Integrating Health Promotion in the National Agenda

Where Do These Provisions Come From?

The language for the Strategy came from Section 3001 of the Health Promotion FIRST (Funding Integrated Synthesis and Training) Act (2009-2010), which was first introduced in the Senate as S.2798 on September 14, 2004 by Senators Lugar (R-IN) and Bingaman (D-NM) and again in 2005, 2007, and 2009 and in the House of Representatives by Representatives Schakowsky (D-IL) and Burgess (R-TX) on April 17, 2008, and again in 2009. Section 3001, titled “Plan for Health Promotion Programs” called for (a) periodic plan with national goals, (f) integration of efforts within the Department of Health and Human Services, (g) coordination with secretaries of other departments of the federal government, and (i) input from outside experts with diverse perspectives.

Where do the ideas behind these provisions come from? A disturbingly large percentage of them come from organizations that are so rich they have a professional lobbyist assigned to each of the 535 members of Congress and another team to the White House. Other ideas come from individual citizens, like you and me. This is a story of how the idea for the National Prevention Strategy first emerged and ended up in the final version of PPaACA.

In early 1999, I was presenting a status report on the science of health promotion to Dr. Kim Mo Im, Minister of Health of Korea. At the end of my presentation, Dr. Kim congratulated me on my excellent presentation and expressed her surprise at how well the scientific foundation of the field had developed. I felt a sense of pride because of my close association with so many of the scientists who had developed the conceptual and scientific basis of our field. Then she said, “Health promotion must be a very important part of national health policy in the United States.” My pride evaporated as I said “No.” She asked “Why not?” and I admitted that I did not know. Her question and my answer plagued me for months, until the obvious answer came to me . . . we as a field never made a concerted effort to integrate health promotion into national policy! I resolved to put forth this effort when I returned to the United States in the summer of 1999.

My first step was to ask my office manager to schedule appointments with my two U.S. Senators and Representative. A couple days later, she told me she had scheduled all three meetings, but that only one of the three names I had given her was correct. The other two were my representative to the State Legislature and a U.S. Senator who had retired 4 years earlier. I had a lot to learn.

My next step was to visit Washington, DC to meet with the heads of about 10 professional associations and advocacy groups to figure out what needed to be done and how to do it. Elaine Auld, CEO of SOPHE (Society for Public Health Education), was one of the first people I met. I remember that she was so patient and that I was so overwhelmed as she told me all the work SOPHE had already done and she gave me an oral primer on how Washington works. During the next year, I had conversations with more than 300 people about what needed to be done and how we should do it. An early consensus was that trying to raise awareness on the importance of health promotion was not very effective; instead we needed to develop and pass legislation to advance health promotion. Two priority areas emerged. First, to enhance the science of health promotion, and second, to develop a national health promotion plan. The key ideas were to harness the resources of all the departments of the federal government, develop the plan at the cabinet level where there is sufficient authority to implement great ideas, and get input from outside experts with diverse perspectives.

I announced the idea publicly at our Art and Science of Health Promotion Conference held in Colorado Springs, Colorado, in February of 2000, then staged the conference in Washington, DC in 2001 and 2003 to advance the effort. The DC conferences included visits to Capitol Hill for nearly 800 people. We educated members of Congress on the health and financial benefits of health promotion and asked them support a resolution we had developed called Building Health Promotion and Disease Prevention into the National Agenda Resolution: 2001 (2001-2002). I wrote my first editorial on these ideas in the January 1999 issue of the American Journal of Health Promotion (O’Donnell, Whitmer, & Anderson, 1999) and wrote 30 subsequent related editorials. In May 2001, we published a special issue on the “Financial Impact of Health Promotion” and delivered a copy to every member of Congress.

By early 2004, it was obvious that I needed help co-ordinating these efforts. Fortunately, a group of dedicated colleagues stepped forward to help launch Health Promotion Advocates (www.HealthPromotionAdvocates.org), a nonprofit policy group created to integrate health promotion into national health policy by introducing and passing legislation. In subsequent years, Health Promotion Advocates worked with members of Congress to develop Health Promotion FIRST Act, and the Healthy Workforce Act, which was introduced in 2007 and 2009 (Healthy Workforce Act, 2009-2010).

In November 2008, shortly after Barack Obama was elected President, staff of Senator Teddy Kennedy (chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee) told me that Senator Kennedy was going to push for universal health care legislation starting in early 2009, that this would be a good time to advance our health promotion legislation, and that I needed to get ready to push it. Universal health care had been a top priority of Senator Kennedy for decades. He thought this was his last best chance because the Democrats had a 60-seat majority in the Senate, a 59% majority in the House, President Obama had agreed to make this his top priority, and Senator Kennedy had been diagnosed with terminal brain cancer 6 months earlier.

The timing was perfect for me. In April 2008, I left a great job at the Cleveland Clinic to accept what I thought was an even better opportunity to develop a health promotion policy, research, and education institute. Unfortunately, my new sponsor institution lost several hundred million dollars in the October 2008 stock crash and I was one of nearly 2,000 people laid off. The silver lining was that this allowed me to devote nearly all of my time to advocacy.

There has always been strong bipartisan support for health promotion, and that support has continued to the current day. I saw the same bipartisanship for the broader goal of universal health care in the early months of 2009. No president had succeeded in passing a comprehensive health care bill, despite numerous attempts in the past half century. The sense of giddiness among Congressional members of both parties was tangible . . . we might finally be able to succeed in providing health insurance coverage for all of our citizens, include reforms that would contain costs, and make health promotion a centerpiece. For me, this was a lifetime dream.

The bipartisanship did not last long. On July 17, 2009, in a conference call organized by Conservatives for Patients Rights, Senator Jim Demint (R-SC), an early hero of the emerging “tea party” said, “If we’re able to stop Obama on this, it will be his Waterloo. It will break him” (Smith, 2009). A few weeks later, Sarah Palin claimed the health care bill would create “death panels that would decide if seniors and the disabled were worthy of receiving medical care.” Although PolitiFacts (2009) later named her claim “The lie of the year,” her message took hold and virtually every Republican member of Congress began to oppose the bill, even though dozens, if not hundreds, of the key provisions in the bill were developed by Republicans. For example, the idea of the individual mandate, through which every citizen would be required to purchase health insurance, was conceived by conservative think tanks, and was originally opposed by President Obama (Potter, 2011).

Health Promotion Advocates maintained its bipartisan approach and concentrated its efforts on advocating that provisions in Health Promotion FIRST Act and the Healthy Workforce Act be included in the health care reform bills being drafted by the Congressional Committees most involved in drafting legislation: the Ways and Means Committee and Energy and Commerce Committee in the House and the Finance Committee and HELP Committee in the Senate. We focused our attention on the chair (Democrats) and ranking (Republican) members of these committees and as many of their 110 individual members in the House and 46 members in the Senate as we could reach. What fascinated me was the high level of receptivity of staff in these offices to our ideas. Despite the political wrangling of their bosses, and regardless of party, these staffers, who are charged by their bosses to develop legislation, were clearly working to come up with ideas to expand coverage, reduce medical costs, and improve health. I marvel at what these staffers are able to accomplish. Each Congressional office works on 35 official issues. In the House, the typical office has three or four staff members, meaning each staffer is responsible for 9 to 12 issues . . . health care being one of them. Senate offices have a few more staff members, but each staffer still is responsible for far more than they can handle on their own. Most of the staffers are in their 20s, and some are in their 30s. Most have only an undergraduate degree. For the most part, they are very bright, charming, hard working, and great synthesizers . . . and they needed help. When they meet an expert who is not trying to sell anything for personal gain, and who comes back again and again, they tend to embrace you as a valued resource. Not only are they happy to hear your good ideas, they ask for advice on other ideas, and they tell other staffers about you. I was amazed when staffers I did not know would call to ask for reactions to an idea, how best to phrase a key sentence, to get a sense of how other members of Congress would react to an idea, and even for a count of how many members of their committee were for or against a certain provision. At one level, this is scary . . . young people with limited expertise and experience and insufficient time, are writing legislation that shapes our nation. From another perspective, this is democracy in action. Citizens who have expertise and passion can shape federal policy. We shared our ideas with many other advocacy groups and they were pushing our ideas as well as their own. The group that impressed me the most, the group that probably had the most impact in shaping health promotion concepts in the final bill, was Trust for America’s Health (http://tfah.org/), led by Jeff Levi and Richard Hamburg.

Once the House and Senate committees had passed a version of a health care reform bill at the committee level, we shifted our focus to the provisions from our bills that were retained in these bills as well as a few provisions from other bills. We engaged our grassroots network to send faxes to their Senators and Representative and were a little surprised by the success of our effort, which was led by Leslie Spencer of Rowan University and Mari Ryan of Advancing Wellness. Using an online tool we had developed, we were able to document more than 11,000 letters faxed to members of Congress. To put this number in perspective, it was comparable to the number sent by the American Public Health Association in support of health care reform. We reached 100% of the members of the Senate and more than 85% of the members of the House.

The rest is well-documented history. The President signed the Patient Protection and Affordable Care Act on March 23, 2010, signed an executive order establishing the National Prevention, Health Promotion, and Public Health Council on June 10, 2010, and first National Prevention and Health Promotion Strategy was released on June 16, 2011.

I am the one writing this story, but it is certainly not only about me. It is the story of more than 2,500 people who came together to produce an outcome none of us knew how to approach before we started but will have a lasting effect on our careers and the health of the American people. It was all consuming, sometimes exhausting, and sometimes expensive. It was also fun, enlightening, and rewarding. All things considered, I can’t think of too many better ways to spend a decade of my life!

What is the moral of the story? Each of us has the ability to shape national policy. Our next challenge is to show how creating a society in which the healthy choice is the easiest choice is one of the few ways to prevent our economy from imploding because of unsustainable fiscal deficits, and at the same time improve the quality of life of our population (O’Donnell, 2011). Will you join me in this pursuit?