Achieving Real Improvements In Americans' Health - Connecticut

striking gaps between how healthy Americans are and how healthy they .... less on health care than the United States does. ..... ronment, and transportation.

After Health Reform By David R. Williams, Mark B. McClellan, and Alice M. Rivlin 10.1377/hlthaff.2010.0071 HEALTH AFFAIRS 29, NO. 8 (2010): 1481–1488 ©2010 Project HOPE— The People-to-People Health Foundation, Inc.


Beyond The Affordable Care Act: Achieving Real Improvements In Americans’ Health

David R. Williams (dwillia[email protected] is the Florence S. and Laura S. Norman Professor of Public Health and a professor of African and African American studies and of sociology at Harvard University, in Boston, Massachusetts.

Improved access to health care is essential if we are to fill the striking gaps between how healthy Americans are and how healthy they could be. But access alone is not enough. Health and longevity are also profoundly influenced by where and how Americans live, learn, work, and play. Recognizing this, the Robert Wood Johnson Foundation’s Commission to Build a Healthier America has identified concrete, feasible actions outside of medical care that constitute an urgent agenda for improving America’s health. These recommendations require action at all levels of society to promote development and health in childhood, good nutrition, and communities conducive to good health. ABSTRACT


ith the enactment of the Patient Protection and Affordable Care Act of 2010, estimates suggest that thirtytwo million Americans will acquire health insurance coverage by 2018. This would reduce the proportion of uninsured people to about 6 percent of the U.S. population. But expanded coverage alone will not make this a healthy nation. Although improved access to health care is essential, especially when people are already sick, reducing the risk of getting sick in the first place is even more important to improving the nation’s health.

A New Commission In 2008 the Robert Wood Johnson Foundation (RWJF) established the Commission to Build a Healthier America. The members of the commission represented business, labor, education, community development, health care services, philanthropy, media, research, and public policy. As a group, they were charged with identifying feasible solutions outside the traditional medical care system for improving the nation’s health. The commission reviewed existing research and solicited advice from a broad range of ex-

perts, innovators, stakeholders, and members of the public through hearings, public testimony, roundtable discussions, meetings with experts, and fact-finding site visits. The commission had additional consultations with elected officials and agency administrators; representatives of business, advocacy, professional, and policy organizations; and the public. The commission concluded that creating a healthy nation is an attainable goal. However, achieving the goal will require a national commitment to health and wellness for all Americans. Health must be incorporated into every aspect of society and daily life. That means nurturing children early in their lives, eating healthy food, getting sufficient exercise, and living in healthy homes and communities. These actions require individuals to accept responsibility for their own health and to make healthy choices. The commission found that for many people— particularly members of disadvantaged groups— it is not easy to choose health. Therefore, we must collectively take steps to support healthy choices for all. The commission also found that many paths lead toward a healthier future. These paths begin in homes, schools, workplaces, and communities. The commission documented effective ways to advance health through better nutrition, more August 2010


Mark B. McClellan is director of the Engelberg Center for Health Care Reform; senior fellow, Economic Studies; and Leonard D. Schaeffer Chair in Health Policy Studies, at the Brookings Institution, in Washington, D.C. He served as administrator of the Centers for Medicare and Medicaid Services in the George W. Bush administration. Alice M. Rivlin is a senior fellow, Economic Studies, and director of Greater Washington Research at the Brookings Institution. She was the first director of the Congressional Budget Office.

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After Health Reform exercise, improved community infrastructure, and, especially, enhanced early childhood experiences. The panel’s final report included ten recommendations that provide a high-level road map for moving forward.1 We summarize those recommendations, review their potential for improving our nation’s health, and describe policybased steps that can be taken immediately.

America’s Unrealized Health Potential Cross-National Comparisons Americans are far less healthy than they could be. Compared with other developed countries, the United States ranks low on many health indicators, and its relative position is slipping. In some respects—obesity is a prime example—Americans are becoming less healthy over time. Some experts predict a reversal of long-standing trends: Many of the next generation of Americans are likely to live shorter, sicker lives than their parents did.2 The health of many Americans is declining despite the fact that other countries spend far less on health care than the United States does. Indeed, the data indicate that our worsening health is a driver of higher medical costs.3 Relative Importance Of Medical Care There is no question that medical care is essential for relieving suffering and curing illness. But medical care prevents only 10–15 percent of premature deaths.4 Research shows that social factors such as education, income, and the quality of neighborhood environments play a much more important role in shaping our health than medical care does.5 For example, college graduates can expect to live five years longer than those who have not completed high school.6 And scientific evidence indicates that although poor health can reduce a person’s economic resources, it is equally true that income is an important driver of health.5 Other Contributors To Disparities Differences in income and education contribute to well-documented disparities in health among racial and ethnic groups.7 Moreover, although immigrants from the major racial and ethnic groups initially enjoy better health than their native-born counterparts, this health advantage declines as the length of their stay in the United States increases and with the passage of generations.7 Health gaps between the United States and other developed countries are not limited to poor Americans and those with little education. The gaps shrink but persist with each increase in income and education level. Even the best-off 1482

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Americans are behind citizens of other countries on key measures of health. Analyses conducted for the commission found that American children and adults at all levels of education and income, and in every racial and ethnic group, fell below an attainable national benchmark of good health.8,9 These shortfalls were evident even in the states that fared best in overall health. These findings demonstrate a tremendous unrealized potential. If all Americans are enabled to become as healthy as those in the healthiest groups, major improvements could be accomplished. Effects On U.S. Productivity Deficiencies in health not only cause unnecessary suffering and premature death but also affect our nation’s productivity. When people are sick, they can’t function as well at school, home, or work as when they are healthy. Nearly one in three low-income American adults is functionally limited by chronic illness.6 Especially now, as the nation struggles to regain its economic footing, it is important to consider the health shortfalls in our workforce. An analysis commissioned by the RWJF estimates that if all Americans enjoyed the same level of good health as college graduates, the national economy would achieve annual average savings of $1 trillion in health care expenses.6 Longer and healthier lives would result in higher worker productivity, reduced spending on social programs, and increases in tax revenues. Another recent report placed the annual price tag of racial and ethnic disparities in health at $309 billion.10 Example: Obesity The costs of our nation’s obesity epidemic illustrate this economic burden. According to the Partnership to Fight Chronic Disease, the doubling of obesity in the United States since 1987 accounts for nearly 30 percent of the increase in health care spending.11 Furthermore, obesity-related costs—such as those stemming from the increased incidence of diabetes and heart disease—are expected to continue rising. According to a recent study, if current trends continue, within twenty-five years there will be more than forty-four million Americans with diabetes, and the annual cost of caring for them will triple to $336 billion, in 2007 dollars.3

Closing The Gaps In Health Closing America’s health gaps requires a commitment to a broad view of the needed improvements. The recent health reform debate highlighted the importance of preventing illness, and the resulting Patient Protection and Afford-

The most important prevention activities occur outside the traditional medical care setting.

able Care Act places increased emphasis on both preventive and primary health care. However, the Commission to Build a Healthier America concluded that the most important prevention activities occur outside the traditional medical care setting, in the places where we live, learn, work, play, and worship. What most influences population health are the consequences of the actions we take and the choices we make in the course of our daily lives, such as how we raise our children, what food we eat, how physically active we are, whether we smoke, and the safety and health of the neighborhoods we live in.12 Social factors begin influencing our health very early in life. Brain, cognitive, and behavioral development in early childhood are strongly linked to an array of important health outcomes later in life, including cardiovascular disease, diabetes, obesity, drug use, and depression. Children who do not receive high-quality supportive care and education begin life with a distinct disadvantage and have a higher risk of becoming unhealthy adults.13 Importance Of Education It has been well established that education plays a key role in economic well-being, but the profound effects that education has on health are less widely recognized.6 People with more education not only live longer, but they also lead substantially healthier lives than people who have less education.6 Education is associated with opportunities that steer people toward better health. More education typically means higher-paying employment with better benefits, including health insurance. The more education parents have, the better able they are to purchase nutritious food; give their children secure child care; provide leisure activities that can reduce the negative health effects of stress; and buy homes in safer, healthier neighborhoods with parks and sidewalks.13 Conversely, limited education is linked to lower-paying jobs, inadequate health insurance, higher levels of stress that can affect health, and

fewer resources for making such healthy choices as engaging in regular physical activity and eating nutritious food. Everyday life can be an allconsuming struggle for the less educated, leaving little or no time, money, or energy to adopt a healthier lifestyle, and even reducing personal motivation for doing so.6 The opportunities created by education are lifelong and often cross generations. Bettereducated parents are better equipped to raise healthy youngsters, and better-educated children are better prepared to achieve and maintain good health for themselves. The same is true of income. Parents with higher incomes pass on to their children certain health advantages and opportunities that parents with lower incomes frequently cannot.6 The impacts of education and income show that good health is not achieved primarily in hospitals and doctors’ offices. Rather, better education and income are associated with differences in how we live our daily lives, which in turn profoundly influence health. Culture Of Health Living healthier lives also requires the creation of a culture of health. In much the same way that America is going “green” to combat global climate change, the nation must better incorporate health into its homes, schools, neighborhoods, and workplaces. This requires that we as a nation embrace a broad vision of health and take responsibility for decisions that support good health. It also requires commitment from leaders in the private and public sectors to support appropriate decisions, not only in the area of health care delivery, but also in the spheres of education, business, and community planning. The commission reached two main conclusions, which became the long-term goals set forth in its report. First, individuals can and must take responsibility for improvements in their own health. Second, society must create conditions that will help people make healthy choices. Many people live and work in circumstances and places that make healthy living extremely difficult. Our society’s leaders and major institutions must create incentives and lower barriers, to bring better health within everyone’s reach.

Recommendations For Policy


Categories Of Recommendations The commission’s nine specific recommendations fell into three categories: (1) promoting early childhood education; (2) promoting good nutrition for all ages; and (3) promoting healthy communities.

In addition to setting its two long-term goals, the commission identified many steps toward better health that can be taken immediately. It made nine recommendations for immediate action, which fall into three main categories: promoting early childhood development and health; promoting good nutrition for Americans of all ages; August 2010


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After Health Reform and promoting healthy communities. A tenth, overarching recommendation emphasizes the need for reliable data, evaluation, and research to promote accountability for outcomes and identify the most successful methods of reaching the goals. Promote Early Childhood Health And Development Three of the commission’s recommendations support this goal: Ensure that all children have high-quality early developmental support, especially in child care and education— which will require substantial additional resources, especially for children in low-income families; provide only healthy food for children in schools; and require all schools from kindergarten through grade 12 to include daily physical activities for students. ▸▸ SUPPORT IN EARLY CHILDHOOD : The strongest supporting evidence that the commission found for the lasting effect of interventions on the quality of health and life had to do with programs that promote early childhood development and that support children and families. Therefore, many of the commission’s general and specific recommendations aimed to ensure that children have the best possible start in life and health. More than forty years of research provides overwhelming evidence that children who participate in high-quality development programs early in life reap many benefits, including greater academic achievement and better socioeconomic outcomes. Moreover, these programs are cost-effective and lead to better daily habits, with direct implications for better health.13,14 Thus, greater support for early childhood developmental programs that have proven effects on short-term outcomes, such as cognitive development, could be the most important health policy change that the nation could undertake. In this context, it is laudable that President Barack Obama proposed the Early Learning Challenge Fund, which would have provided $8 billion over ten years to help states raise the quality of early education programs for children up to age five. This proposal was unfortunately not incorporated into the Affordable Care Act. However, the administration remains committed to funding early childhood learning. Rep. George Miller (D-CA), chair of the House Education and Labor Committee, introduced a bill in September 2009 that would provide $10 billion over ten years to give states incentives to establish high-quality early learning programs. ▸▸ CHILDHOOD OBESITY : Meanwhile, the epidemic of childhood obesity, without a doubt the single greatest threat to our children’s health, is receiving increased attention. Some twelve million U.S. children and adolescents are obese, and 1484

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Greater support for early childhood developmental programs could be the most important health policy change that the nation could undertake.

more than twenty-three million are either obese or overweight.15 Obese children are more likely than other children to become obese adults, suffer from poor health, and die at an earlier age. The challenge has given rise to First Lady Michelle Obama’s “Let’s Move” campaign, which aims to end the epidemic by increasing understanding of nutrition, encouraging schools to provide healthier food, and promoting physical activity. The commission’s main recommendations in this area targeted schools because of how much time children spend in school, and because policy makers can influence what goes on at school. Moreover, a growing body of research indicates that school-based interventions can be effective in increasing physical activity and healthy eating and in preventing overweight and obesity.16,17 ▸▸ EMPHASIS ON FOOD AND ACTIVITY : The most important intervention is requiring schools to offer only nutritious food. Junk food should not be available, and schools should ensure that all of the meals they provide meet the Dietary Guidelines for Americans of the Department of Health and Human Services (HHS).18 Next, schools must do more to help children increase their physical activity through physical education programs, recess that allows physical activity and movement, and recreational activities during and after school. Although children should be physically active for at least one hour each day, only one-third of high school students currently meet this goal.19 Federal and state funding for education should be linked to schools’ making sure that all children achieve at least half of their daily recommended physical activity at school and, over time, should be linked to reductions in childhood obesity rates. Promote Good Nutrition Two of the commission’s recommendations supported this

An area badly in need of cooperative efforts by the public and private sectors is smoking cessation.

goal. First, the panel urged creation of publicprivate partnerships to open and manage fullservice grocery stores in communities without access to healthful food. Second, the commission recommended that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, meet hungry families’ need for nutritious food. ▸▸ PUBLIC - SECTOR INITIATIVES : Not all Americans have ready access to fresh and nutritious food. The WIC program serves half of all U.S. infants, and SNAP provides nutritional assistance to thirty-one million low-income Americans.1 Funding for these federal food programs should be expanded to provide benefits to everyone who needs them, to enable people to purchase sufficient nutritious food. ▸▸ PUBLIC - PRIVATE PARTNERSHIPS : To expand access to healthy food choices, governments and communities can work with private businesses to make fresh and nutritious food more available in poor neighborhoods. Evidence indicates that increased access to affordable, nutritious food at the community level is associated with healthier diets and lower rates of obesity.20 The Fresh Food Financing Initiative in Pennsylvania, a collaborative that has established grocery stores in poor neighborhoods to provide access to fresh food, is an example of a highly successful public-private partnership. The initiative not only expands community residents’ choices of healthy food, but it also supports community development by bringing in new jobs, improving economic sustainability, and increasing safety. These latter measures in turn make it more likely that residents will get more exercise by walking in their neighborhoods.20 Similar collaborations are being established in other locales. Last fall, New York City announced a proposal for a public-private initiative similar to Pennsylvania’s. More recently, the U.S. Departments of the Treasury, Agriculture, and Health and Human Services announced the

Healthy Food Financing Initiative. A $400 million national version of the Pennsylvania program, it seeks to eliminate “food deserts” across the country within the next seven years. Designed to work in concert with the “Let’s Move” campaign, the initiative is a model for a new approach to health by the federal government. Promote Healthy Communities Four of the commission’s recommendations supported this goal. They are as follows: integrating safety and wellness into every aspect of community life, including schools, workplaces, religious institutions, and neighborhoods; creating “healthy community” demonstration projects to evaluate the effects of a range of policies and programs; developing a “health impact” rating system for housing and infrastructure projects that provides incentives for projects to increase community health; and eliminating smoking. ▸▸ WORKING ACROSS AGENCIES : Because health is influenced by so many daily choices, it needs to be a factor in all policy making, including decisions about transportation, housing, education, and community planning. This means working across conventional policy silos to engage in cross-sector partnerships and solutions. At the federal level, there are a growing number of examples of new cooperative health efforts across departments. In September 2009 Kathleen Sebelius, the HHS secretary, announced a community prevention and wellness initiative, supported by $650 million in federal funds. The money will be used to promote more physical activity, better nutrition, and reductions in obesity and smoking. In 2009, acting Surgeon General Steven K. Galson issued a call to action to promote healthy homes with a strategic plan from the Department of Housing and Urban Development accompanying the HHS initiative that describes the steps needed to achieve healthier housing.21 In introducing the initiative, Secretary Sebelius said that healthy homes can lead to healthier lives. The Department of Housing and Urban Development, the Department of Transportation, and the Environmental Protection Agency have launched a collaboration to create healthier, more livable cities. The new interagency partnership will coordinate federal investments in transportation, environmental protection, and housing to make neighborhoods safer, healthier, and more vibrant. ▸▸ LOCAL EFFORTS : Although the report of the Commission to Build a Healthier America urged the federal government to take actions that encourage healthy choices, local communities— together with businesses and nonprofit organiAugust 2010


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After Health Reform zations—must also work to integrate health into their policies and programs. One such effort is a new national initiative from the RWJF and the Pew Charitable Trusts, the Health Impact Project. The initiative is designed to promote health impact assessments as a decision-making tool for policy makers. Health impact assessments are increasingly being used to bring together relevant public input and data from multiple sources. The assessments employ an array of qualitative and quantitative methods to anticipate the potential health consequences of a proposed policy, program, or project.22 However, although the assessments promise to highlight the health effects of policies outside the health care system, their effectiveness has not been rigorously evaluated. ▸▸ SMOKING CESSATION : An area badly in need of cooperative efforts by the public and private sectors is smoking cessation. Despite declines in cigarette use, smoking still causes more deaths annually in the United States than overweight, obesity, high cholesterol, excessive alcohol consumption, and low intake of fruit and vegetables combined.12 Lung cancer is the number-one cause of cancer deaths for both men and women in the United States, killing more people annually than breast, prostate, colon, and pancreatic cancer combined.23 Progress has occurred on many fronts, including ordinances for clean indoor air and smokefree workplaces, tobacco tax increases, and effective, affordable assistance for smokers who want to quit. These activities suggest that the goal of a smoke-free society is achievable.

Creating Accountability For Success In searching for ways to improve the nation’s health, the commission focused on practical, commonsense approaches that show promising results and that can be implemented quickly. America’s health needs to be improved now, not five or ten years from now. That said, some of the specific approaches identified in the commission’s report require rigorous evaluation and replication to assess their impact. The commission explicitly underscored this necessity in its final recommendation: Ensure that decision makers at all levels have the evidence they need to build health into public and private policies and practices. Any public support for a program to improve health should be tied to a demonstration of its positive impact, either on measures of population health or on intermediate results, such as higher educational achievement, that are strongly related to improved population health. Electronic data systems are making such mea1486

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America’s health needs to be improved now, not five or ten years from now.

sures increasingly available. Greater attention to evidence and results will make it easier to direct limited public resources to the programs that have the most potential for improving health.

A Healthier Future For America When the Commission to Build a Healthier America was formed in 2008, health reform discussions focused on health care costs, access to physicians, and insurance coverage. In 2010, the national discussion about what is needed to improve health is changing. More attention is being paid to the role of prevention and the potential health impact of public policy making in all spheres, and not just with respect to health care. Beyond Health Care The commission’s report underscores the fact that reform of the nation’s health care system is a critical, but insufficient, step toward greater health for all Americans. It compiles the evidence on the links between health and social factors—such as those having to do with education, housing, the environment, and transportation. It provides a blueprint for how decision makers can turn their concerns about the impact of social factors on health into action. The challenge of making the United States as healthy as it can—and should—be may seem daunting, especially when we realize how far beyond health care we need to go. Yet stakeholders are already coming together to remove the obstacles in other spheres that prevent individuals from making healthy choices. The commission saw many examples of promising approaches from around the country to improving health that involved practical, feasible steps that individuals and families can take in their everyday lives and that can be encouraged by effective public- and private-sector programs, policies, and initiatives. These pockets of success give us cause for optimism. They indicate that improved health and reduced health disparities are, in fact, within our reach. Hence, the commission strongly endorsed even more vigorous actions to support better

health for all Americans. These will require bringing public and private resources to bear in all aspects of daily life, as well as a concerted focus on those who are farthest behind on the road to optimal health. To be fully effective, programs and policies will need to be rigorously evaluated and replicated, not merely implemented. Stakeholders will need to support increasing the scale and geographic spread of the most successful efforts. Conclusion A great deal of hard work lies

ahead. Although improving access to and rethinking health care is necessary, we must do more than that. We need to modify where and how Americans live, learn, work, and play. We have strong evidence that major strides can be made outside of medical care, and clear opportunities exist to implement, refine, and expand proven strategies. With informed choices on the part of individuals and policy makers, all Americans can have a healthier future. ▪

Preparation of this paper was supported in part by a grant from the Robert Wood Johnson Foundation. The authors thank Mary Darby and Veronic Aghayan for their assistance in preparing the manuscript.

NOTES 1 Robert Wood Johnson Foundation Commission to Build a Healthier America. Beyond health care: new directions to a healthier America [Internet]. Washington (DC): The Commission; 2009 Apr [cited 2010 Apr 21]. Available from: http:// Report.aspx?Publication=64498 2 Olshansky SJ, Passaro DJ, Hershow RC, Lyden J, Carnes BA, Brody J, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005;352(11):1138–45. 3 Huang ES, Basu A, O’Grady M, Capretta JC. Projecting the future diabetes population size and related costs for the U.S. Diabetes Care. 2009;32(12):2225–9. 4 McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21(2):78–93. 5 Smedley B, Syme SL. Promoting health. Washington (DC): National Academies Press; 2000. 6 Braveman P, Egerter S. Overcoming obstacles to health: report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America [Internet]. Princeton (NJ): Robert Wood Johnson Foundation; 2008 Feb [cited 2010 Apr 21]. Available from: http://www ObstaclesToHealth-Report.pdf 7 Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010 Feb;1186:69–101. 8 Egerter S, Braveman P, Cubbin C, Dekker M, Sadegh-Nobari T, An J, et al. Reaching America’s health potential: a state-by-state look at





adult health [Internet]. Washington (DC): Robert Wood Johnson Foundation Commission to Build a Healthier America; 2009 May [cited 2010 Apr 21]. Available from: http:// PDF/d472ee9d-f880-4d04-8358397977f93447/CBHA_AdultHealth Chartbook.pdf Egerter S, Braveman P, Pamuk E, Cubbin C, Dekker M, Pedregon V, et al. America’s health starts with healthy children: how do states compare? [Internet]. Washington (DC): Robert Wood Johnson Foundation Commission to Build a Healthier America; 2008 Oct [cited 2010 Apr 21]. Available from: http:// PDF/819a3435-8bbb-4549-94db7758248075cf/ChildrensHealth_ Chartbook.pdf LaVeist TA, Gaskin DJ, Richard P. The economic burden of health inequalities in the United States. Washington (DC): Joint Center for Political and Economic Studies; 2009. Partnership to Fight Chronic Disease. The 2009 almanac of chronic disease [Internet]. Washington (DC): The Partnership; 2009 [cited 2010 Apr 21]. Available from: http:// 2009AlmanacofChronicDisease_ updated81009.pdf Goodarz D, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJL, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PloS Med [serial on the Internet]. 2009 Apr 28 [cited 2010 Apr 22]; 6(4):e1000058. Available from: http://www 3Adoi%2F10.1371%2Fjournal .pmed.1000058

13 Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA. 2009; 301(21):2252–9. 14 Heckman JJ. Skill formation and the economics of investing in disadvantaged children. Science. 2006; 312(5782):1900–2. 15 Ogden CL, Carroll MD, Flegal KM. High body mass index for age among U.S. children and adolescents, 2003–2006. JAMA. 2008;303(3): 242–9. 16 Story M, Nanney MS, Schwartz MB. Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity. Milbank Q. 2009;87(1):71–100. 17 Foster GD, Sherman S, Borradaile KE, Grundy KM, Vander Veur SS, Nachmani J, et al. A policy-based school intervention to prevent overweight and obesity. Pediatrics. 2008; 121(4):e794–802. 18 U.S. Department of Health and Human Services, U.S. Department of Agriculture. Dietary guidelines for Americans, 2005. 6th ed. Washington (DC): U.S. Government Printing Office; 2005 Jan. 19 Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth risk behavior surveillance— United States, 2007. MMWR Surveill Summ. 2008;57(4):1–131. 20 Giang T, Karpyn A, Laurison HB, Hillier A, Perry RD. Closing the grocery gap in underserved communities: the creation of the Pennsylvania Fresh Food Financing Initiative. J Public Health Manag Prac. 2008;14(3):272–9. 21 U.S. Department of Health and Human Services [Internet]. Washington

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After Health Reform (DC): DHHS. Press release, Acting surgeon general issues “call to action to promote healthy homes”; 2009 Jun 9 [cited 2010 Jul 9]. Available from:

press/2009pres/06/ 20090609a.html 22 Dannenberg AL, Bhatia R, Cole BL, Heaton SK, Feldman JD, Rutt CD. Use of health impact assessment in

the U.S.: 27 case studies, 1999–2007. Am J Prev Med. 2008;34(3):241–56. 23 American Cancer Society. Cancer facts and figures 2010. Atlanta (GA): The Society; 2010.


David R. Williams is a professor at Harvard University.

David R. Williams is the Florence S. and Laura S. Norman Professor of Public Health and a professor of African and African American studies and of sociology at Harvard University. His research, which focuses on social influences on health, has led him to author more than 230 scholarly papers. Active on more than fifty committees and boards since 1992, Williams served during 2006–9 as staff director of the Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier America. He received a master of public health degree from Loma Linda University, and master’s and doctoral degrees in sociology from the University of Michigan, Ann Arbor.

Healthier America. McClellan is director of the Engelberg Center for Health Care Reform; senior fellow, Economic Studies; and Leonard D. Schaeffer Chair in Health Policy Studies, all at the Brookings Institution. He previously served as administrator of the Centers for Medicare and Medicaid Services (2004–6); commissioner of the Food and Drug Administration (2002–4); senior director for health care policy at the White House under President George W. Bush (2001–2); and deputy assistant secretary for economic policy at the Treasury Department during the Clinton administration (1998–99). A former educator and practicing physician, McClellan received his medical degree from the HarvardMIT Division of Health Science and Technology, and he completed his residency in internal medicine at Brigham and Women’s Hospital. McClellan also holds a master’s degree from Harvard University’s Kennedy School of Government and a Ph.D. in economics from the Massachusetts Institute of Technology.

Mark B. McClellan is a senior fellow at the Brookings Institution.

Mark B. McClellan and Alice Rivlin served as cochairs of the RWJF Commission to Build a


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Alice M. Rivlin directs the Greater Washington Research Project at the Brookings Institution.

Rivlin is a senior fellow,

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Economic Studies, at the Brookings Institution, where she directs the Greater Washington Research Project; she also is a visiting professor at the Public Policy Institute of Georgetown University. Rivlin was the founding director of the Congressional Budget Office, where she served from 1975 to 1983. She was assistant secretary for planning and evaluation at the former Department of Health, Education, and Welfare from 1968 to 1969. Under President Bill Clinton, she served from 1994 to 1996 as director of the White House Office of Management and Budget, and she was vice chairman of the Federal Reserve from 1996 to 1999. In 2010 she was named by President Barack Obama to the Commission on Fiscal Responsibility and Reform. She received her doctorate in economics from Radcliffe College. In Williams’s words, the RWJF commission reached clear consensus on the notion that “America needs to build health into all aspects of our communities and society.” That means transforming a culture that, “in many ways, encourages ill health,” he adds. The goal of the commission’s report was “to illustrate that the problem is not so complex that we cannot begin to address it. And we can do so in ways that improve health in years, not decades.”

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