Briefing Document

Background for the Health Promotion FIRST (Funding Integrated Research, Synthesis and Training) Act
and the Healthy Workforce Act

Supported by Health Promotion Advocates

1. Our Mission
To promote a healthy lifestyle for all Americans and thereby reduce medical costs and utilization, improve quality of life, and enhance productivity.

2. What is health promotion?
For the purposes of this legislation, health promotion is defined as the art and science of motivating people to enhance their lifestyle to achieve complete health, not just the absence of disease. Complete health involves a balance of physical, mental, and social health. The most effective health promotion programs include a combination of strategies to increase awareness, facilitate behavior change and develop cultures and physical environments that encourage and support healthy lifestyle practices. Health promotion programs focus on practices such as exercising regularly, eating a nutritious diet, maintaining a healthy weight, managing stress, avoiding dangerous substances such as tobacco and illegal drugs, drinking alcohol in moderation or not at all, driving safely, being a wise consumer of health care and a number of other health related practices. Health promotion programs can be provided in clinical, school, workplace, state, federal and community settings.

3. Lifestyle has a major impact on health

• Approximately 40% of all deaths in the United States are premature – at least 900,000 deaths annually – due to unhealthy lifestyle choices such as tobacco use, poor diet, sedentary lifestyle, misuse of alcohol and drugs, and accidents. Other contributors to early death include genetic predisposition (30%), social circumstances (15%), poor access to quality medical care (10%), and environmental exposures (5%)¹.
   
• Unhealthy lifestyle is the primary contributor to the six leading causes of death in the U.S. – heart disease, cancer, stroke, respiratory diseases, accidents, and diabetes – which collectively account for over 70% of all deaths.^2,3,4,5
   
• People with healthier lifestyles live an average of 6 to 9 years longer⁶ postpone disability by 9 years and compress disability into fewer years at the end of life.⁷
   
• The prevalence of obesity among U.S. adults rose to 30% in 1999-2000, a 33% increase from a decade earlier, and the prevalence of diabetes also rose by 33% during approximately the same period (1990 to 1998).⁹
   
• About two-thirds of American adults are overweight or obese,⁸ 55% do not get enough physical activity,¹⁰ 26% are completely inactive,¹⁰ and only 25% eat recommended amounts of fruit and vegetables.¹¹ If diet and physical activity patterns continue worsening at their current rate, the combined effects of these behaviors will soon surpass tobacco use as contributors to mortality.³

• Among young people (6-19 years), the prevalence of overweight has more than tripled since 1980 to 16%¹², daily participation in high school physical education classes has dropped from 42% in 1991 to 28% in 2003,¹³ more than 60% eat too much saturated fat, and almost 80% do not eat recommended amounts of fruit and vegetables.¹⁴
   
• Lifestyle diseases disproportionately affect women, racial and ethnic minorities, the poor and seniors:
   
  • The prevalence of diabetes among African Americans is about 70% higher than among white Americans, and the prevalence among Hispanics is nearly double that for white Americans.¹⁵
     
  • Women comprise more than half of the people who die each year of cardiovascular disease.¹⁶
     
  • Chronic conditions significantly limit daily activity for 39% of persons over 65 years of age.¹⁷

4. Unhealthy lifestyle has a major economic impact

• Lifestyle-related chronic diseases account for an estimated 70% of the nation’s medical care costs,¹⁸ which translates to over 11% of the U.S. gross domestic product.
   
• Two comprehensive scientific reviews identified 83 peer-reviewed studies reporting that people with unhealthy lifestyle habits have higher medical costs. ^19,20
   
• High-risk status on ten lifestyle factors accounted for 25% of total medical costs in a large study of six large private-sector and public-sector employers. Since this analysis did not include the costs of moderate risk levels or other risk factors, the total impact of unhealthy lifestyle on employer medical costs is much higher than 25%.²¹
   
• Recent research indicates a direct relationship between modifiable lifestyle risks and lower worker productivity,^22,23 and relevant data suggest that the costs to employers in lost productivity due to poor employee health may be substantially more than the direct medical and disability costs. ^24,25,26
   
• Unhealthy lifestyles often lead to chronic disease, many of which cannot be cured and require years or decades of expensive treatments. The chart below lists estimated annual costs of selected unhealthy lifestyles and chronic diseases including obesity,^27,28 smoking,²⁹ inactivity,³⁰ diabetes,³¹ and cardiovascular disease.³² Costs are inflated to 2006 estimates based on the Consumer Price Index (CPI), applying the medical care CPI to direct medical costs and the all-item CPI to indirect costs.³³ 

5. Health promotion improves health and yields major savings

• Comprehensive scientific reviews identified 378 peer-reviewed studies showing that worksite health promotion programs improve health knowledge, health behaviors, and underlying health conditions.³⁴
   
• A systematic scientific review suggests that the impact of lifestyle changes on all-cause mortality in coronary artery disease patients compares favorably with cardio-preventive drug therapies (see chart below).³⁵
   
• In a large clinical trial with a population at high risk for developing type 2 diabetes, lifestyle intervention (58% reduction) was nearly twice as effective in preventing diabetes as pharmaceutical treatment with metformin (31% reduction).³⁶
   
• Several scientific reviews indicate that worksite health promotion programs reduce medical costs and absenteeism and produce a positive return on investment.^19,37,38,39, The most definitive review of financial impact reported the following:
   
  • 18 studies indicated that these programs reduce medical costs, and 14 studies indicated that they reduce absenteeism costs.¹⁹
     
  • 13 studies calculated benefit/cost ratios and all showed the savings from these programs are much greater than their cost, with medical cost savings averaging $3.48 and the absenteeism savings averaging $5.82 per dollar invested in the programs.¹⁹
     

6. Strategies are critically needed to control U.S. medical costs

• Medical costs are expected to exceed 16% of U.S. gross domestic product (GDP) in 2005 and to grow at 7.2% annually through 2015, when medical expenditures will account for 20% of GDP.^40,41
   
• Per capita medical costs in the U.S. are the highest in the world and more than double the median for OECD countries (see chart below),⁴² yet the United States ranks 26th in terms of healthy life expectancy.⁴³
   
• Medicaid is the second largest item in most state budgets, and its portion of the total budgets is increasing each year. ⁴⁴
   
• Between 2000 and 2006, employment-based health insurance premiums increased 87 percent, compared to cumulative inflation of 18 percent and cumulative wage growth of 20 percent during the same period. ⁴⁵ This trend is a tremendous financial hardship for many U.S. employers and is threatening the competitiveness of U.S. employers in the global economy.

7. Federal investment in health promotion is minimal

The US Department of Health and Human Services identifies prevention is one of the four goals in its strategic plan, ⁴⁶ but investments in health promotion do not reflect this priority.

Health challenges have changed, but our health-care system has not. “Of the $1.5 trillion spent on national health care, only 1% goes to population-based prevention,” according to Dr. David Satcher (US Surgeon General at the time of the comment).⁴⁷

Government spends $1,390 per person per year to treat disease and $1.21 to prevent disease.⁴⁸

State governments were encouraged to allocate 20% to 25% of the $246,000,000,000 tobacco settlement to prevent and reduce smoking among children, yet only 4 states allocated funds sufficient to meet these guidelines. Twelve states have committed less than 25% of the CDC minimum and three states have committed none of their tobacco settlement money for tobacco prevention.⁴⁹

Health promotion is the most effective strategy to achieve at least 14 of the 26 major objectives outlined in the federal government’s health objectives (Healthy People 2010 Objectives),⁵⁰ yet the $400,000,000,000+ spent on Medicaid and Medicare each year does not cover health promotion interventions.

The National Institutes of Health (NIH) has doubled its research budget (currently at $27,300,000,000) over a five-year period, yet funding for health promotion research remains nominal.⁵¹

8. The public and opinion leaders support health promotion

There is wide public support for health promotion and prevention.

• 44% of Americans think research on preventing disease is more valuable than research on how to cure and treat disease, compared to only 35% who think research on how to cure and treat disease is more valuable.⁵²
   
• 66% of the public value public health programs, which include prevention research and education about health risks.⁵²

 
• The Institute of Medicine recommends investment in health promotion. The vast majority of the nation’s health research resources have been directed toward biomedical research endeavors. By itself, however, biomedical research cannot address the most significant challenge to improving the public’s health in the new century.⁵³
   
• Behavioral and social interventions therefore offer great promise to reduce disease morbidity and mortality. But as yet their potential to improve the public health has been relatively poorly tapped.⁵³

9. What needs to be done?

Step 1: Additional research is required:

• To develop the basic and applied science of health promotion.
   
• To determine the most effective strategies at the individual, organizational, community and societal level to create lasting health-behavior changes, reduce medical utilization and enhance workplace productivity.
   
• To develop strategies to reach all groups with special attention focused on older adults, young children, racial and ethnic minority groups and citizens who have less education and income.

Step 2: Development of new programs is required.

Research-based programs must be developed in school, workplace, health-care and community settings to reach all members of society.

10. What is the current status of health promotion research?

Health promotion is a promising approach to national health improvement. Hundreds of studies have confirmed that lifestyle factors, such as lack of exercise, poor nutrition, obesity, tobacco use, poorly managed stress and abuse of alcohol and drugs are detrimental to health. Furthermore, hundreds of studies have confirmed that health promotion programs can improve knowledge and behavior, prevent or delay the onset of disability and disease, and enhance the quality of life. As a nation we greatly under-invest in health promotion; we need to move on the promise.

Health promotion is an innovative part of solving the medical care cost crisis. A growing research base supports the positive impact of health promotion programs on medical utilization and costs, as well as worker absenteeism, productivity and other variables of economic interest. We need to expand the innovation.

Unfortunately, research is underdeveloped in terms of harnessing the potential of health promotion. There are too few high quality studies, too few well-trained researchers, too little support for study performance from conceptual to developmental to randomized trial research. Interventions are not as effective as they could be because the basic and applied science of health promotion is not fully developed. Furthermore, there is no established mechanism to synthesize the best research findings and translate this knowledge into common practice. The effectiveness of health promotion programs has improved dramatically in the past two decades, but it remains a quasi-science, much like pre-NIH medical science.

Basic science gaps. We do not understand the interaction of genetics, social norms, personal choice and environmental factors on the health behaviors people practice. We do not fully understand what motivates people to attempt or maintain a lifestyle change. We also do not have an accepted theoretical basis for many of the health promotion interventions in practice; in fact, most commonly accepted practices are more "art" than science. We do know, however, that traditional education and medical interventions have limited impact. Therefore, we need to more fully draw on the expertise of psychology, expand our perspectives and draw on experts in commercial marketing, economics, city planning, genetics, transportation, insurance, taxation and other areas. Bolstering the basic science of health promotion will provide the theoretical framework on which to develop the most effective programs.

Applied science gaps. We do not know the optimal combination of education, skill building, supportive environments, public policy and other factors in stimulating and sustaining behavior change. We do not know the optimal amount of programming....what constitutes the "preventive dose." We have not yet determined the optimal combination of "high tech" versus "high touch" interventions, or what types of people will be most receptive to each approach. We do not fully understand how to best adapt strategies to reach different age groups, genders, racial and ethnic groups or the most important elements for programs in workplace, home, clinical, school, or community settings. We do not know the most effective strategies to offer programs to large populations, such as all Medicare or Medicaid recipients, or the entire population of a state. We have not yet determined which strategies will be most cost effective with the various population groups we seek to reach. In summary, we do not have best practice guidelines, either by population group or targeted institution, to deliver the right process, at the right time, to the right population, in the most efficient manner.

Synthesis and dissemination gaps. Unlike more established fields such as medicine or engineering, there are no stable mechanisms to synthesize health promotion research into principles that can be applied in practice, or to disseminate these findings to those who can use them. As such it takes years for research findings to influence educational curriculum or to improve the strategies used in practice. This also creates a huge gap between discoveries that have already been made and the techniques used in practice, and between the quality of the best programs and the typical programs.

11. What is our plan?

a) Collaborate with other organizations. Over 100 organizations and their members have been involved in identifying needs, setting priorities, and working with their elected officials to support these efforts.

b) Determine the interests and priorities of the agencies within the Department of Health and Human Services. Extensive interviews have been held with the legislative directors of the National Institutes of Health, Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality to develop our proposed Health Promotion FIRST Act. The Department of Health and Human Services has identified prevention as its top priority in its strategic plan, which our proposed legislation directly supports.

c) Work with Congress to introduce Congressional Resolutions. Resolutions were introduced in the 107th US Senate (S Con Res 11) and 107th House of Representatives (H Res 115) calling for increased federal support to develop the basic and applied science of health promotion. Over 100 members of Congress co-sponsored these resolutions.

d) Work with Congress to introduce Legislation.
1. Health Promotion FIRST (Funding Integrated Research, Synthesis and Training Act (S866). Health Promotion FIRST (S.866) was introduced March 15, 2005 by Senator Lugar (R-IN). Co-sponsors are Senators Jeff Bingaman (D-NM), Jim Bunning (R-KY), Richard Durbin (D-IL), Hillary Rodham Clinton (D-NY) and James Jeffords (I-VT). Health Promotion FIRST provides a framework for strategic planning and developing the basic and applied science of health promotion, in anticipation of significant growth in these areas over the next decade. We are working to pass this legislation in the Senate and House of Representatives.

2. Healthy Workforce Act. The Healthy Workforce Act is Title II, Subtitle A of the HeLP America (Healthy Lifestyle and Prevention) Act, (S.1754), which was introduced by Senator Tom Harkin (D-IA), on May 18, 2005. Senator Harkin will introduce this as separate legislation in late 2006. The bill provides employers a 50% tax credit of up to $200 per employee for comprehensive health promotion programs, calls for a national campaign to explain the financial benefits of health promotion to business leaders, funds universities and other professionals to conduct program evaluation for employers, funds other professionals to provide programs to small businesses, and directs the Centers for Disease Control and Prevention to develop model program guidelines.

Contact Us:

E-mail: info@HealthPromotionAdvocates.org
Website: www.healthpromotionadvocates.org

References

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