. Criminal justice reform compensating providers fairly for their routine screenings, early intervention efforts should consider the role that services. Providers should be trained programs should be implemented, healthcare, public health, and other in evidence-based models; to that end, including public education programs partners can play in addressing mental curriculum reform should keep pace that teach participants skills to aid others health needs. with emerging evidence-based practices with mental health issues and treatment programs for those at risk for a psychotic episodes or immediately after their first Examples of Early Childhood and Education Programs to Support psychotic episode.863, 864 Resources for Positive Mental Health, Build Resiliency and Reduce Risks suicide prevention should be targeted to high-risk settings and populations. l N urse-Family Partnership Home Visiting l A nti-bullying programs involving par- l mprove insurance coverage for mental I l S ocial/Emotional Learning and Life ents and implementing a whole-school and behavioral healthcare. Despite Skills Training, e.g. Incredible Years, approach, e.g. Positive Behavioral significant advances in accessibility and Good Behavior Game, Positive Action Interventions and Supports affordability of mental health services, — including support for teachers, care- l B ig Brothers/Big Sisters Mentoring coverage is often limited and does not givers, parents and children Programs match what is needed to provide effec- l “ Early Warning” Identification Strate- l L BGT supportive programs such as tive and ongoing treatment. Insurance gies to track chronic absenteeism — the Safe Schools Program coverage can be improved by expanding paired with early treatment support parity laws to include all employers; 150 TFAH • healthyamericans.org Endnotes 1 ard BW, Schiller JS, Goodman RA. W 10 ffice of the Surgeon General. The Surgeon O 18 enter on the Developing Child at Har- C Multiple chronic conditions among US General’s Call to Action to Promote Health vard University (2010). 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