What are your general suggestions on the development of the National Prevention and Health Promotion Strategy (National Prevention Strategy)?

December 3, 2010 Vice Admiral Regina M. Benjamin, M.D., M.B.A. Surgeon General Chair, National Prevention, Health Promotion and Public Health Council Office of the Surgeon General 5600 Fishers Lane, Room 18-66 Rockville, MD 20857 RE: Draft Framework for the National Prevention Strategy Dear Surgeon General Benjamin: On behalf of the National Partnership for Women & Families, I would like to commend the Council for its focus on improving the health of our nation. Your leadership will continue to be critical as we work to move the country towards a health care system centered on prevention and wellness. A comprehensive and coordinated National Prevention and Health Promotion Strategy will play a vital role guiding these efforts. We appreciate this opportunity to comment early on in the development of the Strategy. In our comments below, we discuss how the National Prevention Strategy can meet the unique needs of women and families. What are your general suggestions on the development of the National Prevention and Health Promotion Strategy (National Prevention Strategy)? Prevention and wellness are especially important for women and families. While women want to make healthy lifestyle choices for themselves and their families, they often neglect their own health because they put the needs of their children, spouses, and aging relatives before their own. Many working women do not have paid time off when they or family members are sick or need preventive care. This exacerbates their own risk for poor health while also exposing their coworkers to infection. In addition, women are more likely to forgo necessary preventive care when budgets are tight. Access to affordable health care is a constant problem for uninsured and low-income women, but the economic recession has forced many more families to postpone obtaining necessary health care services. The Commonwealth Fund reported in 2009 that nearly half of women surveyed report postponing or not receiving a cancer screening or dental exam because of financial concerns (compared to 36 percent of men). 1 Although women s health care needs are not limited to reproductive health, it is an essential determinant of their overall health. Addressing women s reproductive health care needs should 1 Rustgi, S. D., Doty, M. M., and S. R. Collins, Women at Risk: Why Many Women Are Forgoing Needed Health Care, The Commonwealth Fund, May 2009. 1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539 email: info@nationalpartnership.org ~ web: www.nationalpartnership.org

2 be a central component of any prevention and health promotion strategy. Regardless of whether or when they have children, women spend much of their reproductive lives (approximately three decades) trying to avoid pregnancy. For most women, family planning is possible only with consistent use of reliable, effective contraception. The Centers for Disease Control and Prevention included family planning in its list of the Ten Great Public Health Achievements in the 20 th Century 2 for good reason. Widespread use of contraceptives has been the driving force in reducing national rates of unintended pregnancies and sexually transmitted infections (STIs), and reducing the need for abortion. Contraceptive use enables women to plan and space their pregnancies and has contributed to dramatic declines in maternal and infant mortality rates. Additionally, use of birth control has enabled women to pursue education and employment on a timetable consistent with their needs, allowing them to participate fully and equally in society. Whether trying to avoid pregnancy or planning a family, access to birth control and reproductive health care services is a necessary component of basic health care for most women and families. Women also need regular screenings for reproductive health cancers, during and after their reproductive years. To address these important considerations, the National Prevention Strategy needs to go beyond the disease-centric approach taken by the National Prevention, Health Promotion and Public Health Council (Council) in the draft framework. Health is not the mere absence of disease, it is, a state of complete physical, mental and social well-being. 3 The National Prevention Strategy should reflect a comprehensive understanding of prevention and include health promotion strategies aimed at achieving optimal well-being and that meet the particular challenges faced by women in accessing and using preventive care. It should also give attention to community-based prevention as well as evidence-based clinical prevention to enable communities to break down structural barriers to good health. To facilitate this, for example, the framework should encourage collaboration with people who work at the community level to reduce disparities, promote primary prevention, and build healthier communities and environments. What are your thoughts on the following elements of the Draft Framework? Vision The vision should clearly indicate that the National Prevention Strategy will meet the unique health and well-being needs of women, including low-income and minority women. We encourage the Council to consider expanding both the scope and the substance of the draft vision to incorporate the broader conceptualization of health promotion and wellness described above. The focus should not simply be on preventing specific diseases that lead to death and disability, but should clearly support approaches and policies that promote and facilitate healthy living. The vision should indicate that the Strategy is not limited to health and public health sectors, but 2 Centers for Disease Control and Prevention. Ten great public health achievements United States, 1990-1999. JAMA 1999;281(16):1481. 3 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

3 also include non-health sectors such as the workplace, housing, and education, and their impact on health and health outcomes. Goals We believe better refined goals are needed to deliver on the promise of our recommended, more comprehensive vision. We urge you to consider adopting the following goals: Create community and social environments that support healthy choices where people live, learn, work, and play: By expanding the scope of this goal to include social environments, the framework can emphasize the importance of the multiple factors that influence optimal health. Achieve health equity: Health disparities are a persistent and pervasive problem in the United States and whether they are suffering disparities in access to care, in quality of services received, or in incidence of poor health, women, particularly women of color and low-income women, are consistently disadvantaged. The elimination of disparities at all levels should be at the forefront of the National Prevention Strategy, incorporated across all of the strategic directions. Engage residents and collaborate across sectors: Institutions public and private at the local, state, tribal, and federal level should engage residents and collaborate across sectors to implement the best prevention and health promotion practices for community and individual health. Achieve optimal health over the life course: Addressing health risks early and throughout the lifespan and focusing on developmentally sensitive periods will yield greatest health prevention and promotion benefits. 4 In addition, a focus on optimal health prioritizes health prevention and promotion and well-being. For example, women benefit from a life course approach because it recognizes that women s health needs change over time and that healthy aging begins with a healthy childhood. Strategic Directions We strongly encourage you to adopt more clearly defined Strategic Directions. These should be formulated as specific objectives that can be measured and inform policy development. In particular, we urge you to consider adopting the following proposals as Strategic Directions/ Objectives in the final Strategy: Advance workplace policies that have a clear and direct effect on improving American s health, including paid sick days and paid leave and policies that have a particular benefit for women and children s health, such as providing nursing mothers a time and place to express milk at work. 4 N. Halfon, Life Course Health Development: A New Approach for Addressing Upstream Determinants of Health and Spending (2009).

4 No single workplace policy has a more significant impact on preventive and public health as paid sick leave. The lack of paid sick days standards continues to harm our nation s health, particularly for lower-income workers and people of color. Nearly 40 percent of America s private sector workers and eight in 10 of the lowest-wage workers do not have a single jobprotected paid sick day and cannot leave work to care for a sick child or to seek preventive medical care without losing pay or risking their jobs. The effects upon prevention and wellness are significant: workers without paid sick days are 1.5 times more likely than adults with paid sick days to report going to work with a contagious illness like the flu. 5 Between September and November 2009, the peak months of the H1N1 flu pandemic, estimates show that eight million workers went to work sick, and may have infected seven million of their co-workers. 6 The impact is particularly significant for children parents without paid sick days are five times as likely to report taking their child or family member to the emergency room because they were unable to take time off work during normal hours to seek medical care. 7 The Strategy should highlight the important effect of workplace policies on prevention and wellness by setting data collection and pilot project goals around paid sick days and paid leave (within those few states and cities that do have public policies) and by encouraging the adoption of paid sick days standards and programs. It is also important that other workplace policies that support health and wellness be encouraged. For instance, breast feeding holds significant potential to improve infant health and reduce health complications and workplaces should provide nursing mothers a time and place to pump. To advance such policies, the Strategy could support programs that increase awareness and widespread implementation of rights to pump at work, such as those protected under the reasonable break time for nursing mothers provisions in the Affordable Care Act. It could do this through education, collaboration with employers and nursing mother and employee groups, and identification and dissemination of best practices. Identify and provide meaningful information and support to family caregivers. According to the National Alliance of Caregiving and AARP, an estimated 43.5 million Americans provide unpaid care to a family member or friend age 50 or older. Although family members often undertake caregiving willingly and find it an important source of satisfaction, they need preventive and support services themselves. Family caregiving is now a public health issue. A body of research over the past 30 years has shown that caregiving can exact a high cost: health risks, financial burdens, emotional strain, mental health problems, workplace issues, and retirement insecurity. The lack of longer-term paid leave, that would allow family caregivers time off from their wage-earning jobs to care for a seriously ill family member, exacerbates these hardships both by increasing stress and putting 5 National Opinion Research Center at the University of Chicago for the Public Welfare Foundation, Paid Sick Days: Attitudes and Experiences, May 2010. http://www.publicwelfare.org/resources/docfiles/psd2010final.pdf. 6 Institute for Women s Policy Research, Sick at Work: Infected Employees in the Workplace During the H1N1 Pandemic, Feb. 2010. www.iwpr.org/pdf/b284sickatwork.pdf. 7 National Opinion Research Center at the University of Chicago for the Public Welfare Foundation, Paid Sick Days: Attitudes and Experiences, May 2010. Unpublished calculation

5 tremendous economic pressure on caregivers. The health effects of family caregiving for an aging relative are particularly sobering. Studies consistently find high levels of depressive symptoms and other emotional problems among family caregivers as compared to their noncaregiving peers, particularly when they are caring for a loved one with a dementing illness like Alzheimer s disease. Various studies have also linked caregiving with serious health consequences, including increased risk of coronary heart disease; elevated blood pressure and increased risk of developing hypertension; lower perceived health status; poorer immune function; slower wound healing; and, among older spouses, an increased risk of mortality. These burdens and health risks can impede the family caregiver s ability to provide care, lead to higher health care costs, and affect their quality of life and those for whom they care. Reduce the proportion of pregnancies that are unintended and the number of new sexually transmitted infections (STIs), including HIV. Healthy People 2010 made a powerful argument for the prevention of unintended pregnancy: Reducing unintended pregnancies is possible and necessary. Unintended pregnancy in the United States is serious and costly and occurs frequently. Socially, the costs can be measured in unintended births, reduced educational attainment and employment opportunity, greater welfare dependency, and increased potential for child abuse and neglect. Economically, health care costs are increased. An unintended pregnancy is expensive no matter what the outcome. Medically, unintended pregnancies are serious in terms of the lost opportunity to prepare for an optimal pregnancy, the increased likelihood of infant and maternal illness. America has made great strides in reducing unintended pregnancy, however in the last decade some key groups appear to be losing ground. Unintended pregnancy is increasingly concentrated among poor women and women of color. Poor women today are four times as likely to have an unplanned pregnancy, three times as likely to have an abortion and five times as likely to have an unplanned birth as are higher-income women. Disparities in STI rates are also pronounced and growing worse. The rates of many STIs are several times higher among black women and men than among their white counterparts. Racial and ethnic minorities have been disproportionately affected by HIV/AIDS since the beginning of the epidemic, and represented the majority of new AIDS cases, new HIV infections and people living with HIV/AIDS, and AIDS deaths in 2007. Expanding contraceptive use, through increased education and access to high quality services, remains the most effective way to further reduce unintended pregnancy and STIs. What recommendations should be included in the National Prevention Strategy to advance the Draft Strategic Directions? The National Prevention Strategy should commit to support a quality public health infrastructure that includes a robust, diverse workforce that is trained to promote prevention and advance the public s health. Recommendations should include increased federal support for public health programs like the Title X family planning program that have a long history of success in providing preventive health care services to disadvantage communities. The Strategy should

6 also include recommendations to improve linkages between the public health and health care systems to increase their impact and better address challenges such as increased utilization of high-value clinical preventive services and coordination of care. The Strategy should also recommend the prioritization of interventions aimed at populations and communities most at risk for poor health outcomes, including low-income and minority women, older adults with multiple chronic conditions, and LGBT, immigrant and geographically isolated communities. A necessary component of the National Prevention Strategy should be equality in the provision of and access to supported programs and initiatives. In all of its recommendations, the Strategy should explicitly state that programs, activities, providers, and other entities covered by the Strategy should not discriminate in the provision of their services on the grounds of sex, sexual orientation, race, national origin, disability, or age. Indeed, Section 1557 of the Affordable Care Act (ACA) explicitly forbids discrimination on the grounds of sex, race, national origin, disability, or age in health programs or activities receiving federal financial assistance or by programs administered by an Executive Agency or any entity established under Title I of the ACA. Because Section 1557 applies broadly to federally conducted programs and to entities that receive federal funding or assistance, initiatives, programs, and other activities supported by the National Prevention Strategy should comply with Section 1557, as well as, where applicable, other laws prohibiting nondiscrimination by federal fund recipients such as Title VI of the Civil Rights Act of 1964 and the Rehabilitation Act. It is also imperative that any initiatives, programs, or strategies including employer wellness programs and strategies be conducted and executed in a nondiscriminatory manner that does not undermine civil rights protections or allow such programs to become a backdoor method of health-status rating. Programs should not use incentives, penalties, or standards that that cause discrimination against any group protected by Title VII, the Age Discrimination Act (ADEA), the Americans with Disabilities Act (ADA), or the Genetic Information Nondiscrimination Act (GINA). Moreover, they should not require the provision of information explicitly protected under other statutes, such as the ADA and GINA. Any employer-based wellness program must be fully accessible in terms of physical location, machinery and ability to garner incentives/avoid penalties for people with disabilities. Do you have suggestions for how the National Prevention Council can work with state, local, tribal governments, non-profit, or private partners to promote prevention and wellness? The Council should partner with essential community providers. Essential community providers serve as a regular and reliable source of quality preventive care for medically underserved and low-income populations. Partnering with these providers will improve access to preventive care for these important populations. Essential community providers often work in publicly-funded clinics that are strategically located to promote easy access for the populations they serve. Whether clinics are located in low-income urban neighborhoods, rural or remote areas or near public transportation, providers serving in these clinics are accustomed to meeting the special

7 needs of low-income populations and that includes making sure that consumers have easy access health services. Furthermore, the Council should support community health workers/programs, including by addressing issues of financing and credentialing. For decades, public health programs have utilized community health worker programs (CHW) as a way to reach and serve disadvantaged populations. CHWs, who are generally lay members of the same communities these programs are seeking to serve, can provide a variety of functions, including outreach, counseling and education, and patient navigation. A big part of successful efforts to promote prevention and wellness involves the need for non-clinical, talking services, i.e. to either initially just let people know about available services or to provide needed counseling and answer questions that cannot be addressed in the limited time available with health care providers. Conclusion The National Partnership greatly appreciates the opportunity to comment on the National Prevention Strategy Draft Framework. We look forward to future opportunities to work with the Council as it continues to develop strong prevention, health promotion and public health strategies. Sincerely, Debra L. Ness President