The 9th National Forum for Heart Disease and Stroke Prevention
September 23, 2011
Taking Action Toward 2020: A Valedictory Message1
Darwin R. Labarthe
To close the Forum is to serve as the valedictory speaker. Certain conventions
dictate the key elements: make note of our shared past, take stock of the present,
and celebrate our hopes for the future. It is also wise to strive for brevity: No
valedictory address was ever too short.
It is also important to have a theme. I recall such an address at my son’s high school
graduation. The speaker began with the three points we must not fail to take away
from his presentation – “Aim high, …, and … .” I was so taken by the first point that I
failed to hear #2 and #3 or much of the rest of his address. So I’d like to adopt “Aim
high” and add this subtext: “Revolutionary times create new possibilities for
change.”
I – Notes on our shared past: Convergence of interests
Our societal past: We share with all of our citizens the immense burden, pernicious
disparities, inordinate costs, and prolonged neglect of significant opportunities for
prevention of heart disease and stroke.
Over the course of our individual lives and careers, each of us has in one way or
another become engaged in heart disease and stroke prevention.
In our most immediate past – these 36 hours or less during the Forum – we have
shared in a convergence of our individual and corporate interests in the possibilities
of preventing heart disease and stroke.
The message of our shared past is that the National Forum, established to
implement the Action Plan, has become a unique place where meaningful discussion
of divergent views can flourish and lead to effective action in pursuit of our common
interest.
II – Taking stock of the present: Revolutionary times
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Based in part on From CVD to CVH: The Quiet Revolution (unpublished)
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Think for a moment about “the times” in which we live, and factors that influence
our ability to act effectively for heart disease and stroke prevention. There is no
shortage of considerations on the negative side: You might be thinking about the
economic crisis and unemployment, natural disasters, continuing wars in the Middle
East, political divisiveness and rancor, or if you are reflecting on the past decade,
9/11 and the persisting concerns about terrorism and uncertainties of national
security. These issues are put in front of us every day, and they can’t be ignored.
But you may also have positive ideas in mind from your knowledge about heart
disease and stroke prevention: knowledge that preserving good health to middle
age predicts long, healthy life, awareness of demonstrated impact of both
population-wide and clinical interventions on the US decline in CHD deaths,
increasing recognition of the economic value of prevention, growing abundance of
recommendations and guidelines to direct prevention efforts – including
community- and population-wide strategies, and mounting advocacy for prevention
of chronic diseases, which we know to be dominated by heart disease and stroke.
I believe your presence, here in the 9th National Forum, 2011, demonstrates that in
your minds, positive trumps negative. Despite barriers, obstacles, and challenges,
you remain here, engaged and committed to the Forum’s ambitious 2020 goal and
strategic priorities. Washington, DC, is the nation’s capital, but this space today is
the capital of optimism, hope, and aspiration.
I want to turn to another factor in new possibilities for change that I would argue is
truly revolutionary. What is it? First, to support my argument, What is a revolution?
From the Oxford English Dictionary (OED) comes an understanding of ‘Revolution’
as “an instance of great change or alteration in affairs”;Vol VIII, p 617-618 produced “by a
specific act.” Vol III, p 354 Much has been said about ‘revolution’, on the Web: In a recent
search on ‘revolution’, not otherwise specified, Google quickly found 233,000,000
entries; even for ‘public health revolution’ there were 16,000,000. Would there be
anything on the Internet for ‘cardiovascular health revolution’? Perhaps surprisingly,
yes: 138,000 entries. So, is my thesis just ‘old news’? No, there wasn’t a single
citation to link revolution with what I have in mind – the Affordable Care Act. I
would suggest that the ACA is revolutionary and that it creates the possibility of a
new public health. This goes beyond the “quiet revolution” I have cited elsewhere, in
adoption by the Board of Directors of the American Heart Association of the Impact
Goal for 2020, making the revolutionary shift from CVD to CVH (cardiovascular
disease to cardiovascular health).
What is the ACA?
To set the stage, I want to share with you part of a Perspective published last
September in the New England Journal of Medicine, by Assistant Secretary for
Health Howard Koh and HHS Secretary Kathleen Sebelius:
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Too many people in our country are not reaching their full potential for
health because of preventable conditions. Moreover, Americans receive only
about half of the preventive services that are recommended1 – a finding that
highlights the national need for improved health promotion. The 2010
Affordable Care Act2 respond to this need with a vibrant emphasis on disease
prevention. Many of the 10 major titles in the law, especially Title IV,
Prevention of Chronic Diseases [sic] and Improving Public Health, advance a
prevention theme through a wide array of new initiatives and funding. As a
result, we believe that the Act will reinvigorate public health on behalf of
individuals, worksites, communities, and the nation at large (see table) – and
will usher in a revitalized era for prevention at every level of society.
[From Promoting Prevention through the Affordable Care Act, Howard K. Koh,
MD, MPH, and Kathleen Sebelius, MPA.* New England Journal of Medicine
September 30, 2010, 363;14:1296-1299. ]
So here is my proposition: A ‘new’ public health is emerging whose foundation lies
in the Patient Protection and Affordable Care Act, or just ‘the Act’, and especially
Title IV – Prevention of Chronic Disease and Improving Public Health. To make the
case for the new public health, it would be useful first to dispose of the old one. And
to add credibility, it would be helpful to note some of the key developments leading
up to the revolution represented by the ACA. But this is a brief valedictory address,
not a filibuster, so I’ll forego those details for now.
ACA and the New Public Health: Beyond insurance
Recall the language of Koh and Sebelius: “…The 2010 Affordable Care Act responds
to this need with a vibrant emphasis on disease prevention.”
“Vibrant” is a term not widely heard in connection with Public Law 111-148 – March
23, 2010, the Patient Protection and Affordable Care Act, PPACA, Affordable Care
Act, ACA, “health reform law” – or, for our purposes today, simply “the Act”. The
public discourse has focused largely on the tens of millions of Americans who lack
health insurance or the possibility of using effectively the insurance they have.
Significant provisions of the law seem to have escaped the media, and therefore
public attention, almost entirely.
Koh and Sebelius tabulate 28 provisions of the Act supporting their belief that it will
“reinvigorate public health”. The majority of these provisions (18/28) are found as
noted within Title IV – Prevention of Chronic Disease and Improving Public Health.
Together, they hold promise of important public health impact for individuals,
businesses and workplaces, communities and states, and the nation as a whole. The
argument presented by Koh and Sebelius inspires the further thought that the Act
could, in fact, spawn a new public health.
The first four subtitles of the Act give some insight into the range of topics
addressed under Title IV:
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Subtitle A – Modernizing Disease Prevention and Public Health Systems
Subtitle B – Increasing Access to Clinical Preventive Services
Subtitle C – Creating Healthier Communities
Subtitle D – Support for Prevention and Public Health Innovation
A few key provisions of these subtitles support the proposition that the Act offers
promise of a new public health: [Note: Only highlights of the elements described
below were presented at the Forum.]
Subtitle A – Modernizing Disease Prevention and Public Health Systems
The National Prevention, Health Promotion, and Public Health Council is a cabinetlevel body appointed by the President comprising the Secretaries and leaders of 17
Federal Departments and other agencies – what can be viewed as a “whole of
government” authority; its duties include developing a national prevention, health
promotion, public health, and integrative health strategy, recommendations to
Congress on Federal policy changes to achieve national wellness, health promotion,
and public health goals, including the reduction of tobacco use, sedentary behavior,
and poor nutrition. This National Prevention Strategy is described as “an
unprecedented opportunity to shift the nation from a focus on sickness and disease
to one based on wellness and prevention.”
The Prevention and Public Health Fund is to be administered through the Office of
the Secretary, Department of Health and Human Services, “to provide for expanded
and sustained national investment in prevention and public health programs to
improve health and help restrain the rate of growth in private and public sector
health care costs.” The Fund began with an appropriation of $500 million in FY
2010, increasing to a constant level of $2 billion per year in 2015 and after. Its use is
to support community transformation grants (more about that in a moment), an
education and outreach campaign for preventive benefits, and immunization
programs.
Under Clinical and Community Preventive Services, the Preventive Services Task
Force is charged to identify additional topic areas for review and recommendations,
to update its recommendations at least every 5 years, to consider recommendations
of other government and non-government groups, to disseminate its
recommendations, and to identify gaps in research on specific topics, populations,
and age groups, where recommendations are needed. Coordination with the
Community Preventive Services Task Force and Advisory Committee on
Immunization Practices are called for “at the nexus of clinic and community”. The
Community Preventive Services Task Force, in turn, is to address new topic areas
including “the social, economic and physical environments that can have broad
effects on the health and disease of populations and health disparities among subpopulations and age groups” as well as research gaps in these areas.
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Subtitle B – Increasing Access to Clinical Preventive Services
School-based health centers are to provide “comprehensive primary health
services” including physical and mental health assessments and services for
children and adolescents residing in geographic areas determined to be
underserved or in shortage of health professionals.
Medicare coverage is to be provided for an annual wellness visit that provides a
“personalized prevention plan” and includes assessment of body mass index, blood
pressure, and other routine measurements to constitute a health risk assessment
according to a model approach to be developed under the authority of the Secretary
of HHS.
Barriers to use of Medicare services are to be removed by, for example, covering
100% of the costs of services recommended with the strongest, A or B level,
evidence by the Clinical Preventive Services Task Force.
Initiatives are provided for prevention of chronic diseases in the Medicaid
population through grants to States that would “encourage behavior modification
and determine scalable solutions”. A qualifying program would help individuals
achieve tobacco cessation, weight loss or control, reduction of blood pressure and
cholesterol, and avoiding or improving management of diabetes.
Subtitle C – Creating Healthier Communities
Community transformation grants are to be awarded competitively “to State and
local governmental agencies and community-based organizations for the
implementation, evaluation, and dissemination of evidence-based community
preventive health activities in order to reduce chronic disease rates, prevent the
development of secondary conditions, address health disparities, and develop a
stronger evidence-base of effective prevention programming.” The described
activities imply a vision of a “transformed” community as one with healthier school
environments, infrastructure to support active living and access to nutritious foods,
programs targeting a variety of age levels, expanded worksite wellness programs,
and strategies to reduce racial and ethnic disparities in health including social,
economic, and geographic determinants. Menu labeling by chain restaurants for
calorie content and potentially for specific nutrients is also provided for in the
concept of healthier communities.
Subtitle D – Support for Prevention and Public Health Innovation
Improvement of data collection for purposes of understanding health disparities
will require that “any federally conducted or supported health care or public health
program, activity or survey… collects and reports, to the extent practicable, data
with adequate sample size and smallest possible geographic level to permit reliable
estimates by demographic, language, and disability groups.
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Subtitle E – Miscellaneous Provisions
The Act also notes, under Title IV, the sense of the Senate concerning CBO scoring.
This relates to the paradoxical effect of current law that requires the Congressional
Budget Office to assess cost impacts and benefits of proposed legislation strictly in
terms of a 10-year time window. Where benefits of prevention initiatives may
accrue well beyond this window, they are not taken into account, to the detriment of
legislative efforts in disease prevention. The Act expresses the “sense of the Senate
that Congress should work with the Congressional Budget Office to develop better
methodologies for scoring progress to be made in prevention and wellness
programs.”
It is important to note, without similar consideration of detail, Title V of the Act,
which addresses the health care workforce. Health care here includes the full scope
of public health. Numerous provisions call for assessment of workforce needs,
initiatives to undertake the necessary recruitment, education, and retention of
health workers, and mechanisms for repayment of educational loans through public
service.
My message is this: The ACA is truly revolutionary and creates unprecedented
possibilities for positive change in population health. This leads to our hopes for the
future, and a commitment to change.
III – Our hopes for the future: A commitment to lead change
A particular contribution of the National Forum to heart disease and stroke
prevention is to provide, stimulate, and support the needed leadership to advance a
bold agenda, The National Forum’s 2020 Goal and Strategic Priorities for 2020. This
fundamental role underlies the theme of this meeting, “Transforming Leadership,
Policy, and Practice – A Partnership of Leaders”.
The National Forum’s 2020 Goal is: “Heart disease and stroke will no longer be the
leading cause of death for all Americans by 2020.” And our strategic priorities for
2020 are: “Have in place a comprehensive cardiovascular surveillance system to
prevent an manage heart disease and stroke by 2020; achieve health equity and
eliminate cardiovascular disparities via implementation of population-based
interventions by 2020; reduce daily sodium intake in the general population to 1500
mg by 2020.”
These strategies and your commitment to achieving them to the fullest possible
extent will contribute substantially to 2020 goals – not only ours, but the Healthy
People 2020 goals for heart disease and stroke prevention, the American Heart
Association’s 2020 Impact Goal, and parallel targets of other organizations.
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We were introduced yesterday to a new federal initiative launched just 10 days ago
by Secretary Sebelius, CDC Director Tom Frieden, and CMS Director Don Berwick –
the Million Hearts Initiative. Its aim is to prevent 1 million cardiovascular events in
5 years, by strengthening both clinical preventive services and community
interventions, activating levers provided by the Affordable Care Act, and principally
its Title IV. Accountability for this initiative will benefit greatly from progress on
surveillance; it should be expected to improve health equity and diminish
cardiovascular disparities; and it specifically targets sodium intake through
population-wide interventions. Especially for these reasons, it will be important for
the National Forum to consider ways in which support of the Million Hearts
Initiative will contribute to our Goal and Strategic Priorities.
Several means of supporting Million Hearts have been suggested: signing on to the
MH website to register as an interested individual or organization
(www.millionhearts.hhs.gov); continually identify and submit new success stories to
demonstrate progress; propose interventions that could or should be brought to
scale; and suggest new partners who can contribute to success of the initiative.
A final point regarding Million Hearts and the ACA: Clearly Million Hearts is
dependent on the ACA and its many provisions for clinical preventive services,
community programs, and public health. If Million Hearts is to succeed, ACA must be
sustained. We have a very large stake in supporting ACA for this and other reasons.
At the same time, might it be true that success of Million Hearts could serve as the
most powerful demonstration of the impact of the ACA on the nation’s health? This
mutual dependence multiplies the stake we have as leaders in CVD prevention and
public health in both ACA and Million Hearts. We should, as the National Forum,
quickly consider how best to deploy our leadership resources in this effort.
A Zen message from long ago says that “the teacher can open the door, but the
student must walk through”. A paraphrase for the National Forum is: “Leaders must
open the door, so others may follow – and lead still others in turn.”
This meeting has opened the door for each of us to lead the way to 2020, on the way
to a heart-healthy and stroke free world.
Aim high: Revolutionary times create new possibilities for change.
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