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Aug. 8, 2011
TOPEKA “An ounce of prevention is worth a pound of cure.” — Ben Franklin
The federal government is poised to start spending $900 million nationwide over the next five years in an effort to battle costly chronic ailments such as obesity and diabetes.
The initiative is considered the single largest push to date by the national government to encourage disease prevention. But Kansas likely won’t see a dollar of that money.
Why not? Well, one big reason is that no one here asked.
The July 15 deadline for submitting applications for the so-called Community Transformation Grants has come and gone.
The handful of Kansas officials who met the eligibility criteria for submitting proposals to the federal Centers for Disease Control and Prevention chose not to for reasons that have left some public health officials disappointed and baffled.
“I see it as a missed opportunity for the state of Kansas,” said Lougene Marsh, director of the health department in Johnson County, the state’s most populous county. “These large federal grants are not just things that come up frequently.”
Obesity, diabetes, hypertension, and other chronic maladies - most of which are considered preventable - are thought to cost the Kansas economy about $12 billion a year, according to both the Milken Institute (PDF), an independent economic think tank, and the U.S. government (PDF).
About $2.6 billion of that estimated sum is for treatments, while the much greater number of $9.3 billion is from lost productivity resulting from days not worked due to sickness and related consequences.
For purposes of putting $12 billion in perspective, that’s about twice the amount all Kansans pay in state taxes in a single year, including sales and gasoline levies.
That $12 billion cost also represents Kansas’ share of what many view to be one of the nation’s most pressing problems – the growing amount of money spent on health care, which now accounts for about 17 percent of gross domestic product.
Most agree those costs put American companies, such as Boeing or General Motors, at a competitive disadvantage with Airbus or Toyota, both of which hail from countries where health care doesn’t eat up such a large share of the economy.
And many experts say the U.S. would see its health care costs drop dramatically and the nation’s economic situation improve if more Americans would do three seemingly simple things: Exercise more, eat less, and stop smoking.
"It's our position that we could substantially provide high-quality care for all Americans if we were not burdened by the costs of an unhealthy America and the cost of chronic disease," said Michael Milken, chairman of the Milken Institute. "Good health is an investment in economic growth."
Milken, famous in the 1980s as the “Junk Bond King,” turned to philanthropy and health policy issues after serving time in prison for securities fraud and racketeering.
Some say it runs counter to American culture to focus on prevention.
“I am currently on the Institute of Medicine committee that's called Living Well with Chronic Disease,” said Marcia Nielsen, associate dean for health policy at the University of Kansas Medical Center. “So I’ve been spending a lot of time focused on just this situation. The reality is that 75 percent of all our health care costs are spent on chronic diseases after someone’s got sick. All of this stuff is preventable, these risk factors for chronic disease.
“It doesn't mean you can completely rule out getting cancer, but you can sure mitigate the risk factors. Unfortunately, what happens is we are paying for people who are already sick instead of preventing people from getting sick in the first place. We've been doing that for a long, long time, and federal health reform is trying at the margins to fix that.
“But as a society, we're very reluctant to spend money on prevention, and it's because we are focused on the short term,” Nielsen said. “We're an instant gratification kind of culture, and government can't fix that all by itself.”
Kansas ranks low
Those who focus most on prevention within the American health care system are public health officials. They have long lamented the disproportionate amount of money spent on acute care versus preventive care.
Kansas government in 2011, according to the Trust for America’s Health (PDF), spent less per capita on public health than all but eight other states. An examination of health spending by the various Kansas agencies shows that less than 2 cents of every dollar could be categorized as preventive. And federal spending on public health programs in Kansas also was near the bottom in 2011, in large part because federal spending generally requires some sort of local match.
The Trust for America’s Health estimates that if Kansas spent another $10 per person per year – or about $27.3 million total – on proven programs that encourage exercise, good nutrition, and less smoking, Kansas would save $54.3 million in one or two years and about $155 million within five years, measured in 2004 dollars.
Just say no
So why didn't Kansas officials ask for the prevention program money being offered by the CDC through the Community Transformation Grant program?
Not so long ago, it was unheard for a local or state government to spurn federal dollars that required no matching funds.
But with politicians at all levels of government sharply divided over the issues of budget and health reform, what once was unheard of is now growing commonplace, and national political issues are becoming increasingly localized.
Alaska Gov. Sean Parnell and Florida Gov. Rick Scott, both Republicans, have refused any federal dollars tied to the health reform law they refer to as Obamacare.
And last month, Johnson County commissioners on a 4-3 vote decided they would reject the request by Marsh, the county’s top public health official, to apply for a $325,000 Community Transformation Grant, which was authorized by the 2010 health reform law.
Marsh said the money would be used to promote prevention and healthy living among the county’s poor and minorities, both of which are increasing at a faster pace than the county’s general population.
But commissioners who voted against the plan had two things in mind when they rejected it, according to public statements and interviews with KHI News Service: Johnson County already had a variety of programs encouraging healthy living, and they didn’t want to contribute to federal spending, which they view as out of control.
The July 7 vote came amid the debate in Congress over raising the federal government’s debt limit.
“The government's broke, and I'm sure you're well aware of the debt situation,” said 4th District Commissioner Jason Osterhaus, a Republican elected to the commission last November. “So we have to be very careful about what we accept from the federal government as far as money goes. I also felt like this was a redundancy of services.”
Commissioner Calvin Hayden voted against the proposal for the same reasons.
“We've got an abundance of these programs put on by insurance companies and everybody else,” Hayden said. “There might be someone in rural, western Kansas that could actually use the money. ... They're throwing money at us, but what about our rural counties that could maybe legitimately do something with this and maybe accomplish something with it?”
Many groups and organizations in Kansas, including some from rural counties, were aware of the grants and interested in applying.
Chris Weiner, development coordinator for Thrive Allen County based in Iola, said his group wanted to use the grant money to develop a program for nine southeast Kansas counties that are among the state’s poorest and least healthy.
Weiner said the group wanted to develop a regional plan for reducing infant mortality and tobacco use, among other things.
Five groups in addition to Thrive Allen County and the Kansas Department of Health and Environment (KDHE) filed letters of intent to apply with the CDC.
And groups in Wyandotte and Sedgwick counties — homes of Kansas City, Kan., and Wichita — also spent time considering grant applications but did not file letters of intent.
In Wichita, there was a major collaborative effort that included the Medical Society of Sedgwick County, the YMCA, safety net clinics, and other groups. They went so far as to prepare a white paper (PDF) describing what they would do with the grant money. Their planned focus was on preventing diabetes, which occurs at higher rates in Sedgwick County than in Kansas or the nation at large.
But as it turned out, the grants were restricted to applicants representing a minimum of 500,000 people. That meant only two entities in Kansas were eligible to apply: Johnson County and the state of Kansas.
Marsh, in Johnson County, and officials at the KDHE began preparing applications.
In Johnson County, it was commissioners who shot down the idea.
At KDHE, Secretary Robert Moser decided the state would not apply.
KDHE spokeswoman Miranda Myrick said the decision was not based on opposition to the Affordable Care Act or because of the federal budget debate. Instead, Moser concluded the application was not a good idea at this time.
Sherriene Jones-Sontag, a spokesperson for Gov. Sam Brownback, said the administration has not taken a blanket approach to rejecting or not applying for health reform grants. Those decisions are made, she said, "case by case."
“KDHE staff did spend time studying the (grant) and developing a proposal,” Myrick said. “However, this is not the first FOA (funding opportunity announcement) staff have spent time on that we did not submit. We review a lot of FOAs and are frequently approached by partners – state and local – either encouraging us to apply, requesting us to participate as a contributing partner, asking our opinion as to whether there should be a Kansas proposal submitted. We evaluate all grant opportunities carefully and only invest time into those that are core to our mission and for which our assessment tells us that we can reasonably compete.
“Some of our local and state partners were informed by us that we were interested in applying on behalf of the rest of the state, but ultimately ... KDHE made the prudent decision to not go through with the application.”
News of Moser’s decision wasn’t relayed by KDHE to many of the people who were interested in seeing the state pursue the grant.
“If they didn't even apply, I'm not sure what happened there,” said Weiner of Thrive Allen County.
Jon Rosell, executive director of the Medical Society of Sedgwick County, said he learned of the news Aug. 3 from Claudia Blackburn, the county’s public health director, who also found out the same day when a news reporter called asking about it.
“I think it raises curiosity in terms of why” the state didn’t apply, Rosell said. “I don't know why.”
The grants are competitive, which means filing the application is no assurance of receiving a grant.
Nonetheless, the decision left some, like Marsh, feeling that the state had squandered an opportunity to advance community efforts to somehow come to grips with the large toll taken by chronic illness.
“Part of the reason they created these grants in the first place is that we find the best success in community (health) interventions are from those that are owned and implemented by the community and where ultimately accountability comes back to the community,” KU’s Nielsen said. “So not taking advantage of these opportunities is unfortunate.”
Paula Clayton, director of KHDE’s Bureau of Health Promotion, led the agency’s early review of the grant proposal.
She said the agency gave serious consideration to applying but that Moser concluded it wouldn’t be a good fit given the agency’s resources and the grant parameters.
“I think what you’re hearing (from the other interested parties) is a disappointment that we shared,” she said. “Because it (the grant process) was very clearly slanted toward big population centers. The way the state application would have had to been written was as if for one population center. This was problematic for states all across the nation trying to respond to this (grant) because this was really set up for cities and large population centers, and part of Dr. Moser’s realization was that this money and the work that would go into it would not put money into local communities at all. It would require time and compete with time needed for strategic planning for the state agency as it works for its local planning partners.
“Sometimes,” she said, “when you start looking at these (grants), they just turn out looking different than we thought they were. We were as disappointed as anyone that it didn’t turn it out to be something we could do.”
Clayton said the grant would have required major commitments from the state and other organizations.
“There’s a lot of time in planning,” she said. “Some of the work was supported by the grant itself and other was not.”
She said KDHE would have had to conduct a “statewide community health assessment, a statewide policy scan and putting in place a statewide leadership group contingent on a lot of volunteer time from partners.”
A plan would have been needed for “determining how decisions would be made,” assessing priorities across the state and distributing the “implementation dollars.”
“When you look at the work that would be required to apply for implementation, it was pretty intense,” Clayton said, “and would require not only extra effort from the state health department but from a lot of organizations and volunteers.”
Something good yet could come of all the effort and hours put in by so many people across the state as a result of the Community Transformation Grant process.
For example, Rosell said the groups that began meeting in Wichita to plan a grant application want to continue their collaboration on dealing with the diabetes problem, though they’re not exactly sure how they’ll do that.
“Right now, quite honestly, we're struggling to figure out what we do next,” he said. “We don't have any funds. But we’re trying to figure out how we can leverage these relationships and organize this and implement it.
“We'd welcome the opportunity to continue those kinds of conversations at the community level,” he said, “and if KDHE were interested in participating, we'd welcome their involvement as well.”