MMHA6700 Health Care Reform Initiatives Discussion

1 Public Health Reviews, Vol. 35, No 1 A Perspective on the Development of the Healthy People 2020 Framework for Improving U.S. Population Health Jonathan E. Fielding, MD, MPH, MA, MBA,1 Shiriki Kumanyika, PhD, MPH,2 Ronald W. Manderscheid, PhD3 ABSTRACT Since the late 1970s, the federal Healthy People Initiative has been a visible component of the United States’ approach to improving population health. In each decade, a new version of Healthy People is issued, featuring updated goals and identifying topic areas and quantifiable objectives for health improvement during the succeeding ten years, with assessment at that point of progress or lack thereof. Progress has been limited for many objectives, leading to concerns about the effectiveness of Healthy People in shaping outcomes in the context of a decentralized and uncoordinated US health system. This article describes development of Healthy People 2020, launched in December of 2010, from the perspectives of three members of a public advisory committee appointed to guide the process: The Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020 (SAC). The SAC made recommendations, almost all of which were adopted in some form, based on extensive assessments of strengths and weaknesses of the program and deliberations about critical areas to update. As a result, compared to prior versions, Healthy People 2020 gives more prominence to health promotion and preventive approaches, and adds a substantive focus on the importance of addressing societal determinants of health. A new expanded digital interface facilitates use and dissemination rather than bulky printed books as produced in the past. The impact of these changes to Healthy People will be determined in the coming years. Director of Public Health and Health Officer, Los Angeles County, Department of Public Health; Professor, Schools of Public Health and Medicine, University of California at Los Angeles; Los Angeles, CA, USA. 2 Associate Dean for Health Promotion & Disease Prevention, Professor of Epidemiology, Department of Biostatistics & Epidemiology, University of Pennsylvania Perelman School of Medicine; Philadelphia, PA, USA. 3 Executive Director, National Association of County Behavioral Health and Developmental Disability Directors; Washington, DC; Adjunct Professor, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University; Baltimore, MD, USA. 1 Corresponding Author Contact Information: Jonathan E. Fielding at jfielding@ph.lacounty. gov; Director of Public Health and Health Officer, Los Angeles County, Department of Public Health, 313 North Figueroa Street, Room 806, Los Angeles CA, 90012, USA. 2 Public Health Reviews, Vol. 35, No 1 Key Words: Healthy People, population health, health objectives, health promotion, disparities Recommended Citation: Fielding JE, Kumanyika S, Manderscheid RW. A perspective on the development of the Healthy People 2020 Framework for improving U.S. population health. Public Health Reviews. 2013;35: epub ahead of print. MMHA6700 Health Care Reform Initiatives Discussion

 

INTRODUCTION The United States federal Healthy People Initiative is intended to play a crucial, integrative role in guiding national, state, and local approaches to setting quantifiable health objectives and monitoring progress. First conceptualized in 1979, when working toward health targets was a new concept in health policy, Healthy People was strategically envisioned as a national mechanism for action and investment prioritization through the identification and measurement of progress towards a common set of major health objectives.1 From that point forward, this process has continued to define a set of national health objectives at the beginning of each decade, with specific targets for the end of the decade. The Healthy People goals and objectives have the potential to serve as a call to action to states and local authorities because they are issued by the federal government and are linked to national health statistics. Although Healthy People does not carry statutory authority to direct the activities of or hold accountable components of the US health system, it constitutes a detailed framework and plan for improving the Nation’s health and can be adopted for use in policies and programs. The objectives and targets address health and health care issues across a broad spectrum. They can be used for assessing and reporting progress within and across local and state jurisdictions, as well as at the federal level. For example, an authoritative annual reporting of county level health rankings relies heavily on Healthy People objectives and targets for benchmarking.2 The effectiveness of Healthy People has been measured by comparing initial status (baseline data) with mid-course and final assessments made at the national level to determine how much change actually has occurred over the decade and whether targets actually have been achieved.3-5 Of note, these assessments have often revealed a lack of progress toward many targets and a widening of health disparities in relation to many health indicators (see Table 1). The lack of progress raises awareness of the weaknesses of the US health care system and questions the ability of Healthy People to overcome these weaknesses. 3 U.S. Healthy People 2020 Initiative Table 1 Most Current Data on Achievement of Past Healthy People Objectives during the Development of Healthy People 2020 Progressed Toward Target Showed no Progress or Regressed from Target Data Unavailable 32% 34% 11% 23% 319 21% 41% 17% 10% 467 6% 30% 16% 40% Most Recent Data Source Number of Achieved Objectives/ Target Targets 1990 Health Objectives (Final Review) NCHS, 1992 226 objectives, 266 targets* Healthy People 2000 (Final review) NCHS, 2001 Healthy People 2010 (Midcourse Review) DHHS, 2006** * All percentages for the 1990 Health objectives reflect attainment of the 266 measured targets. ** Percentages for Healthy People 2010 objectives do not add up to 100% in this table because 12 percent of objectives (57 out of 467) showed mixed progress and have been excluded. MMHA6700 Health Care Reform Initiatives Discussion

 

NCHS = National Center for Health Statistics DHHS = Department of Health and Human Services Source: Phase I Report Recommendations for the Framework and Format of Healthy People 2020. Section III. Available from URL: http://www.healthypeople.gov/2010/hp2020/advisory/ PhaseI/sec3.htm (Accessed 16 December 2013).5 A detailed analysis of the history and evolution of the Healthy People initiative has previously been published. In that review Green and Fielding describe the relationship of the US initiative to global developments in health promotion and disease prevention and the nature of the continuing efforts to address gaps in baseline data, clarify the process for setting objectives and targets and improve effectiveness in other ways.6 This article describes the development of the most recent version of this initiative, Healthy People 2020, from the perspectives of three members of an external committee appointed to guide the process: The Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020 (hereafter, “SAC”). We describe the SAC process for developing * Secretary of the U.S. Department of Human and Human Services 4 Public Health Reviews, Vol. 35, No 1 recommendations about new features that could update the overall frame­ work in light of the evolution of national thinking about health and disease and address criticisms of past versions. We describe the key design features of the 2020 initiative that emanated from SAC recommendations and some of the thinking that led to them. Finally, we show how Healthy People 2020 articulates directly with the most recent key developments in the US public health and health care arenas: the Patient Protection and Affordable Care Act7 and the recent National Prevention Strategy.8 DEVELOPMENT OF HEALTHY PEOPLE 2020: THE PROCESS The Healthy People 2020 development process took place over approximately three years, led by federal staff within the Office of Disease Prevention and Health Promotion of the Department of Health and Human Services (DHHS). Preparatory work included the conduct of a Healthy People User Study, an independent evaluation of prior iterations of Healthy People.9 This provided, from the outset, a list of questions, concerns, and recommendations related to how the program might be improved. For example, users at state and local levels indicated that the lack of specific guidance on how to implement objectives was a major weakness of prior versions of Healthy People. Other key concerns related to the escalating number of objectives, the lack of transparency in setting targets, and the difficulty of using the printed form of Healthy People, which consisted of heavy, difficult to use volumes. DHHS convened a Federal Interagency Working Group comprising, in addition to staff from the Public Health Service, other staff from a range of federal agencies whose missions and activities influence health, e.g., departments of agriculture, education, housing and urban development, justice, interior, and veterans affairs, and the environmental protection agency. The Federal Interagency Working Group reviewed and commented on draft proposals. The public phase of the process began late in 2007 with the solicitation of nominations for the SAC. Whereas prior advisors had been drawn from within the Public Health Service, the DHHS leadership sought input that was external to government and would allow an increased level of public input, and obtained a charter authorizing formation of a public advisory committee charged with making recommendations to the Secretary of DHHS. Thirteen SAC members were chosen from a large pool of nominees, of whom all except one were able to serve throughout. MMHA6700 Health Care Reform Initiatives Discussion

 

These 12 advisors together brought diverse expertise and perspectives. SAC members served as individuals rather than as representatives of organizations or advocates U.S. Healthy People 2020 Initiative 5 for specific positions. The SAC was charged with providing advice on developing goals, objectives, and initiatives to facilitate implementation of this critical federal initiative.10 By law, the SAC operated under the Federal Advisory Committee Act (FACA) rules that require a transparent process in which all key deliberations and decisions took place in a public forum and there were formal opportunities for input from members of the public, e.g., in the form of written or oral comments at national and regional meetings. The SAC advised throughout the development process, beginning in January 2008 and continuing until 2011, approximately one year after Healthy People 2020 was launched. The SAC convened several well-attended in-person public meetings and numerous web-based teleconferences and formed subcommittees and ad hoc working groups to consider selected issues in depth; these sub­ committees could and did involve experts from outside of the SAC. SAC members also participated in regional public hearings convened by DHHS staff. Thus, in addition to the results of the User Study, SAC deliberations were informed by concurrent feedback obtained at public meetings and through voluminous written comments posted on the advertised website that was designed for this purpose. In the remainder of this article, we describe the results of the Healthy People 2020 development process. SAC perspectives and recommendations were issued in a series of written reports and recommendations (see Table 2). Through these reports, the SAC provided perspectives on the role and function of the Healthy People program, its vision, mission, overarching goals, and the structure of the objectives, how targets should be defined, and ways to think about priority setting. The SAC identified several audiences (users) for Healthy People 2020 and considered the needs and perspectives of these different users, giving particular attention to users in states and local health agencies (see Table 3). User audiences were seen to go beyond those primary audiences who would seek out Healthy People 2020 guidance to include secondary audiences for whom Healthy People outreach would be appropriate. What ultimately became Healthy People 2020 reflected the Federal Interagency Working Group’s vetting and interpretation of the SAC guidance in the context of federal agency perspectives and realities. The series of SAC reports, containing specific recommendations, all of which are on the public record (see Table 2), became key steps in the Healthy People 2020 development process, along with the official release of draft objectives and public comment period that included regional public meetings. 6 Public Health Reviews, Vol. 35, No 1 Table 2 Key Issues Addressed and Guidance Provided by the Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020 Aspect or Issue Addressed Role and Function of Healthy People 2020 Guidance Provided by the Scientific Advisory Committee • Potential roles of HP and designed recommendations to allow HP2020 to serve the needs of several different potential audiences and users. See: Phase I Report. Recommendations for Framework and Format of Healthy People 2020. MMHA6700 Health Care Reform Initiatives Discussion

 

Section IV. Available from URL: http://www. healthypeople.gov/2010/hp2020/advisory/PhaseI/sec4.htm (Accessed 16 December 2013).5 • Recommended vision and mission statements and overarching goals for HP2020 as well as the HP2020 Action Model. The framework was designed to emphasize the importance of inter­vening on upstream determinants of health and disease throughout the life course to prevent behavioral risk factors, promote well-being and health-related quality of life, and achieve equity, in addition to the traditional focus on specific diseases or injuries. See: Phase I Report. Recommendations for the Framework and Format of Healthy People 2020. Available from URL: http://www.healthypeople.gov/ 2010/hp2020/advisory/PhaseI/default.htm (Accessed 16 December 2013).5 Societal • Definitions and descriptions of health determinants in physical, social Determinants of and economic environments; recommendation that these be addressed to Health, Health prevent fundamental causes of diseases, reduce disparities, and achieve Disparities, and health equity. Recommendation for a “health in all policies” approach Health Equity involving collaboration among different branches of government to reach those outside of the health sector with authority and resources for addressing societal determinants. See: Healthy People 2020: An opportunity to address societal determinants of health in the United States. Available from URL: http://www. healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHealth.htm (Accessed 16 December 2013)18; and Koh HK, Piotrowski JJ, Kumanyika S, Fielding JE. Healthy people: a 2020 vision for the social determinants approach. Health Educ Behav. 2011;38:551-7.19 • Recommendation for a specific definition of health disparities linked to social disadvantage as a measure of the extent to which health equity is being achieved. See: Braveman PA, Kumanyika S, Fielding J, Laveist T, Borrell LN, Manderscheid R, Troutman A. Health disparities and health equity: the issue is justice. Am J Public Health. 2011;101:S149-55.15 U.S. Healthy People 2020 Initiative 7 Table 2 contd. Priority setting • Guidance about considerations and approaches for use in setting priorities among HP2020 objectives. See: Phase I Report. Recommendations for the Framework and Format of Healthy People 2020. Appendix 14. Explanation of prioritization criteria for sorting objectives. Available from URL: http://www.healthypeople.gov/ 2010/hp2020/advisory/PhaseI/appendix14.htm (Accessed 16 December 2013).5 Guidance for • Detailed report on ways to evaluate sources of knowledge to support Implementation evidence-based actions offered and recommended a realistic but rigorous approach to ensuring that implementation strategies for HP are grounded in science. See: Evidence-Based Clinical and Public Health: Generating and Applying the Evidence. Available frpm URL: http://www.healthypeople.gov/2010/ hp2020/advisory/EvidenceBasedClinicalPH2010.htm (Accessed 16 December 2013)23; and Recommendations on Action Steps and Evidence for Healthy People 2020. Available from URL: http://www.healthypeople. gov/2010/hp2020/advisory/ASERecommendations2010.htm (Accessed 16 December 2013).29 • List of recommendations for immediate and long term actions to ensure the adoption and effectiveness of HP efforts. MMHA6700 Health Care Reform Initiatives Discussion

 

See: Recommendations for Implementing Healthy People 2020. Available from URL: http://www.healthypeople.gov/2010/hp2020/advisory/FACA_ ImplemRecommendations.htm (Accessed 16 December 2013).24 Leading Health Indicators (LHIs) • Fourteen measures and associated objectives for use in monitoring achievements at the national level, as well as state and local comparisons; informed by the National Prevention Strategy and also with health indicators recommended by an Institute of Medicine Committee. See: Recommendations for Leading Health Indicators for Healthy People 2020. Available from URL: http://www.healthypeople.gov/2020/about/ advisory/LHI_Recommendations_Memo.pdf (Accessed 16 December 2013).30 8 Public Health Reviews, Vol. 35, No 1 Table 3 Healthy People 2020 Audiences and their Information Needs Primary Audience/User Group What they should know about Healthy People 2020 Federal agencies; State and Local health departments; • Relevance of HP to their audiences Professional associations, societies; • Uses of HP for planning, program management, Advocacy organizations; development, evaluation Philanthropies Academics, research and development organizations Secondary Audience/User Group Policy Organizations/Entities State and local elected officials Faith-based organizations General public, community based organizations, voluntary organizations, those familiar with community needs Business/private sector Health care (industry, community health centers, professionals, workers) • Why and how they should share HP with their students • How to align research with HP objectives • Why translational and applied research (especially community-based participatory) are important to achieving and monitoring HP objectives What they should know about Healthy People 2020 • Relevance of HP to health and health care literacy • Why HP should be on the legislative agenda • How HP can help identify the most important policy changes for improving health and reducing disease and injury burden in your area • How health indicators in your area compare with others • Why HP is relevant to your organization’s members • How members can be more informed of issues within HP • How organizations can get involved with HP • How HP can offer guidance for personal decisions (being informed of risk factors, diseases, being able to answer the question, «What can I do?») • How to become involved with HP • How HP can offer guidance for promoting worksite health • How to become involved with HP • Relevance of HP to their audiences (mediated communication) • Uses of HP for planning, program management, development, evaluation Source: Adapted from Phase I Report. Recommendations for the Framework and Format of Healthy People 2020. Section V. Guidelines for implementation of Healthy People 2020. Exhibit 6. Communicating about Healthy People 2020 with key audiences. Available from URL: http://www.healthypeople.gov/2010/hp2020/advisory/PhaseI/sec5.htm (Accessed 16 December 2013).5 U.S. Healthy People 2020 Initiative 9 DEVELOPMENT OF HEALTHY PEOPLE 2020: KEY STRATEGY FEATURES Healthy People 2020 can be viewed as a strategic approach for improving the health of the US population over a ten-year timeline, applicable natio…