By, Donald F. Schwarz, Health Commissioner, City of Philadelphia & Giridhar Mallya, Director of Policy and Planning, Philadelphia Department of Public Health
Only 10 percent of preventable deaths in the U.S. are due to inadequate medical care and 30 percent are due to our genetics. The remaining 60 percent reflect our behaviors, our social circumstances, and our environmental exposures.
It’s this 60 percent that we can improve through public health. And the Affordable Care Act (ACA) recognizes and supports such an approach—here in Philadelphia and across the country.
Through the Prevention and Public Health Fund, the ACA sets aside federal resources so that state and local agencies—public, private, and non-profit—can promote healthy behaviors and environments. In other words, these initiatives aim to make the healthy choice, the easy choice for Americans. Such efforts lead to better health and lower health care costs in the long run.
Currently, too many people live, work, or go to school in communities that make unhealthy choices the default. In Philadelphia, cigarettes are commonly available for under $5 per pack, making a half-pack per day habit cheaper than over-the-counter nicotine patches. Children can buy 350 calories of chips, soda, and candy for just over $1 at local corner stores. And popular lunch items at Chinese take-out restaurants in low-income neighborhoods have more than a day’s worth of sodium.
The City’s Get Healthy Philly initiative—with funding through the ACA and other public and private sources—has tackled these challenges head-on. In fact, Get Healthy Philly takes on the issues that doctors, patients, and insurers can’t address on their own.
Medicaid provides publicly-funded insurance coverage for over 70,000 low-income smokers in Philadelphia. However, local Medicaid plans were not providing comprehensive coverage for smoking cessation aids, like nicotine patches and gum. When smokers are offered such coverage, they are more likely to make a successful quit attempt. That’s good for smokers and good for those paying their medical bills. Get Healthy Philly partnered with Medicaid plans in the city to expand pharmaceutical coverage for smoking cessation in 2010. Since then, there has been a 10 percent to 20 percent increase in utilization of nicotine replacement therapy and a 10 percent decline in smoking rates among Philadelphians covered by Medicaid.
Get Healthy Philly is building on this success by encouraging large employers in the region to remove or reduce copayments for medications used to treat smoking, high blood pressure, high cholesterol, and diabetes. Through such value-based insurance changes, employees can achieve improved adherence to chronic disease therapies and better health, while employers can lower overall health care costs. The ACA is enacting complementary strategies by removing cost-sharing for high-value preventive services, such as immunizations and cancer screening.
Small businesses have also been a key partner in creating a healthier Philadelphia. Now, 650 corner stores and bodegas are part of our Healthy Corner Store Network, led by The Food Trust. Store owners commit to adding at least four new healthy products to their inventory, receive business training, and promote healthy items in their stores. Nearly 300 stores received small shelving and refrigeration units to store and display perishables. As a result, the availability of fresh fruits and vegetables and low-fat milk has increased, and store owners report solid sales and strengthened relationships with their communities. Over the last two years, 60,000 Philadelphians in low-income neighborhoods have seen increased access to healthy foods.
In addition, over 220 Chinese take-out restaurants in the city have committed to reducing sodium in the 3.2 million meals they serve annually. Get Health Philly partnered with the Temple University Center for Asian Health, the Chinese Restaurant Association, and the Asian Community Health Coalition to implement the Healthy Chinese Take-out Initiative. Restaurant owners and chefs received education about the links between excess sodium consumption and hypertension, training in low-sodium cooking techniques, and information on low-sodium ingredients. Six months after this intervention, sodium content dropped by 20 percent in two popular meals—shrimp & broccoli and chicken lo mein. These community-based efforts will support doctors and patients in managing diseases like hypertension, which affects nearly 40 percent of adults in Philadelphia.
Along with effective, scalable programs, public health policy plays a critical role in improving the health of populations. The ACA included federal menu labeling legislation, requiring all chain restaurants in the U.S. to post calorie information on menus and menu boards. Unfortunately, the FDA has yet to issue regulations guiding implementation of the law. Philadelphia is one of several communities that passed and implemented local menu labeling laws prior to the ACA. Moreover, Philadelphia’s law is the strongest in the country, mandating not just calories but also sodium, saturated fat, and carbohydrate labeling on menus of sit-down chain restaurants. Soon after implementation in 2010, most chain restaurants in the city were in compliance. And, a recent evaluation suggests that customers in Philadelphia restaurants purchased lower calorie, lower sodium meals than customers outside of the city in unlabeled establishments. Through Get Healthy Philly, Philadelphia is pursuing other effective public health policies, such as smoke-free parks, universities, and multi-unit housing; nutrition standards for all City-funded food procurement contracts; and content-neutral retail advertising restrictions.
With support from the ACA, Philadelphia and other communities are demonstrating that public health can address gaps in medical care by creating healthier home, school, workplace, and neighborhood environments. These efforts will prove even more important as millions of Americans become insured over the next several years. The goal is to keep people healthy rather than treating them only when they are sick. That’s good practice and sound policy.