ADVISORY GROUP REPORT FINAL TEXT AS PASSED FEBRUARY 26, 2014
The Advisory Group on Prevention, Health Promotion and Integrative and Public Health (Advisory Group) was created under Section 4001 of the Affordable Care Act (ACA). The Advisory Group’s charge is to “develop policy and program recommendations and advise the [National Prevention] Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion.” The focus of our work has been on meeting this mandate and catalyzing public and private sector responses to the strategic directions of the National Prevention Strategy.
Much of the Advisory Group’s attention has been focused on how, with a preventive and integrative approach to health, our nation can improve health outcomes for all Americans, particularly those who experience the greatest disparities. The National Academy of Sciences (NAS) report, “U.S. Health in International Perspectives: Shorter Lives, Poorer Health,” is the most recent and very compelling assessment that concludes while the United States is one of the wealthiest nations in the world, spending the largest amount per capita on health care, we are far from the healthiest nation. One critical factor that the NAS report identifies as perhaps creating this difference is that, while the United States spends more than any other country on health care, we spend significantly less on social services (e.g., income support, education, housing) than other healthier countries, even as evidence amasses that these social factors can have as much, if not more, impact on health as direct services.
The NAS report provides important context for our recommendations to the new Surgeon General as he considers his priorities for his 4-year term. And while these data may seem discouraging, our work as an Advisory Group has helped to identify numerous examples of communities and programs across the country that are beginning to address health in a much more holistic way. These examples embrace everything from encouraging and facilitating better lifestyle choices, to addressing structural and social determinants of health, to improving clinical and community-based health promotion interventions. The challenge over the next 4 years is to harness the already existing tools that can truly create a culture of health in the United States. These tools include:
- The continuing reform of our nation’s health system, including adoption of the Triple Aim (which promotes improved population health outcomes); delivery system reforms, such as accountable care organizations and community health homes; and the coverage provisions of the ACA. The ACA also provides important new access to clinical preventive services and creates new investments in community prevention through the Prevention and Public Health Fund. Further, ensuring integrative health providers’ equal status in insurance coverage promises broader opportunities for a holistic approach to health.
- Many of the ACA-related initiatives focus on making healthy choices easier for all Americans. A primary determinant of health and well-being for individuals is lifestyle choice, and it is critical that programmatic, financing, and structural impediments to supporting those healthy choices be removed. In this context, it is important to note that lifestyle approaches can be both treatment and prevention (depending on the needs of the individual); and in the case of the former, significant health care savings can accrue.
- The National Prevention Council brings together 20 federal agencies and offices, all of which have a direct role in addressing the clinical, social, and structural determinants of health. The National Prevention Strategy (NPS)—in particular, its strategic directions focused on eliminating health disparities, ensuring healthy and safe community environments, and empowering people—offers a strategic pathway for cross- departmental and private cross-sector collaborations that are central to creating a culture of health.
- The President’s initiative on income inequality focuses on a central determinant of health outcomes. In just about any aspect of health, poverty is a great predictor of worse health status.
Our recommendations fall into two categories: (1) policy initiatives we believe the next Surgeon General should lead to ensure achievement of the vision embraced in the ACA and the NPS; and (2) process recommendations that can improve our effectiveness as an Advisory Group and the effectiveness of the National Prevention Council.
- To date, most implementation of the National Prevention Strategy has taken the form of policy and programmatic initiatives within the agencies of the National Prevention Council, with limited examples of cross-agency collaborations. However, it is clear that a true culture of health is created by bringing multiple sectors together. This approach must be modeled by the federal government through more direct collaboration among the member agencies of the National Prevention Council. To that end, the Surgeon General should develop one or more focused initiatives to improve community health that would engage several cabinet-level agencies working collaboratively. It is our hope that a health equity lens, consistent with the President’s initiative on income inequality, can be applied to any initiative that is proposed. We believe a cross-agency initiative can help to demonstrate to all agencies the co-benefits of working together: that a collaborative approach can help agencies achieve their core missions while also improving health outcomes. Different approaches (e.g., braiding of existing funding streams across agencies or issuance of a joint Funding Opportunity Announcement), different intervention areas (e.g., behavioral health, promotion of lifestyle changes), or different population focus (e.g., younger or older Americans who are particularly disadvantaged) make for a broad range of opportunities. In addition, regardless of whether programs are “braided” or formally coordinated, NPC agencies should use a collective impact framework to assess the initiative including use of common data collection, outcome measures, and grant reporting requirements related to health that can promote multisector collaboration.
- As noted above, our nation’s health system is undergoing rapid change, including changes in the system’s approach to health promotion and integrative health. Indeed, integration of a prevention and public health approach into our health system requires new partnerships and policies that can be incentivized and encouraged by the federal government. 1The Surgeon General should ensure that all aspects of the federal government’s support of health system change promote a prevention and integrative health agenda. This would include:
- Monitoring uptake of insurance and access to preventive services by high-risk populations
- Monitoring implementation of Section 2706 (non-discrimination with regard to integrative health providers)
- Monitoring existing and encouraging further investments by the Center for Medicare and Medicaid Innovation in projects related to population health
- Encouraging integration of the NPS into existing programs, including sharing best practices from the various community prevention programs supported by the Prevention and Public Health Fund, including the Community Transformation Grants, the new Community Prevention Grants, and the REACH program
- Assessing opportunities in the new insurance marketplaces to encourage evidence-based clinical and community prevention practices
- The Advisory Group has looked closely at the growing use of health impact assessments (HIAs) to guide policy maker decisions in a variety of contexts. Perhaps one of the best examples of the value of HIAs was those conducted on the Farm Bill, which demonstrated the health impact of cuts to the Supplemental Nutrition Assistance Program.2We believe that broader use of HIAs can dramatically improve policy decisions across the government. The Surgeon General should encourage, coordinate, or conduct health impact assessments of key federal policies and projects as a way of promoting the National Prevention Council’s commitment to “identify opportunities to consider prevention and health” within their departments. In particular, the Surgeon General should suggest to those currently supporting HIA development, new areas of focus.
- The National Prevention Strategy is meant to catalyze new partnerships both within and outside the government. With its emphasis on creating healthier communities, the NPS can be a guide for various types of investment that are now occurring in communities across the country, ensuring they are coordinated and health oriented. The Surgeon General and National Prevention Council should identify ways to link opportunities related to hospital community benefit requirements, bank community reinvestment requirements, and social impact investing that can promote the goals of the National Prevention Strategy. These efforts should be a catalyst for new non-governmental stakeholders to work together with government and other partners to influence health and create healthier communities. Indeed, public health can and should be a partner in these local efforts, in helping to support scaling successful models of community, school, and workplace health promotion as well as addressing social and structural determinants of health. The National Prevention Council and the Office of the Surgeon General can together highlight best practices and perhaps develop metrics that can be used to assess the health impact of these community development investments.
The following recommendations are offered in the hope that the work of the Advisory Group and the National Prevention Council can more effectively achieve the vision of the National Prevention Strategy and be of greater assistance to the Surgeon General in his work.
- The Advisory Group has found quite gratifying our interaction with members of the National Prevention Council. However, this has occurred on an ad hoc basis. The Surgeon General should take steps to strengthen the relationship between Advisory Group members, the Surgeon General, and the members of the National Prevention Council. We believe this interaction will increase the effectiveness of all concerned.
- It is our hope that the individual members of the Advisory Group can become emissaries for the NPS in our respective communities (geographic or constituency), and that as he travels
across the country, the Surgeon General should establish an ongoing communication process regarding the NPS in each community that has an Advisory Group member.
- The Advisory Group has found the annual status reports on implementation of the NPS to be of value. The Surgeon General should continue, refine, and enhance the National Prevention Council’s report. In addition to reporting on past successes, the annual status report should identify new opportunities and goals for the coming year and any challenges that were encountered during the prior year.
- We believe strongly that the efforts of the Office of the Surgeon General and the National Prevention Council are central to the ultimate success of the Affordable Care Act and ensuring that our country becomes healthier and more equitable. But it takes resources to undertake this mission. Resources provided to coordinate the National Prevention Council’s work should be sufficient to carry out our recommended initiatives.
The next Surgeon General is taking office at a crucial time in U.S. health history. With full implementation of the ACA, the vision for a healthier America encapsulated in the National Prevention Strategy, and the President’s renewed commitment to addressing income inequality, the new Surgeon General has a unique opportunity to help create a culture of health throughout the nation. We are thrilled that the Surgeon General-designee, a member of this Advisory Group, comes with a demonstrated commitment to advance this cause. As an Advisory Group, we stand ready to work collaboratively to achieve the goals outlined in this report.
1 Institute of Medicine, “Primary Care and Public Health: Exploring Integration to Improve Population Health” (March 2012) (available at http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx).
2 Health Impact Project, “White Paper: Health Impact Assessment of Proposed Changes to the Supplemental Nutrition Assistance Program” (July 2013) (available at http://www.healthimpactproject.org/resources/body/Health- Impact-Project-Farm-Bill-SNAP-white-paper-07-30-13.pdf).