Comments from Richard Besser, MD, on Healthy People 2030 Proposed Framework

    • September 27, 2017

The following comments were submitted to the U.S. Department of Health and Human Services by Richard Besser, MD, RWJF President and CEO, in response to the agency’s request for comments.

The Robert Wood Johnson Foundation (RWJF) is pleased to provide comments on the Healthy People 2030 Proposed Framework. The Framework builds on nearly 40 years of successes and lessons learned from the Healthy People Initiative, which, on a decennial basis, has produced a roadmap, monitoring tool, and rallying point for bettering the health of the nation. Leaders at the federal, state, and local levels have leveraged Healthy People to prioritize, implement, and evaluate actions across a broad range of health concerns. For the next decade, we support the Framework’s inclusion of additional historical context, foundational principles—many of which are aligned with our Culture of Health Action Framework, and enhanced plans for measuring and reporting on progress. Moreover, we see critical opportunities for magnifying Healthy People 2030’s impact on advancing health equity, addressing the social determinants of health (SDOH), and leveraging the power of policy change. Within each of these areas, we offer recommendations and point towards RWJF-supported resources that could enrich Healthy People 2030 development and implementation.

Alignment between Healthy People 2030 Proposed Framework and Culture of Health Action Framework

RWJF is the nation’s largest philanthropy dedicated to improving health and health care. Since 1972, we have worked with public and private sector partners to advance the science of disease prevention and health promotion; train the next generation of health leaders; and support the development and implementation of policies and programs to foster better health across the country. In the last several years, we have embarked on a journey to build a Culture of Health in the United States—creating a society in which everybody, no matter who they are or where they live, has an opportunity to live out his or her full health potential.

RWJF, in collaboration with the RAND Corporation, developed an Action Framework1 and underlying principles to spur dialogue and collective action on a Culture of Health. These were informed by federal inform Healthy People, as noted in the 2030 Proposed Framework. Therefore, the two frameworks are in close alignment as shown in the Table 1 (below). However, the major distinction between the frameworks might be summed up by these two questions: Is the nation’s health improving (Healthy People)? Does the nation increasingly value and pursue improved health as a societal imperative (Culture of Health)?

 

Table 1: Crosswalk between Healthy People and Culture of Health frameworks

Key commonalities of the frameworks’ include: their broad socioecological view of health; the central importance of health equity; the co-benefits of, and significant returns on, investments in health; the value of considering the health impacts of “non-health” decisions; and the need to work across sectors and systems with shared accountability. Both frameworks take a long-term perspective (Healthy People, 10 years; Culture of Health, 20 years) and allow for new measures and course corrections along the way. These similarities will enable the frameworks to co-evolve and collaboratively benefit the nation’s health.

Differences in the frameworks reveal their distinct, but complementary, purposes. Healthy People includes 10-year targets, enabling ongoing monitoring and assessment of the nation’s progress at mid-course and decade’s end. Culture of Health emphasizes social change, so evaluating progress is more nuanced, requiring qualitative and quantitative approaches. Healthy People focuses on health behaviors, disease prevention, and clinical and public health services, while Culture of Health emphasizes upstream social, economic, and environmental determinants. Culture of Health principles also specifically call out Page 3 of 7 of the PDF (available to the right) the need for affordable, high-quality, efficient, and equitable health care. In this time of continued uncertainty about the nation’s health care system and the critical role of health insurance in assuring good health,2 we recommend that the Healthy People 2030 foundational principles specifically call out the importance of health care coverage and access.

Advancing health equity
Since Healthy People 2000, reducing health disparities has been among the overarching goals of the Healthy People Initiative, and, over time, disparity reduction and equity promotion have only grown in importance. (See Table 2 on page 3.) We applaud this sustained commitment to health equity, for it “is fundamental to the idea of living a good life and building a vibrant society” as described in an RWJF-funded National Academy of Medicine report, Communities in Action: Pathways to Health.3 What follows are several ideas for enhancing the Healthy People 2030’s impact on health equity.

Table 2: Healthy People Equity-Related Goals

First, Healthy People 2020 provides detailed disparities data for most indicators (by race/ethnicity, gender, income, and education), but progress reports have not routinely reported on whether gaps are closing or widening. For example, the mid-course review on Leading Health Indicators (LHIs) reported only on overall trends.4 And while the full mid-course review provided more detailed disparities data, the relative changes in indicators for socially disadvantaged versus advantaged groups were not available.5 Therefore, Healthy People 2030 should explore ways to regularly and systematically report on whether disparities are narrowing or growing. The United Kingdom’s National Health Service offers a strong model for such reporting and accountability.6,7 Second, when recommending interventions, Healthy People 2030 should include information about their likely impact on disparities. This should become more feasible as the U.S. Community Preventive Services Taskforce and the U.S. Preventive Services Taskforce continue to explore subgroup effects in their evidence reviews.8,9

Third, definitions matter. As stated in a recent RWJF report, “Clarity is particularly important in the case of health equity because pursuing equity often involves a long uphill struggle that must strategically engage diverse stakeholders, each with their own agenda. Under those circumstances, if we are unclear about where we are going and why, we can more easily be detoured from a path toward greater equity; our efforts and resources can be co-opted, and we can become lost along the way.”10 Therefore, Healthy People 2030 should define health equity clearly and comprehensively—in a manner that acknowledges the historical and structural underpinnings of inequities in health and the need for societal change. As per RWJF’s definition, health equity means that “everyone has a fair and just opportunity to be healthy. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Other key RWJF-defined principles include:

  • Opportunities to be healthy depend on the living and working conditions and other resources that enable people to be as healthy as possible;
  • Health equity is the ethical and human rights principle or value that motivates us to eliminate health disparities;
  • Health equity can be viewed as a process and an outcome;
  • A commitment to health equity requires constant monitoring, routinely comparing how more and less advantaged groups within that population are faring on those indicators;
  • Social exclusion, marginalization, discrimination, and disadvantage can be measured; and
  • Discrimination is not necessarily conscious, intentional or personal; often it is built into institutional policies and practices.

Addressing the social determinants of health

The Healthy People 2030 Proposed Framework carries forward Healthy People 2020’s commitment to the SDOH. It includes as a principle, “Healthy physical, social and economic environments strengthen the potential to achieve health and well-being,” and as an overarching goal, “Create social and physical environments that promote attaining full potential for health and well-being for all.” We offer five recommendations on addressing SDOH in Healthy People 2030.

First, engage experts from federal agencies beyond those involved in the Healthy People 2020 Federal Interagency Workgroup (FIW), which already includes the Departments of Education and Agriculture. Consider adding representative from the Departments of Housing and Urban Development, Transportation, Commerce, Treasury, and Interior. This would enhance the Workgroup’s ability to identify compelling SDOH objectives and leverage networks and resources across the federal government to spur action. Second, seek broad input on the best SDOH indicators to include in Healthy People 2030. Measures such as pre-school participation, access to green/open space, households headed by single parents, social mobility, and social cohesion were not included in Healthy People 2020. Third, consider adding another SDOH measure to the LHIs,11 particularly one focused on early childhood to acknowledge the critical importance of the first years of life to long-term health and health disparities.12 Fourth, consider adding objectives related to the ratio of health to social spending in the U.S. and our national health status compared to other developed nations. The Proposed Framework notes, “A challenge for Healthy People 2030 is to guide the United States in achieving our population’s full potential for health and well-being so that we are second to none among developed countries. Although much progress has been made, the United States lags behind other Organisation for Economic Co-operation and Development (OECD) countries on key measures of health and well-being, including life expectancy, infant mortality, and obesity, despite having the highest percentage of GDP spent on health.” A significant driver of our relatively poor health performance as a nation is our inefficient and excessive spending in the health sector.13,14,15 While more research on this topic is needed, inclusion of such measures in Healthy People 2030 would stimulate critical dialogue, evidence-building, and action.

Fifth, expand the availability of resources for addressing SDOH through specific social, economic, and educational interventions. In Healthy People 2020, many general resources were referenced but information about specific policies and programs was limited.16,17 This stands in contrast to the recommended interventions for more traditional topics, such as access to care or heart disease and stroke. While this discrepancy may reflect the relative lack of scientific evidence on addressing SDOH, the field has progressed significantly in the past decade. In addition to the Community Guide and Cochrane Collaboration, Healthy People 2030 could draw from other evidence repositories—such as the Campbell Collaboration, What Works for Health, Health Impact Project, and Pew-MacArthur Results First Clearinghouse—for rigorous reviews of interventions in fields as diverse as transportation, housing, and criminal justice. What Works for Health was created by the University of Wisconsin Population Health Institute as part of the RWJF County Health Rankings and Roadmaps initiative. It contains evidence reviews for more than 400 policies and programs, including a determination of their impact on disparities, along with implementation examples and resources. RWJF is also sponsoring the next-generation of research addressing SDOH through Policies for Action.

Leveraging the power of policy change
The Proposed Framework notes, “...we have learned that significant changes (e.g., reduced rates of smoking) may be difficult, but are achievable through persistent effort.” Using the nation’s successes with tobacco control as an example, we can see that persistent effort must include policy change to have lasting, meaningful effects on population health.18 Efforts at the federal, state, and local levels to regulate tobacco sales and marketing, limit the use of tobacco in public places, and increase the price of tobacco products were all crucial to the declines in smoking seen over the last 50 years. As such, RWJF focused its tobacco control efforts on supporting the passage of clean indoor air laws, increasing taxes on tobacco products, and enhancing funding for comprehensive tobacco control programs.19 Policy change has also proved critical to the nation’s and RWJF’s strategies for reversing childhood obesity and increasing access to health care.20,21,22 We provide several recommendations for elevating the role of policy in Healthy People 2030.

First, selectively include policy-related objectives to additional topic areas when scientific evidence demonstrates clear and strong associations between policy enactment and health improvements. Currently, the vast majority of policy-related objectives fall in the Tobacco Use topic area. Examples from this topic area and other areas include: Tobacco Use, objective 17, Increase the Federal and State tax on tobacco products; Environmental Health, objective 16, Increase the proportion of the nation’s elementary, middle, and high schools that have official school policies and engage in practices that promote a healthy and safe physical school environment; Nutrition and Weight Status, objective 3, Increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the Dietary Guidelines for Americans. Examples of potential new policy-related objectives are: the number of states with state-level earned income tax credits (SDOH);23 the number of states and cities with alcohol outlet density restrictions (injury and violence prevention);24 and the number of states with laws permitting expedited partner therapy for sexually transmitted disease prevention (sexually transmitted diseases).25

Second, consider prioritizing objectives and interventions based on their population health impact. While Healthy People must be comprehensive, it should also guide health decision-makers on how best to allocate limited financial, human, and political resources for bettering health.26 Under such a system, policy-related strategies would, in many cases, rise to the top.27,28 Third, leverage Healthy People 2030 to support research on the health effects of policies across diverse sectors and conduct surveillance on the degree to which effective policies have spread across states and cities. Fourth, enhance the understanding of health care leaders, policymakers, and the public of the importance of policy and law in advancing health. Since 2013, RWJF—via a grant to the CDC Foundation—has supported the integration of evidence-based policy and legal tools into Healthy People 2020. Accomplishments include the establishment of a Law and Health Policy Workgroup as part of the FIW and the development of more than 20 national presentations and 7 reports (in progress) on the role of policy and law in achieving Healthy People 2020 objectives. Report topics include: Nutrition and Weight Status, Substance Abuse, Oral Health, Mental Health and Mental Disorders, Maternal, Infant and Child Health, Disability and Health, and Health Care Associated Infections. We look forward to the completion and wide dissemination of these reports in the next year. Lastly, we are greatly encouraged that the 2030 Advisory Committee includes a public health attorney for the first time in Healthy People’s history.

Conclusion
The Healthy People 2030 Proposed Framework builds on nearly four decades of efforts to envision, measure, and galvanize action towards a healthier nation. Its vision, principles, and goals resonate with those laid out in our Culture of Health Action Framework, presenting numerous opportunities for shared learning, stakeholder engagement, and assessment. And, as detailed above, we believe Healthy People 2030 holds great promise for advancing health equity, addressing the social determinants of health, and leveraging the power of policy change to create a society in which everyone can live out his or her full potential. RWJF stands ready to work with the Department of Health and Human Services, the Federal Interagency Workgroup, the Secretary’s Advisory Committee, and public and private sectors partners across the country to make this vision a reality.

 

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

 

References

1 Culture of Health Action Framework, Robert Wood Johnson Foundation. www.cultureofhealth.org/en/taking-action.html

2 Sommers DB et al. Health Insurance Coverage and Health—What the Recent Evidence Tells Us N Engl J Med 2017; 377:586-593. www.nejm.org/doi/full/10.1056/NEJMsb1706645#t=article

3 National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: pathways to health equity. Washington, DC: The National Academies Press.

4 Healthy People 2020 Leading Health Indicators Progress Report, May 2014. www.healthypeople.gov/sites/default/files/LHI-ProgressReport-ExecSum_0.pdf

5 Healthy People 2020 Midcourse Review, Overview of Midcourse Progress and Health Disparities, April 2017. www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B03-Overview.pdf

6 Barr B et al. The impact of NHS resource allocation policy on health inequalities in England 2001-11: longitudinal ecological study. BMJ 2014;348:g3231. www.bmj.com/content/348/bmj.g3231

7 Hu Y et al. Did the English strategy reduce inequalities in health? A difference-in-difference analysis comparing England with three other European countries. BMC Public Health. 2016 Aug 24;16(1):865. www.ncbi.nlm.nih.gov/pubmed/27558269.

8 The Community Guide: Healthy Equity, U.S. Community Preventive Services Taskforce. www.thecommunityguide.org/topic/health-equity

9 Whitlock EP et al. An approach to addressing subpopulation considerations in systematic reviews: the experience of reviewers supporting the U.S. Preventive Services Task Force. Systematic Reviews20176:41. systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0437-3

10 Braveman P et al. What is health equity? And what difference does a definition make? Robert Wood Johnson Foundation, May 2017. www.rwjf.org/en/library/research/2017/04/what-is-health-equity-.html

11 In Healthy People 2020, on-time high school graduation was the only SDOH measure included among the LHIs.

12 Shonkoff JP et al. Neuroscience, Molecular Biology, and the Childhood Roots of Health Disparities Building a New Framework for Health Promotion and Disease Prevention. JAMA. 2009;301(21):2252-2259. jamanetwork.com/journals/jama/fullarticle/184019

13 Bradley EH et al. How Social Spending Affects Health Outcomes. Culture of Health blog post, August 17, 2016. www.rwjf.org/en/culture-of-health/2016/08/how_social_spending.html

14 Bradley ET et al. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf 2011;20:826-831. qualitysafety.bmj.com/content/20/10/826

15 Bradley EH et al. Variation In Health Outcomes: The Role Of Spending On Social Services, Public Health, And Health Care, 2000–09. Health Affairs, May 2016 vol. 35 no. 5760-768. content.healthaffairs.org/content/35/5/760.abstract

16 Healthy People 2020 Evidence Based Resources. www.healthypeople.gov/2020/tools-resources/Evidence-Based-Resources?f%5B%5D=field_ebr_topic_area%3A3499&pop=&ci=&se

17 Healthy People 2020, Social determinants of health interventions and resources. www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources

18 Office on Smoking and Health. Achievements in Public Health, 1900-1999: Tobacco Use--United States, 1900-1999. MMWR, November 05, 1999 / 48(43);986-993. www.cdc.gov/mmwr/preview/mmwrhtml/mm4843a2.htm

19 50 years of Tobacco Control, Robert Wood Johnson Foundation. www.rwjf.org/maketobaccohistory

20 Farley TA et al. Preventing Childhood Obesity: What are we doing right? Am J Public Health. 2014 September; 104(9): 1579–1583. www.ncbi.nlm.nih.gov/pmc/articles/PMC4151921/

21 Building a Culture of Health for All Children: 2016 Progress Report on Voices for Healthy Kids. American Heart Association and Robert Wood Johnson Foundation. voicesforhealthykids.org/wp-content/uploads/2016/10/Voices-for-Healthy-Kids-2016-Progress-Report_facing.pdf

22 Skopec L et al. Changes in Coverage by State and in Selected Metropolitan Areas. Urban Institute, Quick Strike Series. September 2016. www.rwjf.org/en/library/research/2016/09/changes-in-coverage-by-state-and-in-selected-metropolitan-areas.html

23 Earned Income Tax Credit. County Health Ranking and Roadmaps, What Works for Health. www.countyhealthrankings.org/policies/earned-income-tax-credit-eitc

24 Ignition Interlock Devices. County Health Ranking and Roadmaps, What Works for Health. www.countyhealthrankings.org/policies/ignition-interlock-devices

25 Expedited Partner Therapy. County Health Ranking and Roadmaps, What Works for Health. www.countyhealthrankings.org/policies/expedited-partner-therapy-treatable-stis

26 Fielding JE et al. A Perspective on the Development of the Healthy People 2020 Framework for Improving U.S. Population Health. Public Health Reviews, June 2013, 35:3. link.springer.com/article/10.1007/BF03391688

27 Frieden TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health. 2010 April; 100(4): 590–595. www.ncbi.nlm.nih.gov/pmc/articles/PMC2836340/

28 Institute of Medicine. 2011. For the Public's Health: Revitalizing Law and Policy to Meet New Challenges. Washington, D.C.: The National Academies Press. www.nap.edu/catalog/13093/for-the-publics-health-revitalizing-law-and-policy-to-meet

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

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