MMHA6700 Walden University Health Care Reform Initiatives Discussion Healthy People 2020 can be viewed as a strategic approach for improving the health of
MMHA6700 Walden University Health Care Reform Initiatives Discussion Healthy People 2020 can be viewed as a strategic approach for improving the health of the US population over a ten-year timeline, applicable nationally, regionally, and in states, counties, cities and towns.
The Healthy People strategy was designed to define and promote a common sense of purpose and goals, with specific targets.
JonathanFielding, Shiriki Kumanyika, & Ronald Manderscheid
The effects of the continuous effort of various health care reform initiatives to improve a populations health are difficult to track, measure, sustain, and analyze, but evaluating the impact of changing guidelines and requirements is part of effective operational management. How are improvements aligned with an appropriate return on investment, and how can this be measured?
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To prepare for this Discussion:
Read the three articles provided this week, and reflect on how these initiatives have impacted health care organizations.
Post a cohesive response to the following:
Describe how health care reform initiatives and mandates have impacted your organization. What changes in operations have been made in response to these initiatives? How well-organized were these changes? How have they offered measureable improvements in both clinical practice and performance? Explain how these improvements were a result of the reform initiative. 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 Secretarys
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.
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 Nations 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.
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 Secretarys 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. 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 Groups 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.
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Public Health Reviews, Vol. 35, No 1
Table 2
Key Issues Addressed and Guidance
Provided by the Secretarys 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. 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.
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 organizations 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…
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