STATES PROMOTE WELLNESS Volume 28, Issue 488 April 2, 2007 Amy Winterfeld As the saying goes: A stitch in time, saves nine. States are taking this old adage to heart by investing more energy and resources into preventing chronic diseases. More than 90 million Americans live with chronic illness, and treatment for these conditions accounts for 75 percent of yearly health expenditures. According to the Centers for Disease Control and Prevention, over 44 million U.S. adults continue to smoke cigarettes, costing the nation in excess of $75 billion annually. Rates continue to rise for one of the leading precursors to chronic disease, obesity. An estimated 66 million Americans are overwieght or obese, and an estimated 60 percent of American adults do not get enough exercise. The economic toll associated with physical inactivity was nearly $76.6 billion in 2000. Investing in disease prevention and health promotion helps control these costs. Making healthy food choices more available, designing environments to encourage physical activity, offering incentives for healthy behaviors and encouraging preventive screenings are strategies that lower costs. “We have a finite amount of resources to spend on health care,” says Hawaii Representative Josh Green, an ER doctor who chairs the House Health Committee. “The only way to afford the things we must have is to focus on preventive health measures and screenings. We’ll always need trauma centers like the one where I work, but that means we need to be smart about other health costs.” Starting Young During the past 30 years, obesity rates have more than quadrupled for children ages 6 to 11 and more than tripled for young people ages 12 to 19. Many lawmakers are enacting wellness policies for schools, where 98 percent of 5- to 17-year-olds can be found on any given school day in the United States. Beginning this fall, federal law requires school districts participating in federally funded school meals programs—nearly every school district in the country—to establish a local wellness policy that includes goals for physical activity. School meals must meet nutrition standards set by the U.S. Department of Agriculture. And there must be a plan for measuring success. Colorado, Florida, Illinois, Indiana, Kentucky, Mississippi, Ohio, Pennsylvania, Rhode Island, Tennessee and Washington have all enacted legislation in the past few years to support school and state wellness policies.
Legislators have worked to improve the nutritional quality of school foods, provide more opportunities for physical activity, and ensure that nutrition is part of the school curriculum. At the local level, 92 of the nation’s 100 largest school districts have developed a wellness policy. Lawmakers are also looking at ways to encourage kids to get more exercise on the way to school. The federal Safe Routes to School program includes $612 million for grants over five years for communities to build bike lanes, sidewalks and trails that will make it safer and easier for children to bike and walk to school. Getting Workers Healthy Investing in employee health also pays off. Healthy workers are more productive. An analysis of 32 studies of workplace wellness initiatives found 28 with an average return on investment of $3.48 per $1 in program costs, as reported in 2001 in the American Journal of Public Health. Citibank saved $8.9 million over two years after investing $1.9 million for wellness initiatives, translating into a return of $4.70 for each dollar spent on the wellness program. Motorola saw a return of $3.93 for every dollar spent on its wellness program, and saved nearly $10.5 million annually in disability expenses for program participants compared to non-participants. State governments and other public employers are initiating workplace wellness programs as well. The U.S. Department of Health and Human Services awarded Hawaii an innovation in prevention award last November for promoting physical activity and nutrition at work. The state health department has outlined these ideas in an online Worksite Wellness Toolkit, so that other employers can start similar programs. Delaware, Kentucky, Oklahoma, Rhode Island and South Dakota have launched health promotion initiatives for state employees. And Arkansas, North Dakota, Ohio and Vermont have statewide wellness programs for the whole population. In 2005, Nevada’s legislature established a State Program for Fitness and Wellness and a state advisory council to raise awareness and create programs for physical fitness, nutrition and the prevention of obesity and chronic disease. States have also had success by starting on a small scale, building on pilot programs. North Carolina’s HealthSmart program started with nine local programs that identified state employees with specific health conditions and provided them with intensive health advice on lifestyle changes. It was expanded to all state employees in 2005. Delaware launched the Health Rewards pilot study program for state employees in 2003, offering comprehensive health assessments, guidance, and fitness advice to state employees through their group health insurance programs. State efforts to improve workplace wellness have also included smoking bans that cover all workplaces, including bars and restaurants. Hawaii’s ban, effective in November 2006, is “essentially the end of the issue of secondhand smoke in public places,” says Representative Green. Building Healthy Communities Decisions about zoning, community design and land use affect the daily choices people make, whether it is to drive or walk to the store, exercise, or buy healthy foods. Creating incentives can encourage cities and developers to take health and livability into account when retrofitting old developments or building new ones. The design of neighborhoods, transportation systems and biking or walking paths can encourage physical activity. Making healthy foods, such as fresh fruits and vegetables, accessible and affordable, is part of the equation. Encouraging schools and government agencies to buy local produce, providing fiscal incentives for locating grocery stores in all communities—especially underserved urban or rural communities—can have a big impact on people’s health.
Paying for Prevention for the Publicly Uninsured
States have recently begun to structure public insurance programs to cover more preventive care to help ward off chronic conditions, which account for 96 percent of Medicare spending and about 83 percent of Medicaid spending. Examples include the following: - Coverage for obesity prevention services. In Connecticut, the state’s Medicaid managed care plans pay for obesity related services if they are medically necessary. Nutritional counseling, exercise programs and behavioral health services are covered under Medicaid and SCHIP if they meet the necessity criteria. The state also covers gastric bypass surgery through Medicaid, if medically necessary.
- Coverage for smoking cessation treatments. In 2005, 38 states covered some tobacco-dependence counseling or medication for all Medicaid recipients. Four more states offered coverage only for pregnant women. Oregon is the single state offering all smoking cessation medications and counseling treatments recommended by the U.S. Public Health Service.
- Wellness incentives. West Virginia has some of the nation’s highest rates of obesity, diabetes, heart disease and smoking. In three pilot counties, Medicaid patients will be asked to sign contracts agreeing to do their best to stay healthy by attending health improvement programs as directed, having routine checkups and health screenings, taking prescribed medicine and keeping appointments. As an incentive, they will receive anti-smoking and weight loss classes, home health visits as needed, mental health counseling, diabetes management assistance, cardiac rehabilitation and additional prescription medications.
In future years, Medicaid beneficiaries who stick to the plan will qualify for extra benefits, possibly orthodontic or other dental care. Medicaid recipients who do not sign or adhere to the contract will be limited to the standard benefits determined by the state. Critics say the plan may limit access to the enhanced benefits for those most likely to need them, for example, people with existing mental health or substance abuse problems that create difficulties in keeping scheduled appointments. It may also put doctors in an awkward position as administrative enforcers of factors that may be beyond patient control and may interfere with effective doctor-patient relationships.
- Preventive services for those on Medicare. In January, Medicare increased payments to doctors for face-to-face doctor-patient consultations about a patient’s health and potential steps to maintain or improve health. The hope is to encourage more discussions about preventive services like controlling diabetes and get doctors to refer more patients to diabetes self-management training and medical nutrition therapy. Medicare will also now cover these services at federally qualified health centers, increasing access in rural and underserved areas.
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This article first appeared in the February 2007 issue of State Legislatures Magazine.
© Copyright 2007, State Health Notes
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