America is full of sick, wheezing, overweight, diabetic, unhealthy people. That’s not a stereotype: it’s science. We are a nation of heavy drinkers who eat breakfast burritos with one hand while driving to work with the other. A study by the National Research Council and the Institute of Medicine, published in 2013, found that Americans of all age groups have shorter life expectancies than their counterparts in other wealthy, developed nations. American babies are less likely to reach their first birthday than children in peer countries. The U.S. has the highest obesity rate and highest rate of death from heart disease of any developed country, and it had more drug-related deaths, more lung disease, and a higher incidence of AIDS, and also leads the developed world in such dubious categories as teen car crash deaths and gun violence.
For all this poor health, we pay more than any other country — Medicare actuaries estimate as much as 17 percent of our gross domestic product goes to healthcare, almost doubling the amount spent in other industrialized nations.
These are all statistics that James Marks can rattle off, pulling the numbers from his head as easily as from the giant file of studies he keeps in his office just a few hundred feet from the traffic bustling up and down Route 1 in the greater Princeton business community. The figures are especially troubling to Marks because as the senior vice president and director of program portfolios at the Robert Wood Johnson Foundation, it’s his job to do something about it. And if this problem is to be fixed, he believes, businesses will play a big part.
“Our nation is really going to have to come to grips with its high healthcare costs and poor healthcare outcomes relative to our competitors globally,” he says. “We have to have a culture where the business community recognizes health is important to it, and that they are important to health.”
The costs of poor health (and the benefits of good health) are measurable. According to a study by the University of Chicago, gains in life expectancy after 1900 were worth $1.2 million to the average American in 2000. Since 1970 healthcare improvement has added $3.2 trillion a year to the economy. Projecting into the future, even an improvement as small as a 1 percent reduction in cancer would be worth $500 billion.
Starting this month the RWJF will change the way it tries to make those gains. The foundation’s new “Building a Culture of Health” campaign focuses on different targets than the foundation has in the past.
The $9.2 billion Robert Wood Johnson Foundation, with its headquarters on Route 1 and College Road East, has had the goal of improving health since it was started more than 40 years ago by Robert Wood Johnson II as a small community foundation. Today the nonprofit group generates more than $400 million in grants a year with a nationwide reach. It is the country’s largest philanthropic group devoted exclusively to improving health and healthcare for Americans. Its grants go to hospitals, research, and advocacy efforts all around the country.
The foundation has a long history of using its financial clout to spur improvement in health and healthcare. RWJF signaled the direction its efforts would take early on. In 1973, as the country was struggling to implement a nationwide 911 system, RWJF gave funding to a Louisiana company called Acadian Ambulance. The company had radical ideas about emergency response. At the time there was no communication between ambulances and hospitals. Every ambulance that arrived at the hospital was a surprise to the staff. The idea of trained paramedics responding to an accident scene was a new one, and most of the time the only qualification an ambulance crew needed was a driver’s license. Slow, poorly coordinated responses to trauma victims cost many people their lives. People summoning help to the scene of an accident had to call the local fire department, the local ambulance, and the local police department separately, all on local numbers.
Acadian had the forward-thinking idea of equipping its units with two-way radios so they could coordinate with other emergency responders. RWJF, seeing a model that could be adopted all over the country, gave Acadian the money it needed to build the nation’s first emergency response radio network. RWJF’s $65 million grant that year was spread throughout 44 communities in 32 states and helped spur the nationwide 911 system we know today.
The foundation has also played a role in public health advocacy. In the early 1990s, the foundation set out to snuff the nation’s cigarettes. Starting in 1995 RWJF spent $85 million on smoking cessation research and advocacy. Among its investments were scientific studies that showed the harmful effects of secondhand smoke. Governments reacted to the RWJF-funded studies by banning smoking in many indoor public spaces and quadrupling taxes on cigarettes. The RWJF says the number of smokers dropped by 3.7 million between 1993 and 2009, avoiding 38,000 smoking-related deaths.
In 2007 RWJF set its sights on childhood obesity and has since put $500 million into an effort to combat what it calls the “obesity epidemic.” There is some evidence of success on that front, with a recent study in the Journal of American Medicine showing a 43 percent drop in the obesity rates of two to five-year-old children over the past decade (thought the findings of the study have been disputed).
The goal of the Culture of Health campaign is equally ambitious. “We won’t be able to solve our healthcare problems working at the margins,” Marks says. “We’ve really got to look for major changes. You can’t fix this with a little tweak here and a little tweak there. We’ve got to think bigger, and we’ve got to say, ‘Where does health come from?’ It begins, is protected, and is preserved in our communities.”
The Culture of Health campaign will be a far-reaching effort, RWJF CEO Risa Lavizzo-Mourey wrote in a blog post outlining the campaign:
“Seeing a culture of health from a bird’s-eye view means taking in the bigger picture of what defines health in America — how health will always be linked to health care, but also extends to work, family, and community life; how health equity is connected to opportunity; and how we, as a nation, must balance the costs, benefits, and effectiveness of treatment and prevention to provide our people with care of the highest possible value. It means focusing on the grander whole of what being healthy and staying healthy means. And it requires an understanding of a dynamic new world of Big Data, social networking, and creative innovation that is both cross-disciplinary and interprofessional.”
Making communities healthier is more than just an empty catch-phrase. It’s the result of careful cost-benefit analysis. To make his case, Marks points to a study by the journal Health Affairs that showed money spent on prevention was the only investment that actually saved money in the long run. Researcher Bobby Milstein ran a simulation of the American healthcare system and compared the effects of spending money on health coverage and treatment versus spending money on preventative care, environmental conditions, and encouraging healthy behavior. The results showed that better treatment saved lives quickly, but was expensive. Improving preventative health, on the other hand, ramped up slowly, but decreased costs in the long run.
The Culture of Health will focus on these preventative measures. “For something to be sustained, it’s got to provide value that is measurable. We’re saying, where do you get the most health for the money?” Marks says.
RWJF already has developed tools to measure exactly how healthy communities are. For five years it has used publicly available data to track the health rankings of every county in the country. In New Jersey, Hunterdon County is the healthiest. Mercer County is squarely in the middle of the state’s 21 counties at No. 12. The health ratings take into account a myriad of factors including access to doctors, obesity, violent crime, life expectancy, water quality, smoking, and other statistics.
Since adults spend so much time at work, having a healthy workplace is key to having a healthy lifestyle, Marks says. The businesses of the Route 1 corridor face challenges in this regard, since a truly healthy workplace would be one to which the employees could easily walk or bike. Except for a few areas surrounding train stations, this is not the case, including at RWJF itself.
The foundation has been promoting good workplace health for many years, and it recently began practicing what it preached. For years, it was not uncommon to see RWJF’s president, Lavizzo-Mourey, walking to work despite the pedestrian-unfriendly nature of the Route 1 corridor. More recently, the foundation has added a “walking meeting” room with facing treadmills, where workers can talk face-to-face while burning calories. Marks stays in shape by walking, jogging, and using a resistance machine.
RWJF’s lunchroom (free for employees) is now organized to try to encourage healthier habits. Workers can heap their plates with lettuce and veggies marked with a green ladle. Middle-of-the-road foods like humus are served with a yellow ladle. A red ladle means “take it easy” and comes with foods like pasta.
As the cost of healthcare skyrockets, more businesses are starting similar programs, either out of altruism or a desire to save money. Health insurance in the United States costs both workers and employees a great deal of money. For example, IBM pays about $11,000 a year to cover its workers, who chip in $5,000 each. It only makes sense to try to cut those costs however possible. “Worksite health promotion has become standard practice in large businesses,” Marks says. (And few people accuse American big business of not being self-interested.)
Business groups have also taken a broader view of the problem and worry about what poor health does to the future business climate. Ready Nation and America’s Edge are two such groups that have focused on education, but which are turning their attention to healthcare out of concern that the country is under-investing in the children who will be the future workforce.
“They’re seeing this as one of the top threats our nation’s businesses face,” Marks says. “If we’re serious about competing as a nation, this is where we have to focus our attention. If you are a business considering investing in the U.S., healthcare cost is huge,” Marks says, and it suffers compared to competing countries that provide free healthcare to their citizens.
The military has also taken notice of the obesity problem, noting that three quarters of young Americans do not qualify for military service. The Department of Defense, in a report bluntly titled “Too Fat to Fight,” said poor education, poor health, and criminal records disqualified 75 percent of young people from military careers, with health factors ruling out 27 percent of the recruiting pool.
Marks’s background in both healthcare and education go all the way back to his roots in the New York town of Alden, where he grew up. His father was a doctor, and his mother was an art teacher. Marks graduated from Williams College before earning his MD at the State University of New York at Buffalo. He went on to get a master’s of public health degree at Yale. He held the title of assistant surgeon general as director of the Centers for Disease Control’s National Center for Chronic Disease Prevention and Health Promotion from 1996 to 2003.
Companies are also taking healthcare into consideration when deciding where to move. Although Marks admits “healthy communities” doesn’t top the list of factors for most companies when they decide to move, it might be a secondary consideration and a tie-breaker when all other things are equal. Some business leaders have told Marks that they use education and obesity rates in an area as a proxy for future healthcare costs.
Mitch Daniels, the pro-business Republican former governor of Indiana, launched the “Healthy Indiana Plan” in 2007, which included preventative care free to low-income residents. Marks noted that Daniels considered the health of the workforce to be crucial to the future economic development of the state.
Marks points to the case of Volkswagen, which chose Chattanooga, Tennessee, for the site of a $1 billion factory in part because the location was considered a healthier community. IBM chose Dubuque, Iowa, for a parts and service center for the same reason. “It may not be the first reason a company selects a location, but it is moving up as a priority,” Marks says. “We’re seeing business and civic leadership start to recognize that this is something communities can do to make them become more attractive.”
But how to tell which interventions work and which ones don’t? Marks has been studying public health initiatives around the country to see what has been successful. One such success story came from Hernando, Mississippi, a small town on the outskirts of Memphis, Tennessee, where the mayor launched an innovative plan to make the town’s employees healthier and cut down on the town’s health insurance bill.
According to the Memphis Daily News, Mayor Chip Johnson created a parks department, a farmer’s market, and an employee wellness program where there were none before. He made an employee gym using donated equipment and encouraged town workers to use it. When the insurance companies cut the healthcare bill by $130,000 as a result of the employees being healthier, he got the town council to agree to give the money to the workers as a pay raise, just to encourage their good habits.
The Robert Wood Johnson Foundation likes to hold up Hernando as an example of the benefits of a healthy community, and singled the town out for praise in 2012, noting that after the pro public-health drive, the town got its first new non service-industry business in decades.
Encouraging healthy communities would also mean encouraging people to travel by mass transit. Studies show big health benefits to using mass transit versus driving a car to work, including the fact that mass transit commuters are an average of seven pounds lighter than their car-driving counterparts.
A healthy community also means having sidewalks to encourage walking, having good access to grocery stores and produce markets, and having public parks and recreation facilities available so that people can stay active. Marks would like to see the United States follow Europe’s lead in having a “health in all policies” policy, where public health is taken into account with every zoning decision, railroad station placement, and budget item.
The details of the plan will come Wednesday, June 25, when RWJF plans to launch the campaign at the Aspen Ideas Festival. The festival, held every year in Colorado, is a week-long conference where intellectuals, artists, and leaders gather for seminars, panels, and discussions. The press will get a preview Friday, June 20.
Changing the culture of health may seem like a daunting task, but Marks is encouraged that the recent campaign against childhood obesity seems to have had some success. Healthier cafeteria meals, removing snack and soda machines from schools, and more physical exercise have made a difference — nationwide childhood obesity rates have peaked, and have even started to fall. Future generations will reap the economic benefits of those public health efforts.
But despite the usefulness of money as a metric, the value of good health cannot truly be measured by financial figures alone. Studies show that people who make it to age 70 in good health have a chance of spending more of their golden years active and out of medical treatment. “Economists will tell you, and they do, that when you are healthier, you live longer, and that’s going to cost more in food and housing, and that’s true,” Marks says. “But where would we rather spend our money? On getting to know our grandkids and playing with them, or on being hospitalized?”
Robert Wood Johnson Foundation, Route 1 and College Road East, Box 2316, Princeton 08543-2316; 609-452-8701. Risa Lavizzo-Mourey MD, CEO. www.rwjf.org.