CPPW: A First Step in Transforming Public Health in the United States Jeffrey Levi, PhD Executive Director June 2, 2010

Overview  CPPW is the largest single non-emergency commitment to public health the federal government has ever made How did we get here: Why community prevention? Why now? What is Congress expecting of you? What’s the evidence base – why do policy makers believe you can meet their expectations? How does CPPW relate to some of the prevention and public health investments in health reform? How should we measure success of CPPW two years from now?

Why now?  Public health has traditionally focused on communicable diseases with biomedical interventions – treatment or a vaccine  However, the biggest drivers of illness and death (and lower productivity and competitiveness) are chronic diseases for which there are not effective clinical preventive measures Challenge: combine community level (more efficient) public health perspective with focus on diseases generally treated in the clinical setting but for which there aren’t effective medical preventive interventions

Health Care Spending: $2.2 Trillion in 2007 Health Behaviors 50% Environment20% Access to Care 10% Genetics20% Prevention 4% Medical Services 96% Factors Influencing Health National Health Expenditures SOURCE: CDC, Blue Sky Initiative, University of California at San Francisco, Institute of the Future, 2000

American Recovery and Reinvestment Act: Downpayment on Health Reform  $650 million to “carry out evidence-based clinical and community-based prevention and wellness strategies…that deliver specific, measurable health outcomes that address chronic disease rates.”  “a historic commitment to wellness initiatives will keep millions of Americans from setting foot in the doctor's office in the first place -- because these are preventable diseases and we're going to invest in prevention.” – President Barack Obama, Feb. 17, 2009

What is Community-Level Prevention?  Interventions that promote healthy environments and behaviors – making it easier for people to make healthy choices, such as: Changing community norms and growing community empowerment  Coalition and social network building  Social marketing campaigns Changing the physical and social environments  Organization practices and governmental policies  Facilities and programs  These changes cut across diseases

Why community prevention?  Coverage is important, but what surrounds (or precedes) coverage is also important Achieving good health outcomes requires healthy communities, not just healthy individuals  Drivers of health care costs (chronic disease, injuries) can often be effectively prevented in the community as opposed to managed in the health care setting Reducing costs as a critical policy outcome  Disparities in chronic diseases related to disparities in the “health” of communities Poverty, race/ethnicity and obesity Poor communities provide less support for healthy lifestyles (food, physical activity)

What makes us think this will work?

Prevention for a Healthier America

Prevention for a Healthier America: Financial Return on Investment? INVESTMENT:$10 per person per year HEATH CARE COST NET SAVINGS: $16 Billion annually within 5 years RETURN ON INVESTMENT (ROI): $5.60 for every $1 With a Strategic Investment in Proven Community-Based Prevention Programs to Increase Physical Activity and Good Nutrition and Prevent Smoking and Other Tobacco Use

Key Findings 1. Are there community-level interventions that could reduce chronic disease levels – and thus affect the biggest driver of increased disease, disability, and cost? Yes. Regardless of chronic condition targeted, most interventions fell into 4 categories: physical activity, nutrition, obesity, and smoking cessation. Reduced or delayed incidence of disease; mitigation of disease 2. If we increased funding for community-level interventions, we could see a return on investment and more than break even in terms of ROI. 3. Savings can be shown by payer – with private payers and Medicare the biggest “winners.”

Or Are We Just Delaying High End-of-Life Costs?  Compression of morbidity: extending healthy life expectancy more than total life expectancy – literally compressing chronic disease and disability into a smaller proportion of life Primary prevention delays or prevents disability vs. management of disability (current focus of health care system)  Preventing obesity – delaying or avoiding a knee replacement  Managing disability – providing a knee replacement  Obesity results in more chronic conditions, but not shorter life

Multiplier Effect

What did the successful programs have in common?  Multi-faceted approach: no magic bullet MAPPS-type approach  Adapted to individual community needs  Leadership from the community  Broad engagement of multiple sectors of the community  Focus on changing policies and the environment that were sustainable and could achieve long-term change These factors help assure success, but create a challenge since one size does not fit all

Thinking across stove-pipes  Building healthier, more resilient communities able to face multiple health challenges is the goal  Funding sources should provide flexibility for the most appropriate interventions  Community interventions aren’t limited to one disease Physical activity and youth  Obesity, depression, sexual risk, educational performance, tobacco use Alcohol taxes  Alcoholism, motor vehicle accidents, domestic violence, STDs  Organizing done through CPPW will change perspectives on health of the community beyond nutrition, physical activity and tobacco.

Lessons for policy makers  Making healthy choices easy choices can improve health and reduce costs  We need to create an environment and policies where it is possible to expect individuals to exercise personal responsibility  Community prevention only works if all who affect, or are affected by, the health environment are at the table – public health cannot do this alone This is the vision that drove CPPW and prevention in health reform

What happens next?  Health reform National Prevention Strategy  Health in all policies Community Transformation Grants  Policy, environmental, programmatic and infrastructure changes to promote healthy living and reduce disparities Prevention and Public Health Fund (short and long term) National menu labeling requirement  Lessons from CPPW will drive the development of the Community Transformation Grants

The End is the Beginning  March 2010: CPPW Awards By September 30, 2010 – Prevention Fund = $500 m. By September 30, 2011 – Prevention Fund = $750 m.  March 2012: CPPW projects wind down By September 30, 2012 – Prevention Fund = $1 billion Community Transformation Grants underway?  2014 – Full health reform access begins October 1, 2014 – Prevention Fund reaches $2 billion

What will success look like?  You will have made a measurable impact on disease and, by extension, costs, in your communities.  National and local recognition that creating healthy communities (public health) is a shared responsibility Communities (public and private sectors) have a responsibility to create the opportunity for individuals to make healthy choices – so the exercise of personal responsibility is a viable option Leadership must come from more than the public health community, and include the public and private sectors Use CPPW experience and apply to other challenges, including Community Transformation Grants