Breastfeeding and New Federal Prevention Efforts in the Affordable Care Act

I will discuss some of the policies that have recently been instituted with the goal of improving the health of the U.S. population and of which we can take advantage to support breastfeeding. Having these policies in place is, in fact, only the very beginning: Much work remains to see them properly implemented.

I think it is important to consider philosophically where we are in public health today and that we are going through a remarkable period of transformation—as we try to turn our sick care systems into a true health system.

We are beginning to put into place the elements of a healthcare system, and in connection with that, there is beginning to be the awareness that to accomplish that, we have to think about health first. Some of that does not represent a great philosophical shift, but rather the recognition that the biggest challenges in achieving health are not necessarily going to be resolved or prevented through biomedical solutions.

Also, if we want to reduce healthcare costs, we have to think about some of the noninterventionist, nonclinical approaches to achieving this. What happens outside the clinic is a part of the transformation. A great part of that is what individual people do and how we empower them to do healthy things and make healthy choices in their lives.

I think that relates to two other issues. One of them is to move away from intervention on a disease-by-disease basis and think about crosscutting interventions. Physical activity is a perfect example. We often talk about physical activity solely in the context of preventing or reducing obesity. However, it is also an effective treatment and preventive measure for diabetes. Beyond this, children who are more physically active do better in school, and people who are more physically active are less likely to be depressed. Therefore, thinking in this perspective is an essential part of the new framing of the concept of health.

Another part of the transformation, which reflects a lot of your work, is thinking less about programs, even though they can be important, and much more about policies and structural impediments to leading healthy lives. Some of that can be reversed by policies, such as the requirement in the Patient Protection and Affordable Care Act for removing impediments to breastfeeding in the workplace. ¹ But there are many other opportunities within health reform—through programs, policies, and funding—to address some of these policy-related and structural impediments to ensuring health that I will discuss.

A third transformation in the philosophy of health is the National Prevention Strategy, ² which represents another opportunity to address these issues. Senator Harkin talked at length about this, and I think his talk was a perfect example of why the Affordable Care Act is such an important change agent. It is law. However, that doesn't mean that we have solved the problem that the Affordable Care Act was meant to address. We have to move on to doing that as our next objective.

Moreover, just as everyone else involved in health reform has discovered, getting the Act passed was very hard work. It is even harder to implement health reform, and not just because it is complex. We have to make sure that every piece of it works correctly and as intended. That means that a lot of work remains for us in making sure, as the various executive agencies of the federal government implement the law, that it functions in the right way. We are very fortunate in having someone like Senator Harkin, as chair of the authorizing committee for both the U.S. Department of Health and Human Services and the U.S. Department of Labor, to make sure that this happens. One key implementation step that Senator Harkin talked about is the Community Transformation Grants (CTGs) program, ³ which was created through the Affordable Care Act. Those grants will help community-level prevention, but will also and just as importantly help in other ways to implement policies and structural interventions that can make a difference in people's lives.

The process expected in the operation of these CTGs is also important. The objective is to bring together the various elements of communities that make a difference in health. This goes beyond public health agencies. It can include schools and the business community. It can even involve agencies for public safety, since, for example, it is sometimes very important to create a safe environment in which people can be physically active.

The money spent under the CTGs will be going to states and to cities and counties with more than 500,000 people as targeted areas. Some of it will be for improving access to disease-preventive clinical services. Again, the purpose of the grants is to remove structural barriers to health—they will not directly provide these preventive health services but create policies and programs that assure greater use of them—and the preventive services themselves will be covered (without cost sharing) by insurers as part of health reform. Other specifically targeted areas are active living and healthy eating, the risks of tobacco use, hypertension, and the prevention of high blood cholesterol levels. The Centers for Disease Control and Prevention has committed $900 million to the CTGs over the next 5 years, with $143 million in funding this year. The CTGs are funded through the Prevention and Public Health Fund, which will provide $750 million this year, 1 billion dollars next year, and ultimately 2 billion dollars a year indefinitely if the Fund is not repealed. In addition to the CTGs the Prevention Fund will be supporting a variety of other public health and prevention activities.

The goal of the transformation grants is to fund policy changes and structural changes that have a lasting impact once they are implemented. The passage and adoption of laws for smoke-free air, seat-belt laws, and laws for child car seats are all examples of legal changes that make a difference and have an immediate impact on health outcomes.

Some of the money in the CTGs can be focused toward improved choices in nutrition at schools, supermarkets, or corner stores. Seattle is working with corner grocery stores and getting them to offer fruits and vegetables. The city is providing some of the money so that stores can buy the refrigeration equipment needed to provide this and is helping with advertising and with marketing. These are all skills that public health personnel don't learn in their professional schooling. You have to look for them elsewhere, but the point is that you are bringing all of the necessary skills to bear on solving a problem. It is a new conceptualization of what public health does.

What this might look like for breastfeeding will again depend on locally determined needs and initiatives. You may need an educational outreach program in one community, and in another community you may need stronger regulation of what happens in the workplace. There is flexibility within communities to do this. For those who care about breastfeeding, the need is to be part of local coalitions and to have a seat at the table as decisions are being made about the specific policies that will be adopted or pursued with the CTGs. In fact, one of the options in the announcement of the funding opportunity for active living and healthy eating is to support policies and programs that promote breastfeeding. ³

However, the concept and implementation of transformation have not been without opposition. Some state governors have resisted applying for transformation grant money because it is money authorized by the Affordable Care Act. Representative Virginia Foxx of North Carolina has said that mothers have been breastfeeding for millions of years and don't need training in it. ⁴ In still another instance of opposition, Dennis Smith, the Wisconsin Secretary of Health Services and former head of Medicaid at the federal level, has said, “Why are we asking for taxpayers' money for stuff that we are already doing? How long have people been doing tobacco cessation, for heaven's sake? This is stuff that goes on all the time.” ⁵

What is reassuring is that the letters of intent submitted to the Centers for Disease Control and Prevention for the transformation grants indicate that a significant number of jurisdictions have already identified their local breastfeeding coalitions as part of the larger coalitions that will be working on the local uses of the CTG.

I would also like to briefly return to the National Prevention Strategy, which was mandated by the Affordable Care Act. It was assembled by the National Prevention Council, which has 17 federal agencies as members, and is a recognition that prevention is now a theme throughout the federal government and that every agency in the federal government has a role to play in making the United States a healthier country.

The notion underlying this is to think not only about the clinical prevention of disease, but about prevention throughout our society and what we can do through the National Prevention Strategy to improve the health and quality of life of individuals, families, and communities, by moving from being a nation focused on sickness and disease to a nation focused on prevention and wellness. The goal is to increase the number of Americans who are healthy at every stage of life.

I am privileged to chair the advisory group to the National Prevention Council. The Council has identified four strategic directions in which to move the United States to a focus on prevention and wellness: Healthy and safe community environments, clinical and community preventive services, empowered people, and the elimination of health disparities. Breastfeeding fits into each of those strategic directions, and the Prevention Strategy specifically calls for support of policies and programs that promote breastfeeding, and goes on to explain why this is important and how it might be done.

That is a general goal for the nation. The Strategy then identifies what the federal government will do in terms of specific commitments and what other, non-federal sectors can do. The commitment of the federal government is to support breastfeeding, including implementing the breastfeeding provisions of the Affordable Care Act.

Probably more important is that there are about a dozen or so key indicators as goals for various parts of the Strategy. One is that the proportion of infants who are breastfed exclusively through 6 months of age should reach 25.5% in 10 years.

The bottom line is that we now have some wonderful building blocks for transforming our definition of health—with breastfeeding being one of those building blocks—but a lot of organizing remains to be done around them: At the federal level to make sure that the federal government really moves forward with its commitments, and that local governments really be engaged in initiatives like the CTGs. The challenge is to take the very general wording in the Prevention Strategy and articulate what it would require to implement in terms of specific actions. Then, we as an advisory group can turn to the Prevention Council and say, “This is interesting. What are you doing to make it happen?”

There is a genuine commitment philosophically among the agencies on the Prevention Council to work together and address vital issues in our nation's health, but they need to see a constituency behind that commitment to make it a true priority of their agencies' work.