In May 2008, when Minnesota Gov. Tim Pawlenty signed a bill bringing widespread health reform to his state, the top of the legislation clearly read: “Article 1, Public Health.”
For Sanne Magnan, the state’s commissioner of health, the placement not only underscored public health’s role in reform, but reflected advocates’ perseverance in telling the oft-unheard public health success story. Almost a year later, work at the Minnesota Department of Health is well under way toward achieving quality and accessible health care for all Minnesotans, and public health remains front and center.
In the run-up to reform, Magnan, MD, PhD, said telling public health’s story in ways “people could get their arms around” was key in promoting the field’s role in reform. For example, Magnan said she often used the “simple, but poignant” story of diabetes when talking with legislators, as almost everyone knows someone affected by the disease. She would tell them that while improvements in chronic disease care would certainly help residents living with the disease, it was not going to solve growing diabetes rates. Getting at the root of the diabetes problem meant investing in public health and prevention, she said.
“Health care is downstream, while health and prevention are upstream, and we made that message very clear to policy-makers here in Minnesota,” Magnan told The Nation’s Health. “The question is: How can we get better health instead of just how do we get better health care?”
That question is one public health workers nationwide are answering as states continue to act as health reform laboratories, creating solutions, passing legislation, working out the kinks and gathering results. For years, states have been ground zero for such reforms and, in turn, their experiences are likely to help lead the way as national policy-makers turn their attention to reforming the way all Americans access — and think about — health care. As such discussions move forward, public health advocates such as APHA are working to educate federal legislators as to why no national health reform effort will reach its full potential without investing in a strong foundation — and that foundation is public health. In fact, APHA’s National Public Health Week 2009 has a theme of “Building the Foundation for a Healthy America,” which urges public health workers nationwide to bring their voices and experiences to the health reform debate.
“Now is the time to make our messages more loud and clear than ever before,” said APHA Executive Director Georges Benjamin, MD, FACP, FACEP (E). “Work to keep people healthy — from birth to senior years — must be as important a priority as treating disease and providing health insurance. And prevention not only works in saving lives, but in saving money.”
According to January’s “State of the States” report on health reform from the Robert Wood Johnson Foundation and AcademyHealth, “since state efforts have dominated (health) reform efforts recently, in part, because there has been little to no federal action, there is a wealth of experience and lessons that can inform the national discussion.” While Massachusetts has garnered the most headlines in recent memory — probably due to being the first state to require all residents to have insurance coverage — it is far from alone in tackling the health care problem. Over the past few years, several states have instituted reforms that include efforts to ease the burden on employers, plans to better manage chronic diseases and expansions of public health care safety nets such as the State Children’s Health Insurance Program. In Minnesota, the state’s 2008 health reform law not only boosted the typical aspects of reform, such as provider payments and insurance coverage, but the work of the community-based Steps to a Healthier Minnesota, an outgrowth of the Centers for Disease Control and Prevention’s Steps to a HealthierUS initiative.
Minneapolis’ Sabathani Farmers Market, shown in August 2007, is part of the Steps to a Healthier Minnesota Program.
Photo by Bill Smoger, courtesy Minneapolis Department of Health and Family Support
Known in the reform law as the Statewide Health Improvement Program, or SHIP, the new program received funding via the new law that the health department will distribute in the form of community-based grants to tackle obesity and tobacco use. In gaining legislators’ support, Magnan said it was key to be able to illustrate the department’s past successes, such as communities mobilizing around healthy eating and tobacco-free parks. They were powerful examples of how to continue down the prevention road, and without them, the new program’s role in health reform would have been less likely, Magnan noted.
“Health care is so visible whereas public health is not, so we need to keep reminding people of the importance of good public health and the infrastructure that’s needed,” she said.
Supporting community-based efforts is a prominent fixture in Vermont’s health reform plan as well, which passed its first round of reform legislation in 2006. Officially codified in the reform law was the state’s Blueprint for Health, an effort the Vermont Department of Health had kicked off in 2003 to tackle the health and economic impacts of chronic disease. With health reform bringing new funds to the blueprint effort, today six Vermont communities — covering about half the state — are creating and trying out new ways to ease the burden of chronic diseases, said Lisa Dulsky Watkins, MD, a public health physician and assistant director of Vermont’s Blueprint for Health. With an overall philosophy that chronic disease efforts cannot work in isolation, the blueprint meshes public health and health care components. For example, Watkins said, community care teams working to create better patient-centered medical homes include a prevention specialist from the local health department who not only works with physicians, but oversees grants that promote exercising and good nutrition.
“My personal hope is that there will truly be a dovetailing of these efforts,” Watkins told The Nation’s Health. “The two disparate worlds (of health care and public health) have tremendously important overlaps. The health of a population is the sum of the health of its individuals.”
Bringing better prevention to chronic disease care is also a centerpiece of health reform plans in Iowa, which enacted widespread reform last year. Among the reform’s measures was the creation of the Prevention and Chronic Care Management Advisory Council and additional funding for community wellness grants, both under the direction of the Iowa Department of Public Health. Tom Newton, MPP, Iowa’s director of public health, said public health officials were involved throughout the reform process, noting that while a “large amount of responsibility has been passed onto us, we’ve really embraced it because we really do believe that public health should be involved in health reform.”
“Don’t allow your voice to be trumped,” Newton told The Nation’s Health. “In this (national) health reform debate, there will be a lot of voices and, unfortunately, those who scream the loudest often get the most. As public health officials throughout the years, we haven’t been willing to scream very loud. But now is the time to make your voice heard.”
For more on state health reform efforts, visit www.statecoverage.org.
- Copyright The Nation’s Health, American Public Health Association