Chronic Costs: December 2009

Making healthy choices easier for Americans can prevent deadly diseases and save money.

By Amy Winterfeld

Cut health care costs—but don’t do it by killing off grandma.

Those are the marching orders for health reform. But what are the real options for reducing health care expenditures?

One is to reduce the cost of chronic diseases that increasingly afflict our population. Chronic conditions account for more than 75 percent of U.S. health care spending, according to research by Johns Hopkins. Seven of the most common chronic diseases—diabetes, heart disease, cancer, stroke, high blood pressure, pulmonary conditions and mental disorders—cost the American economy an estimated $1.3 trillion annually, $280 billion for treatment and $1 trillion in lost productivity, says the Milken Institute, a nonpartisan think tank.

If we do nothing to prevent these diseases, researchers estimate the annual cost could balloon to $4.2 trillion by 2023. Exactly how much can be saved, and over what time period, is subject to debate. What’s not in dispute, however, is that many promising state policies and programs could help prevent some of the most prevalent chronic diseases and reduce their costly complications.

“Chronic diseases linked to obesity, poor nutrition, physical inactivity and tobacco use are the leading causes of death and disability in our nation,” says Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention.

Smoking, not exercising and eating poorly are the top three behaviors that actually cause preventable illnesses and death in the United States. These behaviors contribute to deaths from this nation’s three leading killers—heart disease, cancer and stroke—and the sixth leading cause of death, diabetes. In addition, 36 million Americans—12 percent of the population—live with disabilities caused by chronic conditions that limit their daily activities.

Although “chronic diseases are costly and common,” says David Hoffman, director of Chronic Disease Prevention and Control for New York state, they “are also often preventable. Prevention is an investment and there is growing evidence that it works. The combination of clinical and community prevention can have a real impact on both improved quality of life and health care costs.”

Programs that increase physical activity, improve nutrition and prevent smoking and other tobacco use have a return on investment of $5.60 for every $1 invested, according to the Trust for America’s Health, a public health advocacy group. An investment of $10 per person over five years could save Medicare, Medicaid and private insurers $16 billion annually, including $5 billion in Medicare and $1.9 billion in Medicaid costs.

Tackling Tobacco

Tobacco use costs taxpayers more than $96 billion in medical expenses and $97 billion in lost productivity every year, according to the Centers for Disease Control. Nearly half of the 44.5 million Americans who smoke will die prematurely from tobacco-related diseases.

State policymakers have played a role in discouraging tobacco use by enacting policies that help stop kids from starting to smoke, create smoke-free environments and provide support for smokers who want to quit. States have prohibited smoking in public places and on the job, raised taxes on tobacco, and offered programs to help people kick the habit.

Most states impose cigarette excise taxes of at least $1 per pack. Thirteen states and the District of Columbia charge at least $2 per pack. The average state cigarette excise tax was $1.27 per pack in May 2009. Increases in cigarette prices reduce cigarette smoking. Research by the Campaign for Tobacco Free Kids found a 10 percent increase in the price of cigarettes cut youth smoking rates by 6.5 percent, adult rates by 2 percent and total consumption by 4 percent.

At least 20 states, the District of Columbia and Puerto Rico prohibit smoking in most workplaces, restaurants and bars. And Arkansas, California, Louisiana, Maine and Puerto Rico prohibit smoking in a vehicle with a child.

Tennessee Senator Tim Burchett proposed such legislation in his state this year. “It’s part of my efforts to protect children,” says Burchett, whose legislation did not pass. “You wouldn’t let your kids ingest poison. And cigarette smoke is poison.”

All states offer services such as “quit smoking” hotlines, and at least 40 states offer state employee tobacco cessation programs. Many include access to counseling and medications at low or no cost. In addition, the Centers for Disease Control funds programs to prevent and control tobacco use in all the states, the District of Columbia, seven territories, and seven tribal support centers.

Pass the Salad

State legislators, recognizing that it’s easier for people to eat healthy food when it’s readily available in their neighborhood, are helping to make that happen.

Pennsylvania’s Fresh Food Financing Initiative is one example. This public-private effort, started in 2005 with $30 million in state money, aims to bring markets that stock a variety of healthy food to underserved areas.

Pennsylvania’s initiative was shepherded through the legislature in 2004 by Representative Dwight Evans, who also secured $95 million in private funding from The Reinvestment Fund, an organization that raises money to help reclaim neighborhoods. Grants, loans and tax credits were offered as incentives to grocery operators to build new stores or improve existing facilities, such as adding refrigerated storage for fresh produce.

“This was seed money to get things started,” Evans says.

The effort has created jobs, given people more food choices and helped “build morale in the community,” he says.
By 2009, the program served an estimated 400,000 people statewide through 74 grocery outlets, large and small, in 27 Pennsylvania urban, suburban and rural counties. It has created or retained more than 4,800 jobs.

The “vast majority of projects are in rural, not urban, Pennsylvania,” Evans says.

Illinois, Louisiana and New York started similar efforts this year. New York legislators appropriated $10 million for a state revolving loan fund to support grocery store development. Backing from the Illinois Retail Merchants Association helped persuade the Illinois General Assembly to approve $10 million for a fresh food program. The Illinois program, a public-private partnership, plans to raise another $20 million from philanthropic groups.

In Louisiana, legislators passed the Healthy Food Retail Act, creating a financing program that will provide grants and loans to supermarkets, farmers’ markets and food retailers to improve access to fresh fruits and vegetables in underserved communities in the state.

It’s all a boost that’s sorely needed. Only 33 percent of U.S. adults eat enough fruit and only 27 percent eat enough vegetables, according to a report released in September by the Centers for Disease Control.

Top Three Risks for Diabetes

Many causes account for the increasing number of Americans—24 million and growing—with type 2 diabetes. Obesity, poor nutrition and lack of regular physical activity top the list of risk factors that, if prevented, would lower the numbers, the costs and the most serious complications from diabetes.

In Tennessee in 2007, adult diabetes rates had increased 112 percent over the past decade. Currently, nearly 70 percent of adults in the state—more than 3 million people—are overweight, adding an estimated $3 billion to the state’s health care costs. A statewide diabetes coordinator, a post created by the legislature, is trying to ensure that diabetes prevention and treatment programs are not duplicative and have the greatest effect possible.

“We are at a crisis level with type 2 diabetes, and it is almost 100 percent preventable,” says Burchett, who sponsored the legislation to create the post.

The diabetes coordinator, says Burchett, is “somebody to hold our feet to the fire. A constant reminder that we need to do something.”

Georgia also enacted legislation authorizing a statewide diabetes coordinator in 2009, and legislation is pending in New York.

Get Physical

Physical activity decreases the risk of many chronic diseases—including heart disease, stroke, colorectal and breast cancers, and type 2 diabetes—and can help maintain a healthy weight.

On average, direct annual medical costs for people over age 15 who are physically active are $1,019, while the costs for physically inactive people average $1,349. Community-based physical activity programs, based on a recent study sponsored by the Centers for Disease Control, reduced new cases of many chronic diseases, including colon cancer, type 2 diabetes and heart disease.

Some legislators are looking at policy options to provide safe, enjoyable venues for physical activity for all ages in communities and workplaces. Recent legislative actions include a variety of approaches.

Minnesota legislators took a comprehensive approach, allocating $47 million this year for a statewide program to reduce smoking, encourage physical activity and teach better nutrition. Communities and tribes will apply for the grants by choosing from a menu of activities, such as tobacco-free policies, employee wellness programs, healthy eating policies in schools and day care centers, better access to healthy foods, and promoting walking and recreational facilities.

“We have to move upstream to prevent the chronic diseases that bring people into the health care system in the first place,” says Dr. Sanne Magnan, Minnesota commissioner of health. “Not only do those diseases reduce quality of life and life expectancy, but the costs of treating them create a substantial burden.”

In Texas, legislators created a program to look at the nutrition and physical activity standards in facilities that care for young children. California legislators are considering a pilot program to reward child care programs that establish those standards.
Recent legislation in Florida, Louisiana, Maryland, Mississippi, Oregon and Texas has improved the quality of physical activity for school children, including children with disabilities. Legislators in Maine and Oregon created ways for their states to seek both public and private funds for physical education and activity in schools, while Arkansas and Louisiana legislators resolved to support recess during the school day.

But why should kids have all the fun playing basketball in the gym, running around the track or hitting homers out on the field? Since taxpayers pay for them, many states encourage or require schools to open their facilities to the community. School officials, concerned about cost or liability, can form joint-use agreements with communities that legislators can encourage.

North Carolina lawmakers, for example, recently directed the State Board of Education to promote agreements between local school boards and other local government entities for use of school facilities for physical activity by community members.

Legislators also have supported policies that encourage mixed-use developments to make it convenient to walk and bike among homes, schools and businesses. And they have funded the development of walking and biking trails and “complete streets” with sidewalks and bike lanes. Massachusetts, Oklahoma and Washington lawmakers recently supported the Safe Routes to School initiative. To ease employee health care costs, states also have established wellness programs for state employees.

The Robert Wood Johnson Foundation’s Commission to Build a Healthier America thinks state policies can make a difference in helping people stay healthy.

“We need to cultivate a national culture infused with health and wellness—among individuals and families and in communities, schools and workplaces,” the commission said.

While good health depends largely on personal choice and responsibility, the commission added that “society’s leaders and major institutions can create incentives and lower barriers so that individuals and families can take steps to achieve better health. … and to choose healthful behaviors, especially for those who face the greatest obstacles.”

Amy Winterfeld tracks chronic disease prevention for NCSL.