 While most reporting on the recent national health reform debate in the United States emphasized its expansion of coverage, efforts at cost containment, requirement to purchase insurance (with subsidies for those needing help), and new federal regulation of the insurance industry, some of the most important long-term impacts of the Patient Protection and Affordable Care Act of 20101 may spring from less noticed provisions, particularly those focused on prevention, health promotion and integrative care.
Prevention has two major components. The first, early disease detection, is addressed in the new law with provisions requiring both private and public insurance plans to cover—with no payments required from patients—all screening methods rated A or B by the U.S. Preventive Services Task Force. This includes dozens of procedures ranging from blood pressure and lipid level monitoring to tests for colorectal cancer and sexually transmitted diseases. The reasoning is that if more people are screened and more cases of disease are detected earlier as a result, many people will live longer and with a better quality of life. While it is not clear that this saves money overall (since screening, subsequent treatments and longer lives add to the system’s costs, even as savings accrue from preventing or minimizing illness), it is widely agreed by people across the political spectrum that such a prevention-oriented policy is justified on moral grounds.
Lifestyle-Based Health Promotion
The second, and in the long run the most important aspect of prevention is lifestyle-based health promotion, primarily in the form of a healthy diet, regular exercise and stress management. The goal here is to stop disease before it starts, and if that fails, to reverse its course or at least minimize the damage. The most fundamental health question we as a society face in the coming years is whether enough of us are willing to change behaviors that are harmful to our health and replace these with health-affirming choices. These individual decisions are at the heart of what Mark McClellan, Director of the Food and Drug Administration and later the Centers for Medicare and Medicaid Services under President George W. Bush, calls “consumer side reform.”2 If we aren’t willing to make such changes, neither reform nor regulation of the health insurance industry will save us from the consequences of our actions. But if enough of us are willing, we could be on the cusp of a great health renaissance.
Though the key choices ultimately rest with each individual, representative government can play an active and essential role as well, coordinating (in partnership with private and nonprofit sector health advocacy groups and associations of health professionals) a multifaceted, long-term campaign for the promotion of health. To some extent, this is nothing new. The Surgeon General, National Institutes of Health, Centers for Disease Control and Prevention, and many other federal and state agencies have a variety of programs in place (anti-smoking, anti-obesity, etc.) that pair noble aspirations with limited resources. Some of these programs, particularly on smoking cessation, have been very effective vehicles of change.
Confronting a Tidal Wave of Advertising
It is no secret that the positive messages from these prevention and health promotion initiatives have been drowned out for many decades by an ever-rising tidal wave of advertising from the manufacturers of junk food, alcohol, and prescription medications. Television programming in the United States is awash in ads for foods and beverages that promote illness and obesity, alongside ads for the pharmaceuticals used to treat the ailments these foods and beverages cause. The absence of any significant countervailing message urging viewers to seek out the vegetables, fruits and other whole foods known to be cornerstones of good health is more than a disgrace—it is a national tragedy. Most people believe what they are repeatedly told, especially when exposure to these expertly-crafted messages begins at an age when their capacity for critical thinking has not yet developed and matured.
Unless these patterns change in a major way very soon, the nation’s crippling rates of diabetes, heart disease, hypertension, obesity and cancer will implode our economy (as public and private health expenditures continue to rise at unsustainable rates), eventually endangering the very fabric of our society. To a significant extent, as informed people on all sides of the political landscape increasingly recognize, this implosion is already underway. The situation is very serious but not irreversible.
Bending the Arc
The new health reform legislation and the actions it seeks to catalyze may or may not ultimately reverse America’s alarming health trajectory. We may or may not be entering a new era of personal responsibility, where society moves toward a health paradigm based on prevention and health promotion. But clearly we must make the effort. As President Obama recently stated, quoting Abraham Lincoln, “I am not bound to win, but I am bound to be true. I am not bound to succeed, but I am bound to live by the light that I have.”
Many provisions in the new health reform law have the potential to bend the arc of current health trends in the right direction, particularly if accompanied by vigorous support at the highest levels of government and a plethora of coordinated and sustainably funded grassroots projects across the country. President Obama has gone out of his way on numerous occasions to emphasize the importance of prevention. First Lady Michelle Obama’s highly visible anti-obesity campaign and the Obama family’s organic vegetable and fruit garden at the White House also carry great iconic power. And within the agency most directly responsible for prevention and health promotion initiatives, Secretary of Health and Human Services Kathleen Sebelius has called for a major coordinated effort.
Structures for Coordination
The new reform law creates the organizational structures for such coordination. A potentially very important section (Section 4001) mandates the creation of a new National Prevention, Health Promotion and Public Health Council, within the Department of Health and Human Services. Chaired by the Surgeon General, this council will be a permanent policy coordinating body, unlike presidential or congressional commissions, which create reports and then disband. The council’s membership will be comprised of the top officials from a dozen federal agencies, including the Secretaries of Health and Human Services, Agriculture, Education, and Labor, and the Directors of the Federal Trade Commission and the Environmental Protection Agency.
Advising the council will be a presidentially appointed 25-member Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. The law specifically states that this advisory group must include “licensed integrative health practitioners” among its members. The council and advisory group were proposed by the White House Commission on Complementary and Alternative Medicine Policy in its landmark 2002 report,3 (and, at about the same time, by the National Policy Dialogue on Integrated Healthcare),4 as a permanent mechanism through which the commission’s recommendations on health promotion and integrative care could be implemented after the commission completed its work. Through the steadfast efforts of groups like the Integrated Healthcare Policy Consortium and the Samueli Institute (whose Wellness Initiative for the Nation5 laid the groundwork for key provisions in the new law), and with vital legislative support from Senators Tom Harkin (D-IA), Barbara Mikulski (D-MD), and Bernie Sanders (I-VT), that hope is now a reality.
The legal mandate for the council and advisory group is to “provide coordination and leadership at the Federal level, and among all Federal departments and agencies, with respect to prevention, wellness and health promotion practices, the public health system, and integrative health care in the United States.” Furthermore, it is tasked to “consider and propose evidence-based models, policies, and innovative approaches for the promotion of transformative models of prevention, integrative health, and public health on individual and community levels across the United States.”
Together, this council and advisory board could and should serve as a critical pivot point for operationalizing the paradigm shift we seek. Will they live up to their transformative potential? Nobody knows. Could they? Absolutely. Needless to say, organizational structures, flow charts, and legislative language have their limits. They mean little unless the structures and slots they create are filled with pragmatic visionaries able to reach a bold, wide-ranging, evidence-based consensus on needed action steps. But even that consensus will not be enough; after all, the general outlines of a national wellness and health promotion strategy have been known for years by experts in the field.
What has been missing is a lasting, coordinated commitment by governmental and non-governmental organizations across the board to apply this knowledge with the all-hands-on-deck urgency it merits, on a scale never before seen, through sustained community organizing programs on a nationwide basis. This is achievable, but no one expects it to be easy. Hopefully, we have now reached a tipping point where such long-needed action may come to fruition. The new reform law’s substantial expansion of the existing nationwide network of federally funded community health centers (which enjoy broad bipartisan support) provides one excellent mechanism for the delivery of prevention, health promotion, and integrative care services.
Carrots and Sticks
A successful national prevention and health promotion strategy will require both carrots and sticks. It must include massive and ongoing public education and public relations campaigns promoting a healthy lifestyle. More deeply incorporating evidence-based health messages into the curriculum of the nation’s schools (possibly including ‘healthy cooking’ and ‘healthy eating’ classes) should be an important part of this outreach. But we also need reasonable yet strict limits on the power of those who sell illness-inducing products. Enforcing such limits on purveyors of harmful beverages and foods may prove to be among the most challenging pieces of the puzzle. For example, should there be significantly increased taxes on sodas and other processed food products heavily laden with refined carbohydrates, salt, and fat, similar to taxes on tobacco? Should there be firm limits or bans on advertising junk food to children or to the population at large? America has for the most part refrained from taking such steps as its health crisis has metastasized.
Tobacco policy provides a clear precedent. Should we add disease and obesity-producing foods to the list? If so, where do we draw the lines? These and many other questions will test the mettle and creativity of those charged to develop and implement more effective health-affirming policies.
Peril and Possibility Revisited
For those of us in the United States, it is crucial that we not allow our disappointment with the imperfections of the health reform law (such as falling short of full universality, failure to sufficiently rein in the pharmaceutical industry and excessive reliance on for-profit insurance companies) to blind us to its significant strengths, particularly in the arenas of prevention, health promotion and integrative care.
We stand at a potentially transformative moment when the nation’s attention to health issues has reached a high pitch, one that is likely to continue as the various working parts of the new law go live over the next several years. Through its recognition of the scale of the perils we face, its emphasis on the fundamental role of prevention and health promotion, and its willingness to pursue new answers through a wide array of studies and projects (for which it allots significant funds), the Patient Protection and Affordable Care Act seeks to open doors that have previously been closed. It asks us all to imagine the possibilities.6
Integrative health practitioners (whose rights the new law expands with a hard-won provider nondiscrimination clause, Section 2706) can thrive in this milieu. Thinking holistically is at the core of our being. We embrace a worldview based on promoting balance of body and mind through natural methods of prevention and treatment. This is the common bond that unites our professions and undergirds their philosophical foundations. We know first-hand how it feels to pursue innovative solutions to vexing problems and to test them in the crucible of clinical practice and research, persistent in our quest to change not only health care but health consciousness.
We are now being called to take part in a great turning of the wheel. The task is daunting and the need is urgent. Let the new era begin.
Daniel Redwood, DC, is Associate Professor at Cleveland Chiropractic College–Kansas City and Editor-in-Chief of Health Insights Today and
The Daily HIT.
© 2010 The Journal of Alternative and Complementary Medicine
This editorial was published in the May 2010 issue of The Journal of Alternative and Complementary Medicine. It appears here with permission from the publisher, Mary Ann Liebert, Inc.
REFERENCES
- Patient Protection and Affordable Care Act. H.R. 3590, 2010. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf
- Klein E. Mark McClellan on the Affordable Care Act: ‘It’s an important step.’http://voices.washingtonpost.com/ezra-klein/2010/03/mark_mcclellan_on_the_affordab.html.
- Final Report: White House Commission on Complementary and Alternative Medicine Policy. Washington, DC. Department of Health and Human Services. NIH Publication 03-5411, 2002. http://whccamp.hhs.gov.
- Quinn S, Traub M. National Policy Dialogue to Advance Integrated Healthcare: Finding Common Ground. Integrated Healthcare Consortium, 2002. http://www.ihpc.info/resources/NPDFR.pdf.
- Wellness Initiative for the Nation. Alexandria, VA. Samueli Institute, 2009. http://www.samueliinstitute.org/news/news-home/WIN-Home/WIN-Download.html.
- Redwood D. The health reform moment: peril and possibility in the Obama era. J Altern Complement Med. 2009;15(1):1-3.
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