ISSUE REPORT Prevention for a Healthier America: INVESTMENTS IN DISEASE PREVENTION YIELD SIGNIFICANT SAVINGS, STRONGER COMMUNITIES FEBRUARY 2009 PREVENTING EPIDEMICS. PROTECTING PEOPLE. ACKNOWLEDGEMENTS: This issue brief is supported by a grant from the Robert Wood Johnson Foundation and The California Endow ment. The opinions expressed are those of the authors and do not necessarily reflect the views of the Foundations. TFAH BOARD OF DIRECTORS CONTRIBUTORS Lowell Weicker, Jr. Jeremy Cantor, MPH President Program Manager Former 3-term U.S. Senator and Prevention Institute Governor of Connecticut Gabriel Cohen Cynthia M. Harris, PhD, DABT Policy Associate Vice President New York Academy of Medicine Director and Associate Professor, Institute of Public Larry Cohen, MSW Health, Florida A & M University Executive Director Margaret A. Hamburg, MD Prevention Institute Secretary Ruth Finkelstein, ScD Senior Scientist, Nuclear Threat Initiative (NTI) Vice President for Health Policy Patricia Baumann, MS, JD New York Academy of Medicine Treasurer Ana Garcia, MPA President and CEO, Bauman Foundation Policy Associate Gail Christopher, DN New York Academy of Medicine Vice President for Health Sherry Kaiman WK Kellogg Foundation Director of Policy Development John W. Everets Trust for America’s Health David Fleming, MD Julie Netherland, MSW Director of Public Health Policy Associate Seattle King County, Washington New York Academy of Medicine Robert T. Harris, MD Barbara A. Ormond, PhD Former Chief Medical Officer and Senior Vice President Senior Research Associate for Healthcare The Urban Institute BlueCross BlueShield of North Carolina Brenda C. Spillman, PhD Alonzo Plough, MA, MPH, PhD Senior Research Associate Vice President of Program, Planning and Evaluation The Urban Institute The California Endowment Janani Srikantharajah Theodore Spencer Program Assistant Project Manager Prevention Institute National Resources Defense Council Rebecca St. Laurent, JD Research Assistant REPORT AUTHORS Trust for America’s Health Jeffrey Levi, PhD. Bogdan Tereshchenko Executive Director Research Assistant Trust for America’s Health The Urban Institute and Associate Professor in the Department of Health Policy Serena Vinter, MHS The George Washington University School of Senior Research Associate Public Health and Health Services Trust for America’s Health Laura M. Segal, MA Timothy Waidmann, PhD Director of Public Affairs Senior Research Associate Trust for America’s Health The Urban Institute Chrissie Juliano, MPP Policy Development Manager Trust for America’s Health Prevention for a Healthier America: INVESTMENTS IN DISEASE PREVENTION YIELD SIGNIFICANT SAVINGS, STRONGER COMMUNITIES TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES BY PROTECTING THE HEALTH OF EVERY COMMUNITY AND WORKING TO MAKE DISEASE PREVENTION A NATIONAL PRIORITY. 1 Introduction and Key Findings 1 SECTION E ven though America spends more than $2 trillion annually on health care -- more than any other nation in the world -- tens of millions of Americans suffer every day from preventable diseases like type 2 diabetes, heart disease, and some forms of cancer that rob them of their health and quality of life.1 Keeping people healthier is one of the most ments in physical activity, nutrition, and pre- effective ways to reduce health care costs. venting smoking and other tobacco use can This study, which was developed through a lead to reductions of type 2 diabetes and high partnership of the Trust for America’s blood pressure by 5 percent in one to 2 years; Health (TFAH), The Urban Institute, The heart disease, kidney disease, and stroke by 5 New York Academy of Medicine (NYAM), the percent in 5 years; and some forms of cancer, Robert Wood Johnson Foundation (RWJF), COPD, and arthritis by 2.5 percent in 10 to 20 The California Endowment (TCE), and years. According to the literature, the per capi- Prevention Institute, examines how much ta cost of many effective community-based pro- the country could save in health care costs if grams is under $10 per person per year. we invested more in disease prevention, Therefore, TFAH concludes that an invest- specifically by funding proven community- ment of $10 per person per year in proven based programs that result in increased levels community-based disease prevention pro- of physical activity, improved nutrition (both grams could yield net savings of more than quality and quantity of food), and a reduc- $2.8 billion annually in health care costs in one tion in smoking and other tobacco use rates. to 2 years, more than $16 billion annually with- The researchers found that if the country in 5 years, and nearly $18 billion annually in 10 reduced type 2 diabetes and high blood pres- to 20 years (in 2004 dollars). With this level of sure rates by 5 percent the country could save investment, the country could recoup nearly more than $5 billion in health care costs; also $1 over and above the cost of the program for reducing heart disease, kidney disease, and every $1 invested in the first one to 2 years of stroke prevalence by 5 percent could raise the these programs, a return on investment (ROI) savings to more than $19 billion; and with addi- of 0.96. Within 5 years, the ROI could rise to tional 2.5 percent reductions in the prevalence 5.6 for every $1 invested and rise to 6.2 within of some forms of cancer, chronic obstructive 10 to 20 years. This return on investment rep- pulmonary disease (COPD) and arthritis sav- resents medical cost savings only and does not ings could increase to more than $21 billion. A include the significant gains that could be review of a range of evidence-based studies achieved in worker productivity, reduced shows that proven community-based disease absenteeism at work and school, and prevention programs can lead to improve- enhanced quality of life. NATIONAL RETURN ON INVESTMENT OF $10 PER PERSON (Net Savings in 2004 dollars) 1-2 Years 5 Years 10-20 Years U.S. Total $2,848,000,000 $16,543,000,000 $18,451,000,000 ROI 0.96:1 5.6:1 6.2:1 3 RETURN ON INVESTMENT In general, ROI compares the dollars invested in something to the benefits produced by that investment: ROI = (benefits of investment - amount invested) amount invested In the case of an investment in a prevention program, ROI compares the savings produced by the intervention, net of the cost of the program, to how much the program cost: ROI = ____net savings______ cost of intervention When ROI equals 0, the program pays for itself. When ROI is greater than 0, then the program is producing savings that exceed the cost of the program. The researchers evaluated 84 studies that I Offer information and support for peo- met their criteria to develop the assumptions ple trying to quit smoking and other for the drops in disease rates and the costs of tobacco use; and the programs. To be included in the review, I Raise cigarette and other tobacco tax rates. the studies had to focus on: Note: Additional examples can be found in 1) Prevention programs that do not require the Methodology Section and a full list of all medical treatment; the studies is available in Appendix A: 2) Programs that target communities rather Bibliography of the Literature Review. than individuals; and To build the model, the researchers evaluated: 3) Evidence-based programs that have been I Which diseases can be affected by shown to reduce disease through improv- improving physical activity and nutrition ing physical activity and nutrition and and preventing smoking and other preventing smoking and other tobacco tobacco use; use in communities. I How effective programs are at reducing Examples of the types of studies include rates of disease; programs that: I The range of estimated costs for these I Keep schools open after hours where chil- types of programs; dren can play with adult supervision; I The current rates of these diseases and I Provide access to fresh produce through current annual costs for treating these farmers markets; diseases; and I Make nutritious foods more affordable I The amount that could be saved if dis- and accessible in low-income areas; ease rates were reduced based on the I Require clear calorie and nutrition label- estimates. ing of foods; The project researchers built this model to I Provide young mothers with information yield conservative estimates for savings -- about how to make good choices about using low-end assumptions for the impact of nutrition; these programs on disease rates and high-end 4 assumptions for the costs of the programs. In The model also does not take into account addition, the health savings costs in this potential savings for increases in worker pro- model are in 2004 dollars and do not include ductivity, which could be significant. For exam- spending in nursing homes, which is signifi- ple, smoking-caused productivity losses cur- cant for these conditions. They also assumed rently total more than $90 billion per year, not the programs would only result in a one-time even including the losses from smokers taking reduction in the prevalence of each disease. more sick days than nonsmokers.2 Nor does it For instance, they assumed type 2 diabetes take into account the effect of the prevention rates would only drop once even though the programs on other health conditions that programs would continue over time and it is might be reduced as a result of these interven- likely the rates would continue to drop as the tions (e.g., increasing exercise improves heart programs continued over the years. This health as well as risk of injury due to falling). assumption helps take into account the possi- For more details on the methodology, see bility that some people may backslide while Section 4. others may continue to improve. ROI FOR PAYERS: MEDICARE, MEDICAID, AND PRIVATE INSURERS In addition to total dollars saved, the study looked at how this investment could benefit dif- ferent health care payers. Medicare could save more than $487 million annually in the first one to 2 years, more than $5.2 billion annually within 5 years, and nearly $5.9 billion annually in 10 to 20 years. Annually, Medicaid could save $370 million annually in the first one to 2 years, some $1.9 billion annually within 5 years, and more than $2 billion annually in 10 to 20 years. And, annually private insurers and individuals (through reductions of out-of-pocket costs) could see the biggest savings, with nearly $2 billion annually in the first one to 2 years, more than $9 billion annually within 5 years, and more than $10 billion annually in 10 to 20 years. Net Savings By Medicare, Medicaid, And Private Insurers For An Investment Of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare, U.S. Total $487,000,000 $5,213,000,000 $5,971,000,000 Medicaid, U.S. Total $370,000,000 $1,951,000,000 $2,195,000,000 Other payers and out-of-pocket, $1,991,000,000 $9,380,000,000 $10,285,000,000 U.S. Total * In 2004 dollars, net savings 5 A HEALTHIER AND LESS COSTLY LIFE: NOT JUST DEFERRING COSTS TO END OF LIFE The return on investment for community- cies, but the health care costs of an obese per- based disease prevention programs does not son will be significantly higher than a non-obese just defer high health care costs to the end of person over the course of a lifetime. Therefore, life. By increasing physical activity and good higher costs are not offset by reduced longevity. nutrition and decreasing smoking and other Obese people also have “fewer disability-free life tobacco use, we are ensuring that more people years and experience higher rates of diabetes, will be healthier for longer periods of their life. hypertension, and heart disease.”3 Being healthier throughout their lifetimes, As one example, a person who is obese has these individuals might avoid developing a higher risk for needing a knee replace- complications or compounding conditions ment. If the obesity is prevented, the need - that may develop if they are less healthy - and cost -- for a knee replacement may be (e.g., gain too much weight, are physically delayed or avoided altogether. inactive, or practice poor nutrition). Also, studies have found that smokers, on A recent study by Lakdawalla, Goldman, and average, have significantly higher health care Shang in Health Affairs demonstrated that obese costs than non-smokers, but smokers dying and non-obese people have similar life expectan- sooner does not save money.4, 5 Scientists refer to this effect as “compression of morbidity,” which means extending healthy life expectancy more than total life expectancy. Chronic disease and disability are compressed into a smaller portion of a person’s life -- and his or her lifelong health care management costs are lower and quality of life is improved.6, 7 DIFFERENT TYPES OF PREVENTION EFFORTS YIELD DIFFERENT RETURNS A number of studies have examined whether tion focuses on the reduction of further com- prevention efforts result in cost savings in plications of an existing disease or problem, addition to helping people be healthier. A through treatment and rehabilitation.9 February 2008 article, “Does Preventive Care Many factors influence whether specific pre- Save Money? Health Economics and the vention efforts result in cost-savings. For Presidential Candidates,” in The New England instance, prevention efforts involving direct Journal of Medicine (NEJM) reviewed a wide medical treatment or pharmaceuticals often range of studies looking at the potential cost- have higher costs. These “tertiary” preven- savings for prevention programs and noted tion measures are aimed at trying to reverse a that “studies have concluded that preventing condition or prevent it from getting worse. illness can in some cases save money but in “Secondary” prevention efforts, which include other cases can add to health care costs.”8 early detection and prompt intervention to There are 3 types of prevention: primary, sec- control a problem or disease and minimize ondary, and tertiary. Primary prevention the consequences of a disease, are more cost- involves taking action before a problem arises in effective if they are targeted to at-risk popula- order to avoid it entirely, rather than treating or tions. In addition, the NEJM authors acknowl- alleviating its consequences. Primary prevention edged that there are prevention programs can include clinical interventions, such as specific that are not implemented on a wide enough immunizations, and broader public health inter- scale to determine whether they could bring ventions, such as clean water and sewage sys- about “substantial aggregate improvements in tems; fortification of food with specific nutrients, health at an acceptable cost.”10 such as folic acid; and protection from carcino- The TFAH model is based on studies of gens, such as second-hand tobacco smoke. strategic low-cost, community-based pri- Secondary prevention is a set of measures mary and secondary prevention efforts that used for early detection and prompt interven- have demonstrated results in lowering dis- tion to control a problem or disease and mini- ease rates or improving health choices, but mize the consequences, while tertiary preven- do not involve direct medical care. 6 Current Health and Economic Costs ASSOCIATED WITH PHYSICAL INACTIVITY, POOR NUTRITION, AND SMOKING AND 2 SECTION OTHER TOBACCO USE ACCORDING TO MCKINSEY & COMPANY AS OF 2008, “THE AVERAGE FORTUNE 500 COMPANY WILL SPEND AS MUCH ON HEALTH CARE AS THEY MAKE IN PROFIT. HOW CAN WE POSSIBLY COMPETE IN THE GLOBAL ECONOMY WITH THAT KIND OF BURDEN?”11 — ANDY STERN, PRESIDENT OF THE SERVICE EMPLOYEES INTERNATIONAL UNION (SEIU) “IF WE CAN CREATE A HEALTH CARE PLAN THAT CONTAINS COSTS OR DRIVES THEM DOWN, THAT IMPROVES THE HEALTH OF THE EMPLOYEE AND EXTENDS THEIR LIFE, AND AVOIDS CATASTROPHIC ILLNESS AND DOESN’T COST THEM ANY MORE MONEY, WHY WOULD ANYONE QUARREL WITH THAT PLAN?”12 — STEVEN BURD, CHIEF EXECUTIVE OFFICER OF SAFEWAY General Motors (GM) estimates it pays $1,500 per car produced in health care coverage costs to employees and retirees (more than it pays for steel), and these costs are passed onto the consumer. In addition, GM claims that rising health care costs were a critical factor in the decision to cut 25,000 jobs (a cut that can impact up to 175,000 jobs in other sectors of the economy).13, 14 America’s future economic well-being is inex- And if we invest more in keeping Americans tricably tied to our health. Helping Americans healthy, not only will we spare millions of stay healthier is the best way to drive down people from needless suffering, we will also health care costs and ensure our workforce is save the country billions of dollars. competitive in the global economy. Right now, however, America’s health care The skyrocketing costs of health care are system is set up to focus on treating people hurting the U.S. economy. Health care costs once they have a health problem. Some are more than 3 times higher than in 1990 experts describe this as “sick care” instead of and more than 8 times higher than in 1980.15 health care. Poor health is putting our economic securi- The country will never be able to contain ty in jeopardy. High health care costs are health care costs until we start focusing on undermining business profits, causing some how to prevent people from getting sick in companies to relocate jobs overseas where the first place, putting an emphasis on costs are lower and productivity is higher. improving the choices we make that affect 7 our risk for preventable diseases. Experts As a nation, if we develop strategies and pro- widely agree that 3 of the most important grams that help more Americans become factors that influence our health are: physically active, practice good nutrition, and stop smoking and other tobacco use 1) Physical activity; (while also helping our youth from ever 2) Nutrition (including eating foods of high starting smoking or other unhealthy prac- nutritional value and in the right quanti- tices), we could have a tremendous payoff ties); and both in improving health and reducing health care costs. 3) Whether or not we smoke. MAJOR FACTORS IN U.S. HEALTH: LACK OF PHYSICAL ACTIVITY, POOR NUTRITION, AND SMOKING AND TOBACCO USE In the past 3 decades, the health of Americans has changed dramatically. Adult obesity rates have doubled since 1980, and childhood obesity rates have tripled.16 Two-thirds of adults are either overweight or obese.17 The childhood obesity epidemic is putting today’s youth on course to possibly be the first generation to live shorter, less healthy lives than their parents.18 In addition, after years of declines, smoking rates have leveled off, with 21 percent of adults and 20 percent of high school students continuing to smoke.19, 20, 21 Obesity and smoking put people at significantly higher risk for developing serious and costly diseases. Current Health Statistics Right now, more than half of Americans live with one or more chronic disease, such as heart disease, stroke, diabetes, or cancer.22 I One in 4 Americans has heart disease, one in 3 has high blood pressure.23 I Twenty-four million Americans have type 2 diabetes, and another 54 million are pre-diabet- ic, at high risk for developing type 2 diabetes.24, 25, 26 An estimated 2 million adolescents have pre-diabetes.27 The risks of developing heart disease, stroke, and kidney disease are exponentially higher if a person is both obese and a smoker. There are other conditions related to activity, nutrition, and smoking, but combined, these sets of diseases are the most common and costly. Diseases Related to Physical Inactivity and Poor Nutrition People who do not engage in adequate physical activity, have poor nutrition habits, and/or are obese are at increased risk for type 2 diabetes, high blood pressure (hypertension), heart disease, stroke, kidney disease, some forms of cancer, arthritis, and chronic obstructive pulmonary disease (COPD).28 I More than 75 percent of high blood pressure cases can be attributed to obesity.29 I Over time, type 2 diabetes and high blood pressure put people at increased risk for devel- oping even more serious conditions, including heart disease, stroke, or kidney disease. I Other obese or inactive individuals can also develop heart disease, stroke, or kidney disease without first being diabetic or hypertensive. I Approximately 20 percent of cancer in women and 15 percent of cancer in men can be attributed to obesity.30 I Obesity is a known risk factor for the development and progression of knee osteoarthritis and possibly osteoarthritis of other joints. For example, obese adults are up to 4 times more likely to develop knee osteoarthritis than normal weight adults.31 Among individuals who have received a doctor’s diagnosis of arthritis 68.8 percent are overweight or obese.32 For every pound of body weight lost, there is a 4-pound reduction in knee joint stress among overweight and obese people with osteoarthritis of the knee.33 8 Financial Costs of Obesity, Physical Inactivity, and Poor Nutrition I More than one quarter of America’s health care costs are related to obesity.34, 35 Health care costs of obese workers are up to 21 percent higher than non-obese workers.36 Obese and physically inactive workers also suffer from lower worker productivity, increased absenteeism, and higher workers’ compensation claims.37 I The Minnesota Department of Health estimates physical inactivity costs the state approxi- mately $100 per person (year 2000 costs), at a total of $495 million in direct costs ($383 million in hospital, outpatient, and professional expenses and $112 million for outpatient prescription drugs.)38 BlueCross BlueShield of Minnesota found that 31 percent of its heart disease, stroke, colon cancer, and osteoporosis costs were due to physical inactivity -- about $84 million in 2000, which was $56 per member, regardless of their level of activ- ity.39 Canadian researchers estimate that Canada could save $150 million per year of the $2.1 billion it currently spends on health care costs related to physical inactivity (25 per- cent of costs of coronary artery disease, stroke, hypertension, colon cancer, breast cancer, type 2 diabetes, and osteoporosis) if activity levels were increased by 10 percent.40 Current Physical Activity and Nutrition Falls Short of National Goals I The percent of adults who do not engage in any form of physical activity ranges from 15.7 percent in Minnesota to 31.8 percent in Mississippi, and many more do not engage in the recommended levels.41 I Many Americans are eating larger quantities of food than is healthy and they are often consuming foods with low nutritional value. On average, we consume approximately 300 more calories daily than Americans did in 1985.42 I The U.S. Department of Agriculture (USDA) reports that America’s fruit and vegetable consumption is “woefully low” and is limited to only a small range of potential options.43 I Since the 1980s, sugar and fat consumption has dramatically increased while whole grains and milk consumption has dropped.44, 45 Diseases Related To Smoking Smoking harms nearly every organ in the body.46 I Smoking causes the vast majority of all deaths from lung cancer. I Smoking is a major cause of heart disease, cerebrovascular disease, chronic bronchitis and emphysema.47 I Smoking is a known cause of cancer of the lung, larynx, oral cavity, bladder, pancreas, uterus, cervix, kidney, stomach and esophagus.48 Financial Costs of Smoking I Tobacco use costs the U.S. more than $180 billion annually in health care bills and lost productivity.49 Lifetime health care costs for individuals who smoke are $17,500 higher than for those who do not smoke.50 Current Smoking Rates Fall Short of National Goals I Despite progress over the past decade, every single day more than 1,000 new kids become regular, daily smokers while another 4,000 kids try their first cigarette.51 9 State-By-State ROI T his section examines how much states could save if we invested $10 per person in strategic community-based disease prevention programs aimed at improving physical activity and nutrition and preventing smoking 3 SECTION and other tobacco use. The estimates in this section characterize Second, community-based interventions tar- likely relative magnitudes of the savings get entire communities. Health insurance states could realize from well-designed com- coverage in most communities is mixed with munity-level programs implemented some people covered by private insurance statewide. These estimates should be con- and others by Medicaid or Medicare. Some sidered preliminary for two reasons. First, community residents are uninsured. Disease they are based on the estimated national patterns also vary by community and these proportions of spending attributable to per- patterns may be associated with insurance sons with intervention-amenable diseases coverage, as in the case of age and Medicare applied to state data on spending by payer coverage. Distribution of costs of program reported by CMS.52 TFAH calculated them interventions to different payers across the using preliminary estimates of savings by community is, therefore, not straightforward. state and payer produced by Urban While the reductions in medical expendi- Institute researchers. The estimates do not tures can be assigned to specific payers, costs take into account differences in state popu- of the intervention are not assignable. lation characteristics, such as the distribu- The federal and state governments share the tion by age and ethnicity, disease preva- costs of Medicaid, however, each state pays a lence, or environmental characteristics, different percentage share. The following such as urban/rural population distribu- state charts reflect the proportions that the tion, which can have a significant effect on federal and state governments pay in each costs and savings. For example, state preva- state based on their percentage share lences range from 4 percent to 9.8 percent according to the data in the Kaiser Family for diabetes, 20 percent to 32.5 percent for Foundation’s www.statehealthfacts.org hypertension, and 24 percent to 37.3 per- “Federal and State Share of Medicaid cent for high cholesterol.53 Spending, FY 2006. 11 Alabama Total Annual Intervention Costs (at $10 per person): $45,170,000 Alabama Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $87,800,000 $295,700,000 $324,700,000 State Net Savings (Net savings = Total savings $42,600,000 $250,600,000 $279,500,000 minus intervention costs) ROI for State 0.94:1 5.55:1 6.19:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion $11,500,000 $67,600,000 $75,400,000 of net savings) Medicaid Net Savings (federal share) $2,870,000 $16,800,000 $18,800,000 (proportion of net savings) Medicaid Net Savings (state share) $1,260,000 $7,410,000 $8,270,000 (proportion of net savings) Private Payer and Out of Pocket Net $27,000,000 $158,600,000 $176,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Alaska Total Annual Intervention Costs (at $10 per person): $6,570,000 Alaska Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $16,000,000 $53,800,000 $59,100,000 State Net Savings (Net savings = Total savings $9,430,000 $47,300,000 $52,500,000 minus intervention costs) ROI for State 1.44:1 7.20:1 8.01:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $2,540,000 $12,700,000 $14,200,000 (proportion of net savings) Medicaid Net Savings (federal share) $459,000 $2,300,000 $2,560,000 (proportion of net savings) Medicaid Net Savings (state share) $455,000 $2,280,000 $2,540,000 (proportion of net savings) Private Payer and Out of Pocket Net $5,970,000 $29,900,000 $33,200,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 12 Arizona Total Annual Intervention Costs (at $10 per person): $57,460,000 Arizona Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $89,000,000 $299,700,000 $329,100,000 State Net Savings (Net savings = Total savings $31,500,000 $242,200,000 $271,600,000 minus intervention costs) ROI for State 0.55:1 4.22:1 4.73:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $8,510,000 $65,400,000 $73,300,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,050,000 $15,700,000 $17,600,000 (proportion of net savings) Medicaid Net Savings (state share) $1,010,000 $7,750,000 $8,690,000 (proportion of net savings) Private Payer and Out of Pocket Net $19,900,000 $153,300,000 $171,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Arkansas Total Annual Intervention Costs (at $10 per person): $27,470,000 Arkansas Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $49,600,000 $167,100,000 $183,500,000 State Net Savings (Net savings = Total savings $22,100,000 $139,600,000 $156,000,000 minus intervention costs) ROI for State 0.81:1 5.09:1 5.68:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $5,980,000 $37,700,000 $42,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,580,000 $10,000,000 $11,100,000 (proportion of net savings) Medicaid Net Savings (state share) $563,000 $3,550,000 $3,960,000 (proportion of net savings) Private Payer and Out of Pocket Net Savings (proportion of net savings) $14,000,000 $88,400,000 $98,700,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 13 California Total Annual Intervention Costs (at $10 per person): $358,410,000 California Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $621,400,000 $2,092,700,000 $2,297,700,000 State Net Savings (Net savings = Total savings $262,900,000 $1,734,300,000 $1,939,300,000 minus intervention costs) ROI for State 0.73:1 4.84:1 5.41:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $71,000,000 $468,200,000 $523,600,000 (proportion of net savings) Medicaid Net Savings (federal share) $12,700,000 $84,100,000 $94,000,000 (proportion of net savings) Medicaid Net Savings (state share) $12,700,000 $84,100,000 $94,000,000 (proportion of net savings) Private Payer and Out of Pocket Net $166,400,000 $1,097,800,000 $1,227,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Colorado Total Annual Intervention Costs (at $10 per person): $45,990,000 Colorado Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $82,600,000 $278,300,000 $305,600,000 State Net Savings (Net savings = Total savings $36,600,000 $232,300,000 $259,600,000 minus intervention costs) ROI for State 0.80:1 5.05:1 5.65:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $9,890,000 $62,700,000 $70,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,770,000 $11,200,000 $12,500,000 (proportion of net savings) Medicaid Net Savings (state share) $1,770,000 $11,200,000 $12,500,000 (proportion of net savings) Private Payer and Out of Pocket Net $23,200,000 $147,000,000 $164,300,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 14 Connecticut Total Annual Intervention Costs (at $10 per person): $34,940,000 Connecticut Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $79,100,000 $266,400,000 $292,500,000 State Net Savings (Net savings = Total savings $44,100,000 $231,500,000 $257,600,000 minus intervention costs) ROI for State 1.26:1 6.63:1 7.37:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $11,900,000 $62,500,000 $69,500,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,140,000 $11,200,000 $12,400,000 (proportion of net savings) Medicaid Net Savings (state share) $2,140,000 $11,200,000 $12,400,000 (proportion of net savings) Private Payer and Out of Pocket Net $27,900,000 $146,500,000 $163,000,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Delaware Total Annual Intervention Costs (at $10 per person): $8,290,000 Delaware Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $19,500,000 $65,800,000 $72,300,000 State Net Savings (Net savings = Total savings $11,200,000 $57,500,000 $64,000,000 minus intervention costs) ROI for State 1.36:1 6.95:1 7.72:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,040,000 $15,500,000 $17,200,000 (proportion of net savings) Medicaid Net Savings (federal share) (proportion of net savings) $547,000 $2,790,000 $3,110,000 Medicaid Net Savings (state share) $545,000 $2,780,000 $3,090,000 (proportion of net savings) Private Payer and Out of Pocket Net $7,130,000 $36,400,000 $40,500,000 Savings(proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 15 Washington D.C. Total Annual Intervention Costs (at $10 per person): $5,800,000 D.C. Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $18,700,000 $63,000,000 $69,100,000 State Net Savings (Net savings = Total savings $12,900,000 $57,200,000 $63,300,000 minus intervention costs) ROI for State 2.23:1 9.86:1 10.93:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,480,000 $15,400,000 $17,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $876,000 $3,880,000 $4,300,000 (proportion of net savings) Medicaid Net Savings (state share) $375,000 $1,660,000 $1,840,000 (proportion of net savings) Private Payer and Out of Pocket Net $8,170,000 $36,200,000 $40,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Florida Total Annual Intervention Costs (at $10 per person): $173,670,000 Florida Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $369,700,000 $1,245,300,000 $1,367,300,000 State Net Savings (Net savings = Total savings $196,100,000 $1,071,600,000 $1,193,600,000 minus intervention costs) ROI for State 1.13:1 6.17:1 6.87:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $52,900,000 $289,300,000 $322,200,000 (proportion of net savings) Medicaid Net Savings (federal share) $11,200,000 $61,200,000 $68,100,000 (proportion of net savings) Medicaid Net Savings (state share) $7,810,000 $42,700,000 $47,500,000 (proportion of net savings) Private Payer and Out of Pocket Net $124,100,000 $678,300,000 $755,500,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 16 Georgia Total Annual Intervention Costs (at $10 per person): $89,350,000 Georgia Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $153,100,000 $515,700,000 $566,200,000 State Net Savings (Net savings = Total savings $63,700,000 $426,300,000 $476,900,000 minus intervention costs) ROI for State 0.71:1 4.77:1 5.34:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $17,200,000 $115,100,000 $128,700,000 (proportion of net savings) Medicaid Net Savings (federal share) $3,740,000 $25,000,000 $28,000,000 (proportion of net savings) Medicaid Net Savings (state share) $2,430,000 $16,200,000 $18,200,000 (proportion of net savings) Private Payer and Out of Pocket Net $40,300,000 $269,900,000 $301,800,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Hawaii Total Annual Intervention Costs (at $10 per person): $12,590,000 Hawaii Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $24,500,000 $82,600,000 $90,700,000 State Net Savings (Net savings = Total savings $11,900,000 $70,100,000 $78,200,000 minus intervention costs) ROI for State 0.95:1 5.57:1 6.21:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,230,000 $18,900,000 $21,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $682,000 $3,990,000 $4,460,000 (proportion of net savings) Medicaid Net Savings (state share) $478,000 $2,800,000 $3,120,000 (proportion of net savings) Private Payer and Out of Pocket Net $7,570,000 $44,300,000 $49,500,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 17 Idaho Total Annual Intervention Costs (at $10 per person): $13,950,000 Idaho Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $22,600,000 $76,200,000 $83,700,000 State Net Savings (Net savings = Total savings $8,690,000 $62,300,000 $69,700,000 minus intervention costs) ROI for State 0.62:1 4.47:1 5.00:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $2,340,000 $16,800,000 $18,800,000 (proportion of net savings) Medicaid Net Savings (federal share) (proportion of net savings) $589,000 $4,220,000 $4,730,000 Medicaid Net Savings (state share) (proportion of net savings) $253,000 $1,810,000 $2,030,000 Private Payer and Out of Pocket Net $5,500,000 $39,400,000 $44,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Illinois Total Annual Intervention Costs (at $10 per person): $127,140,000 Illinois Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $247,900,000 $835,200,000 $917,000,000 State Net Savings (Net savings = Total savings $120,800,000 $708,000,000 $789,800,000 minus intervention costs) ROI for State 0.95:1 5.57:1 6.21:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $32,600,000 $191,100,000 $213,200,000 (proportion of net savings) Medicaid Net Savings (federal share) $5,860,000 $34,300,000 $38,300,000 (proportion of net savings) Medicaid Net Savings (state share) $5,860,000 $34,300,000 $38,300,000 (proportion of net savings) Private Payer and Out of Pocket Net $76,500,000 $448,200,000 $499,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 18 Indiana Total Annual Intervention Costs (at $10 per person): $62,230,000 Indiana Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $120,400,000 $405,500,000 $445,200,000 State Net Savings (Net savings = Total savings $58,100,000 $343,300,000 $383,000,000 minus intervention costs) ROI for State 0.94:1 5.52:1 6.16:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $15,700,000 $92,600,000 $103,400,000 (proportion of net savings) Medicaid Net Savings (federal share) $3,550,000 $20,900,000 $23,400,000 (proportion of net savings) Medicaid Net Savings (state share) $2,080,000 $12,300,000 $13,700,000 (proportion of net savings) Private Payer and Out of Pocket Net $36,800,000 $217,300,000 $242,400,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Iowa Total Annual Intervention Costs (at $10 per person): $29,540,000 Iowa Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $57,900,000 $195,100,000 $214,300,000 State Net Savings (Net savings = Total savings $28,400,000 $165,600,000 $184,700,000 minus intervention costs) ROI for State 0.96:1 5.61:1 6.26:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $7,670,000 $44,700,000 $49,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,750,000 $10,200,000 $11,300,000 (proportion of net savings) Medicaid Net Savings (state share) $1,000,000 $5,800,000 $6,520,000 (proportion of net savings) Private Payer and Out of Pocket Net $17,900,000 $104,800,000 $116,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 19 Kansas Total Annual Intervention Costs (at $10 per person): $27,380,000 Kansas Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $54,300,000 $182,900,000 $200,800,000 State Net Savings (Net savings = Total savings $26,900,000 $155,500,000 $173,400,000 minus intervention costs) ROI for State 0.98:1 5.68:1 6.34:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $7,270,000 $41,900,000 $46,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,570,000 $9,110,000 $10,100,000 (proportion of net savings) Medicaid Net Savings (state share) $1,030,000 $5,970,000 $6,660,000 (proportion of net savings) Private Payer and Out of Pocket Net Savings (proportion of net savings) $17,000,000 $98,400,000 $109,700,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Kentucky Total Annual Intervention Costs (at $10 per person): $41,400,000 Kentucky Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $86,200,000 $290,300,000 $318,700,000 State Net Savings (Net savings = Total savings $44,800,000 $248,900,000 $277,300,000 minus intervention costs) ROI for State 1.08:1 6.01:1 6.70:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $12,000,000 $67,200,000 $74,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $3,010,000 $16,700,000 $18,600,000 (proportion of net savings) Medicaid Net Savings (state share) (proportion of net savings) $1,330,000 $7,410,000 $8,250,000 Private Payer and Out of Pocket Net Savings (proportion of net savings) $28,300,000 $157,500,000 $175,500,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 20 Louisiana Total Annual Intervention Costs (at $10 per person): $44,960,000 Louisiana Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $83,000,000 $279,800,000 $307,200,000 State Net Savings (Net savings = Total savings $38,100,000 $234,800,000 $262,200,000 minus intervention costs) ROI for State 0.85:1 5.22:1 5.83:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $10,200,000 $63,400,000 $70,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,580,000 $15,900,000 $17,700,000 (proportion of net savings) Medicaid Net Savings (state share) $1,110,000 $6,870,000 $7,680,000 (proportion of net savings) Private Payer and Out of Pocket Net $24,100,000 $148,600,000 $166,000,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Maine Total Annual Intervention Costs (at $10 per person): $13,140,000 Maine Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $33,200,000 $111,900,000 $122,800,000 State Net Savings (Net savings = Total savings $20,100,000 $98,700,000 $109,700,000 minus intervention costs) ROI for State 1.53:1 7.52:1 8.35:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion of net savings) $5,420,000 $26,600,000 $29,600,000 Medicaid Net Savings (federal share) (proportion of net savings) $1,220,000 $6,020,000 $6,690,000 Medicaid Net Savings (state share) (proportion of net savings) $723,000 $3,550,000 $3,940,000 Private Payer and Out of Pocket Net Savings (proportion of net savings) $12,700,000 $62,500,000 $69,400,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 21 Maryland Total Annual Intervention Costs (at $10 per person): $55,530,000 Maryland Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $115,100,000 $387,800,000 $425,800,000 State Net Savings (Net savings = Total savings $59,600,000 $332,200,000 $370,200,000 minus intervention costs) ROI for State 1.07:1 5.98:1 6.67:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $16,000,000 $89,700,000 $99,900,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,890,000 $16,100,000 $17,900,000 (proportion of net savings) Medicaid Net Savings (state share) $2,890,000 $16,100,000 $17,900,000 (proportion of net savings) Private Payer and Out of Pocket Net $37,700,000 $210,300,000 $234,300,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Massachusetts Total Annual Intervention Costs (at $10 per person): $64,360,000 Massachusetts Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $160,500,000 $540,800,000 $593,700,000 State Net Savings (Net savings = Total savings $96,200,000 $476,400,000 $529,300,000 minus intervention costs) ROI for State 1.50:1 7.40:1 8.23:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $25,900,000 $128,600,000 $142,900,000 (proportion of net savings) Medicaid Net Savings (federal share) $4,660,000 $23,100,000 $25,600,000 (proportion of net savings) Medicaid Net Savings (state share) $4,660,000 $23,100,000 $25,600,000 (proportion of net savings) Private Payer and Out of Pocket Net $60,900,000 $301,500,000 $335,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 22 Michigan Total Annual Intervention Costs (at $10 per person): $100,930,000 Michigan Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $191,900,000 $646,300,000 $709,600,000 State Net Savings (Net savings = Total savings $90,900,000 $545,400,000 $60,800,000 minus intervention costs) ROI for State 0.90:1 5.40:1 6.03:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $24,500,000 $147,200,000 $164,300,000 (proportion of net savings) Medicaid Net Savings (federal share) $4,990,000 $29,900,000 $33,400,000 (proportion of net savings) Medicaid Net Savings (state share) (proportion of net savings) $3,830,000 $22,900,000 $25,600,000 Private Payer and Out of Pocket Net Savings (proportion of net savings) $57,500,000 $345,200,000 $385,300,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Minnesota Total Annual Intervention Costs (at $10 per person): $50,940,000 Minnesota Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $109,200,000 $367,800,000 $403,900,000 State Net Savings (Net savings = Total savings $58,200,000 $316,900,000 $352,900,000 minus intervention costs) ROI for State 1.14:1 6.22:1 6.93:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion of net savings) $15,700,000 $85,500,000 $95,300,000 Medicaid Net Savings (federal share) $2,820,000 $15,300,000 $17,100,000 (proportion of net savings) Medicaid Net Savings (state share) (proportion of net savings) $2,820,000 $15,300,000 $17,100,000 Private Payer and Out of Pocket Net $36,900,000 $200,600,000 $223,400,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 23 Mississippi Total Annual Intervention Costs (at $10 per person): $28,930,000 Mississippi Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $53,200,000 $179,400,000 $196,900,000 State Net Savings (Net savings = Total savings $24,300,000 $150,400,000 $168,000,000 minus intervention costs) ROI for State 0.84:1 5.20:1 5.81:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion of net savings) $6,570,000 $40,600,000 $45,300,000 Medicaid Net Savings (federal share) (proportion of net savings) $1,790,000 $11,000,000 $12,300,000 Medicaid Net Savings (state share) (proportion of net savings) $566,000 $3,500,000 $3,910,000 Private Payer and Out of Pocket Net Savings (proportion of net savings) $15,400,000 $95,200,000 $106,300,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Missouri Total Annual Intervention Costs (at $10 per person): $57,530,000 Missouri Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $116,400,000 $392,100,000 $430,500,000 State Net Savings (Net savings = Total savings $58,900,000 $334,600,000 $373,000,000 minus intervention costs) ROI for State 1.02:1 5.82:1 6.49:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $15,900,000 $90,300,000 $100,700,000 (proportion of net savings) Medicaid Net Savings (federal share) (proportion of net savings) $3,530,000 $20,000,000 $22,300,000 Medicaid Net Savings (state share) (proportion of net savings) $2,170,000 $12,300,000 $13,700,000 Private Payer and Out of Pocket Net Savings (proportion of net savings) $37,200,000 $211,800,000 $236,100,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 24 Montana Total Annual Intervention Costs (at $10 per person): $9,260,000 Montana Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $17,900,00 $60,300,000 $66,200,000 State Net Savings (Net savings = Total savings $8,650,000 $51,000,000 $56,900,000 minus intervention costs) ROI for State 0.94:1 5.52:1 6.16:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion of net savings) $2,330,000 $13,700,000 $15,300,000 Medicaid Net Savings (federal share) $592,000 $3,490,000 $3,890,000 (proportion of net savings) Medicaid Net Savings (state share) $247,000 $1,460,000 $1,630,000 (proportion of net savings) Private Payer and Out of Pocket Net $5,480,000 $32,300,000 $36,000,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Nebraska Total Annual Intervention Costs (at $10 per person): $17,470,000 Nebraska Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $35,500,000 $119,700,000 $131,500,000 State Net Savings (Net savings = Total savings $18,100,000 $102,300,000 $114,000,000 minus intervention costs) ROI for State 1.04:1 5.86:1 6.53:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $4,880,000 $27,600,000 $30,700,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,040,000 $5,920,000 $6,600,000 (proportion of net savings) Medicaid Net Savings (state share) $707,000 $3,990,000 $4,450,000 (proportion of net savings) Private Payer and Out of Pocket Net $11,400,000 $64,700,000 $72,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 25 Nevada Total Annual Intervention Costs (at $10 per person): $23,320,000 Nevada Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $41,200,000 $139,000,000 $152,600,000 State Net Savings (Net savings = Total savings $17,900,000 $115,700,000 $129,300,000 minus intervention costs) ROI for State 0.77:1 4.96:1 5.55:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $4,850,000 $31,200,000 $34,900,000 (proportion of net savings) Medicaid Net Savings (federal share) $954,000 $6,150,000 $6,870,000 (proportion of net savings) Medicaid Net Savings (state share) $787,000 $5,070,000 $5,670,000 (proportion of net savings) Private Payer and Out of Pocket Net $11,300,000 $73,200,000 $81,800,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. New Hampshire Total Annual Intervention Costs (at $10 per person): $12,980,000 New Hampshire Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $26,500,000 $89,500,000 $98,200,000 State Net Savings (Net savings = Total savings $13,600,000 $76,500,000 $85,300,000 minus intervention costs) ROI for State 1.05:1 5.90:1 6.57:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,670,000 $20,600,000 $23,000,000 (proportion of net savings) Medicaid Net Savings (federal share) $659,000 $3,710,000 $4,130,000 (proportion of net savings) Medicaid Net Savings (state share) $659,000 $3,710,000 $4,130,000 (proportion of net savings) Private Payer and Out of Pocket Net $8,600,000 $48,400,000 $53,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 26 New Jersey Total Annual Intervention Costs (at $10 per person): $86,760,000 New Jersey Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $187,100,000 $630,400,000 $692,100,000 State Net Savings (Net savings = Total savings $100,400,000 $543,600,000 $605,400,000 minus intervention costs) ROI for State 1.16:1 6.27:1 6.98:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $27,100,000 $146,700,000 $163,400,000 (proportion of net savings) Medicaid Net Savings (federal share) $4,870,000 $26,300,000 $29,300,000 (proportion of net savings) Medicaid Net Savings (state share) $4,870,000 $26,300,000 $29,300,000 (proportion of net savings) Private Payer and Out of Pocket Net $63,500,000 $344,100,000 $383,200,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. New Mexico Total Annual Intervention Costs (at $10 per person): $19,010,000 New Mexico Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $32,000,000 $107,900,000 $118,500,000 State Net Savings (Net savings = Total savings $13,000,000 $88,900,000 $99,500,000 minus intervention costs) ROI for State 0.69:1 4.68:1 5.24:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,520,000 $24,000,000 $26,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $901,000 $6,140,000 $6,870,000 (proportion of net savings) Medicaid Net Savings (state share) $366,000 $2,490,000 $2,790,000 (proportion of net savings) Private Payer and Out of Pocket Net $8,260,000 $56,300,000 $63,000,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 27 New York Total Annual Intervention Costs (at $10 per person): $192,920,000 New York Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $460,400,000 $1,550,600,000 $1,702,500,000 State Net Savings (Net savings = Total savings $267,500,000 $1,357,700,000 $1,509,600,000 minus intervention costs) ROI for State 1.37:1 7.04:1 7.83:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $72,200,000 $366,500,000 $407,600,000 (proportion of net savings) Medicaid Net Savings (federal share) $12,900,000 $65,800,000 $73,200,000 (proportion of net savings) Medicaid Net Savings (state share) $12,900,000 $65,800,000 $73,200,000 (proportion of net savings) Private Payer and Out of Pocket Net $169,300,000 $859,400,000 $955,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. North Carolina Total Annual Intervention Costs (at $10 per person): $85,310,000 North Carolina Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $166,000,000 $559,000,000 $613,800,000 State Net Savings (Net savings = Total savings $80,600,000 $473,700,000 $528,500,000 minus intervention costs) ROI for State 0.95:1 5.55:1 6.20:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $21,700,000 $127,900,000 $142,600,000 (proportion of net savings) Medicaid Net Savings (federal share) $4,970,000 $29,100,000 $32,500,000 (proportion of net savings) Medicaid Net Savings (state share) $2,850,000 $16,700,000 $18,700,000 (proportion of net savings) Private Payer and Out of Pocket Net $51,000,000 $299,800,000 $334,500,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 28 North Dakota Total Annual Intervention Costs (at $10 per person): $6,360,000 North Dakota Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $13,500,000 $45,700,000 $50,200,000 State Net Savings (Net savings = Total savings $7,230,000 $39,400,000 $43,900,000 minus intervention costs) ROI for State 1.14:1 6.20:1 6.90:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $1,950,000 $10,600,000 $11,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $462,000 $2,520,000 $2,800,000 (proportion of net savings) Medicaid Net Savings (state share) $240,000 $1,300,000 $1,450,000 (proportion of net savings) Private Payer and Out of Pocket Net $4,570,000 $24,900,000 $27,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Ohio Total Annual Intervention Costs (at $10 per person): $114,610,000 Ohio Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $237,700,000 $800,500,000 $878,900,000 State Net Savings (Net savings = Total savings $123,000,000 $685,900,000 $764,300,000 minus intervention costs) ROI for State 1.07:1 5.99:1 6.67:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $33,200,000 $185,200,000 $206,300,000 (proportion of net savings) Medicaid Net Savings (federal share) $7,150,000 $39,800,000 $44,400,000 (proportion of net savings) Medicaid Net Savings (state share) $4,780,000 $26,600,000 $29,700,000 (proportion of net savings) Private Payer and Out of Pocket Net Savings (proportion of net savings) $77,900,000 $434,200,000 $483,800,000 * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 29 Oklahoma Total Annual Intervention Costs (at $10 per person): $35,230,000 Oklahoma Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $65,000,000 $219,000,000 $240,400,000 State Net Savings (Net savings = Total savings $29,800,000 $183,800,000 $205,200,000 minus intervention costs) ROI for State 0.85:1 5.22:1 5.83:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $8,040,000 $49,600,000 $55,400,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,960,000 $12,100,000 $13,500,000 (proportion of net savings) Medicaid Net Savings (state share) (proportion of net savings) $928,000 $5,720,000 $6,390,000 Private Payer and Out of Pocket Net $18,800,000 $116,300,000 $129,900,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Oregon Total Annual Intervention Costs (at $10 per person): $35,890,000 Oregon Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $68,100,000 $229,400,000 $251,900,000 State Net Savings (Net savings = Total savings $32,200,000 $193,500,000 $216,000,000 minus intervention costs) ROI for State 0.90:1 5.39:1 6.02:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $8,700,000 $52,200,000 $58,300,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,920,000 $11,500,000 $12,900,000 (proportion of net savings) Medicaid Net Savings (state share) $1,200,000 $7,200,000 $8,040,000 (proportion of net savings) Private Payer and Out of Pocket Net $20,400,000 $122,500,000 $136,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 30 Pennsylvania Total Annual Intervention Costs (at $10 per person): $123,770,000 Pennsylvania Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $271,700,000 $915,000,000 $1,004,700,000 State Net Savings (Net savings = Total savings $147,900,000 $791,300,000 $880,900,000 minus intervention costs) ROI for State 1.20:1 6.39:1 7.12:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings (proportion of net savings) $39,900,000 $213,600,000 $237,800,000 Medicaid Net Savings (federal share) $7,900,000 $42,200,000 $47,000,000 (proportion of net savings) Medicaid Net Savings (state share) $6,450,000 $34,500,000 $38,400,000 (proportion of net savings) Private Payer and Out of Pocket Net $93,600,000 $500,900,000 $557,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Rhode Island Total Annual Intervention Costs (at $10 per person): $10,790,000 Rhode Island Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $25,000,000 $84,200,000 $92,500,000 State Net Savings (Net savings = Total savings $14,200,000 $73,400,000 $81,700,000 minus intervention costs) ROI for State 1.32:1 6.81:1 7.57:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $3,840,000 $19,800,000 $22,000,000 (proportion of net savings) Medicaid Net Savings (federal share) $752,000 $3,880,000 $4,320,000 (proportion of net savings) Medicaid Net Savings (state share) $629,000 $3,240,000 $3,610,000 (proportion of net savings) Private Payer and Out of Pocket Net $9,000,000 $46,500,000 $51,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 31 South Carolina Total Annual Intervention Costs (at $10 per person): $41,950,000 South Carolina Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $81,700,000 $275,200,000 $302,200,000 State Net Savings (Net savings = Total savings $39,700,000 $233,300,000 $260,200,000 minus intervention costs) ROI for State 0.95:1 5.56:1 6.21:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $10,700,000 $62,900,000 $70,200,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,670,000 $15,600,000 $17,400,000 (proportion of net savings) Medicaid Net Savings (state share) $1,180,000 $6,940,000 $7,750,000 (proportion of net savings) Private Payer and Out of Pocket Net $25,100,000 $147,600,000 $164,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. South Dakota Total Annual Intervention Costs (at $10 per person): $7,700,000 South Dakota Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $14,700,000 $49,700,000 $54,600,000 State Net Savings (Net savings = Total savings $7,080,000 $42,000,000 $46,900,000 minus intervention costs) ROI for State 0.92:1 5.47:1 6.10:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $1,910,000 $11,300,000 $12,600,000 (proportion of net savings) Medicaid Net Savings (federal share) $447,000 $2,650,000 $2,960,000 (proportion of net savings Medicaid Net Savings (state share) $239,000 $1,420,000 $1,590,000 (proportion of net savings) Private Payer and Out of Pocket Net $4,480,000 $26,600,000 $29,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 32 Tennessee Total Annual Intervention Costs (at $10 per person): $58,860,000 Tennessee Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $121,900,000 $410,600,000 $450,900,000 State Net Savings (Net savings = Total savings $63,000,000 $351,800,000 $392,000,000 minus intervention costs) ROI for State 1.07:1 5.98:1 6.67:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $17,000,000 $94,900,000 $105,800,000 (proportion of net savings) Medicaid Net Savings (federal share) $3,910,000 $21,800,000 $24,300,000 (proportion of net savings) Medicaid Net Savings (state share) $2,200,000 $12,200,000 $13,600,000 (proportion of net savings) Private Payer and Out of Pocket Net $39,900,000 $222,700,000 $248,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Texas Total Annual Intervention Costs (at $10 per person): $225,180,000 Texas Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $378,800,000 $1,275,700,000 $1,400,700,000 State Net Savings (Net savings = Total savings $153,600,000 $1,050,500,000 $1,175,500,000 minus intervention costs) ROI for State 0.68:1 4.67:1 5.22:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $41,400,000 $283,600,000 $317,300,000 (proportion of net savings) Medicaid Net Savings (federal share) $9,040,000 $61,800,000 $69,200,000 (proportion of net savings) Medicaid Net Savings (state share) $5,850,000 $40,000,000 $44,800,000 (proportion of net savings) Private Payer and Out of Pocket Net $97,200,000 $665,000,000 $744,100,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 33 Utah Total Annual Intervention Costs (at $10 per person): $24,220,000 Utah Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $33,700,000 $113,600,000 $124,700,000 State Net Savings (Net savings = Total savings $9,520,000 $89,400,000 $100,500,000 minus intervention costs) ROI for State 0.39:1 3.69:1 4.15:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $2,570,000 $24,100,000 $27,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $654,000 $6,140,000 $6,900,000 (proportion of net savings) Medicaid Net Savings (state share) $269,000 $2,530,000 $2,840,000 (proportion of net savings) Private Payer and Out of Pocket Net $6,030,000 $56,600,000 $63,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Vermont Total Annual Intervention Costs (at $10 per person): $6,210,000 Vermont Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $14,600,000 $49,300,000 $54,200,000 State Net Savings (Net savings = Total savings $8,450,000 $43,100,000 $48,000,000 minus intervention costs) ROI for State 1.36:1 6.95:1 7.73:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $2,280,000 $11,600,000 $12,900,000 (proportion of net savings) Medicaid Net Savings (federal share) $479,000 $2,450,000 $2,720,000 (proportion of net savings) Medicaid Net Savings (state share) $340,000 $1,730,000 $1,930,000 (proportion of net savings) Private Payer and Out of Pocket Net $5,350,00 $27,300,000 $30,300,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 34 Virginia Total Annual Intervention Costs (at $10 per person): $74,720,000 Virginia Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $136,500,000 $459,900,000 $504,900,000 State Net Savings (Net savings = Total savings $61,800,000 $385,100,000 $430,200,000 minus intervention costs) ROI for State 0.83:1 5.16:1 5.76:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $16,600,000 $104,000,000 $116,100,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,990,000 $18,600,000 $20,800,000 (proportion of net savings) Medicaid Net Savings (state share) $2,990,000 $18,600,000 $20,800,000 (proportion of net savings) Private Payer and Out of Pocket Net $39,100,000 $243,800,000 $272,300,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Washington Total Annual Intervention Costs (at $10 per person): $62,060,000 Washington Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $120,400,000 $405,800,000 $445,500,000 State Net Savings (Net savings = Total savings $58,400,000 $343,700,000 $383,500,000 minus intervention costs) ROI for State 0.94:1 5.54:1 6.18:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $15,700,000 $92,800,000 $103,500,000 (proportion of net savings) Medicaid Net Savings (federal share) $2,830,000 $16,600,000 $18,500,000 (proportion of net savings) Medicaid Net Savings (state share) $2,830,000 $16,600,000 $18,500,000 (proportion of net savings Private Payer and Out of Pocket Net $36,900,000 $217,500,000 $242,700,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 35 West Virginia Total Annual Intervention Costs (at $10 per person): $18,110,000 West Virginia Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $42,300,000 $142,600,000 $156,600,000 State Net Savings (Net savings = Total savings $24,200,000 $124,500,000 $138,500,000 minus intervention costs) ROI for State 1.34:1 6.88:1 7.65:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $6,540,000 $33,600,000 $37,400,000 (proportion of net savings) Medicaid Net Savings (federal share) $1,710,000 $8,820,000 $9,810,000 (proportion of net savings) Medicaid Net Savings (state share) $635,000 $3,260,000 $3,620,000 (proportion of net savings) Private Payer and Out of Pocket Net $15,300,000 $78,800,000 $87,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. Wisconsin Total Annual Intervention Costs (at $10 per person): $54,990,000 Wisconsin Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $116,600,000 $392,900,000 $431,400,000 State Net Savings (Net savings = Total savings $61,600,000 $337,900,000 $376,400,000 minus intervention costs) ROI for State 1.12:1 6.15:1 6.85:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $16,600,000 $91,200,000 $101,600,000 (proportion of net savings) Medicaid Net Savings (federal share) $3,450,000 $18,900,000 $21,000,000 (proportion of net savings) Medicaid Net Savings (state share) $2,530,000 $13,900,000 $15,400,000 (proportion of net savings) Private Payer and Out of Pocket Net $39,000,000 $213,900,000 $238,300,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 36 Wyoming Total Annual Intervention Costs (at $10 per person): $5,060,000 Wyoming Return on Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Total State Savings $10,100,000 $34,200,000 $37,600,000 State Net Savings (Net savings = Total savings $5,110,000 $29,200,000 $32,500,000 minus intervention costs) ROI for State 1.01:1 5.77:1 6.44:1 * In 2004 dollars Indicative Estimates of State-level Savings by Payer: Proportion of Net Savings for an Investment of $10 Per Person 1-2 Years 5 Years 10-20 Years Medicare Net Savings $1,380,000 $7,880,000 $8,700,000 (proportion of net savings) Medicaid Net Savings (federal share) $268,000 $1,530,000 $1,710,000 (proportion of net savings) Medicaid Net Savings (state share) $227,000 $1,290,000 $1,440,000 (proportion of net savings) Private Payer and Out of Pocket Net $3,230,000 $18,400,000 $20,600,000 Savings (proportion of net savings) * In 2004 dollars * Source: TFAH calculations from preliminary Urban Institute estimates, based on national parameters applied to state spending data. 37 Methodology The study consists of a: A) Literature Review of Community-Based Prevention Studies; and B) Return on Investment Model 4 SECTION A. LITERATURE REVIEW In order to identify effective community-based way. In the review, no studies directly includ- disease prevention programs and the results ed information about all of the areas modeled and costs of these programs, TFAH consulted for this project, which include: the expenses with NYAM to conduct a comprehensive liter- of diseases, a community-based disease pre- ature review. Overall, the literature review vention program, data on the impact of inter- identified 84 studies that met their criteria as ventions on diseases over time, and the per effective “public health interventions.” (See capita cost of implementing the program. Background box on page 40 for more detail.) Experts at the Urban Institute developed a These interventions included both communi- composite based on the available data report- ty-based programs and policy changes. The ed in the literature to derive assumptions for studies focused on how programs or policy costs and health impacts. changes resulted in improved health or posi- Accordingly, TFAH calls for increased evi- tive behavior changes within either an entire dence-based research into community-based community or a particular at-risk targeted disease prevention programs that explicitly community. They did not include medical include information about the impact of inter- interventions, such as pharmaceutical, doctor- ventions on diseases over time and the costs based, or clinical-based studies. for the programs. This type of research would Overall, however, the researchers found the help policymakers better determine how to literature evaluating community-based disease effectively invest in public health programs prevention programs to be limited, and out- and assist those in the field in determining the comes were not reported in a standardized potential cost of identified programs. 39 BACKGROUND ON LITERATURE REVIEW The full bibliography of the literature review is available in Appendix A. The studies includ- ed in the literature review had to meet the following criteria: 1. Report on a community-based public health program that showed results on improving health or behavior change related to the 8 diseases most impacted by physical activity, nutrition, and tobacco use (type 2 diabetes, high blood pressure, heart disease, kidney disease, stroke, some forms of cancer, COPD, and arthritis); 2. Meet a threshold for scientific study design and likelihood the study could be replicated; and 3. Did not involve direct health care services, be provider driven, or be conducted in a health care setting. The researchers narrowed down more than 300 peer-reviewed journal articles and study descriptions to the 84 that were included in the review. I To find the studies, the researchers searched the MEDLINE database via PubMed of studies from 1975 to 2008, cross checked findings in The Guide to Community Preventive Services and other meta-analyses, and interviewed public health experts.54 I When specific needed data were not included in studies, the researchers contacted study authors directly when possible to ask them about disease rate changes, behavior changes, or cost data. I Study designs had to be: A) randomized controlled studies; B) quasi-experimental studies without obvious selection bias; or C) (if no other studies were available) pre-post studies with no comparison group, or comparison groups with likely selection bias.55 Studies that did not meet these criteria were eliminated. A majority of the 84 studies looked at programs that addressed a number of related health factors, such as weight, nutrition, and physical activity. Researchers often call these studies “multifactorial.” Eleven of the studies examined mass media or social marketing campaigns. Six of the studies focused on intensive counseling to support lifestyle changes. One study focused on the impact of a cigarette tax in reducing smoking. Two studies examined employer-based health promotion efforts. While this report focuses on health care costs of adults, it also includes studies about interventions targeted at children because these studies have shown that these interventions have an impact on improving the health of the parents and families of those children and also improves the health of the children as they enter adulthood. There are many other disease prevention efforts that may be effective or show promise that may not be part of model because they did not meet all of the criteria for inclusion. 40 Examples of Studies from the Literature Review SHAPE UP SOMERVILLE: EAT SMART. PLAY HARD.56 In 2002, the U.S. Centers for Disease Control and Prevention (CDC) funded an environ- mental change intervention to prevent obesity in high-risk, early elementary-aged children in Somerville, Massachusetts. The Shape Up Somerville team put together a program for the first to third graders that focused on increasing physical activity options and improving dietary choices. Prior to the intervention, Tufts researchers found that 46 percent of Somerville’s first to third graders were obese or overweight based on the BMI for age per- centile. After one year of Shape Up Somerville, on average the program reduced one pound of weight gain over 8 months for an 8-year-old child. Based on conversations with the Somerville project leaders, project researchers estimate that citywide the per capita cost was between $3 and $4.57 The intervention included: I Improved School Food -- Fruit/vegetable of the month, taste tests for students, educa- tional posters, food staff training, new vegetarian recipes, daily fresh fruit. I Healthy Eating and Active Time Club (HEAT) In-School Curriculum -- New curriculum that focused on increasing healthy food consumption, decreasing unhealthy food con- sumption, increasing physical activity and decreasing sedentary time. The Club imple- mented Cool Moves -- creative ways to include physical activity into classroom hours. I HEAT Club After-School Program -- Curriculum with lesson plans using crafts, cooking demonstrations, and physically active games for education. The program also had a field trip to an organic farm where students were able to participate in the harvesting process. I Parent and Community Outreach -- Including a monthly newsletter to parents as well as to the community containing updates on the project, health tips and healthy food coupons. I “Shape Up Approved” Restaurants -- In 2005, 21 restaurants were considered “Shape Up Approved.” L In order to be “Shape Up Approved” the restaurant must meet the following criteria: • Offer low fat dairy products • Offer some dishes in a smaller portion size • Offer fruits and vegetables as side dishes • Have visible signs that highlight the healthier options I School Nurse Education -- School nurses were formally trained to annually measure height and weight, as well as how to counsel families of overweight or obese children. I Safe Routes to School -- Formed a community walking committee and received funding from the Robert Wood Johnson Foundation through the Active Living by Design Initiative. They then hired a Pedestrian/Bike Coordinator for the City and created Safe Routes to School maps and distributed them to all the parents of first to third graders. The Mayor authorized all crosswalks to be repainted and to have bike racks installed at all elemen- tary schools. I Policy Initiatives -- The Somerville School Department put together a comprehensive Wellness Policy in 2006. 41 THE IMPACT OF PROPOSITION 99: CALIFORNIA’S ANTI-SMOKING LEGISLATION58 In 1988, the state of California voted to enact Proposition 99, Three years after implementation of Proposition 99 the California Tobacco Tax and Health Promotion Act. researchers found a 9 percent reduction rate in cigarette sales Proposition 99 increased the tax on cigarettes and other tobacco in California and a decrease in the prevalence of cigarette products from $0.10 to $0.35. The revenue from the tax was smoking among adults from 26.7 percent in 1988 to 22.2 per- allocated to a variety of health promotion projects including: cent in 1992. This means that the act reduced cigarette con- I 20 percent allocated to a health education account to create sumption by close to 705 million packs between January 1989 school-based programs discouraging children from smoking; and December 1991. A 2001 analysis found that there are “approximately one million fewer smokers in California than I 45 percent to hospitals and physicians to provide for would have been expected [and] per capita cigarette con- patients who cannot afford to pay; sumption has fallen by more than 50 [percent].”59 I 5 percent to research; The results of Proposition 99 suggest that placing a tax on certain I 5 percent to parks and recreation; and products and using the revenue from the tax for educational and I 25 percent to an unallocated account to go to any of the health programs can have a substantial effect on public health. other programs or for fire prevention measures. HEALTHY EATING, ACTIVE COMMUNITES (HEAC)60 Healthy Eating, Active Communities (HEAC), a program PE for grades K-12, as well as more opportunities for non- funded by The California Endowment, brings together com- competitive physical activity. munity residents and public institutions, and works with local I After School -- such as improving cooperation with parks government and with private businesses, in an effort to pre- and recreation departments. vent childhood obesity by improving the environment chil- I In Neighborhoods -- improving access to affordable fresh dren inhabit. The program, at a cost of $7 annually per capita produce, providing safer walkways and parks, and limiting in the target communities with minimal additional expenses the promotion of unhealthy foods. for technical assistance, has already accomplished significant changes in the food and physical activity environments and I In the Healthcare Sector -- HEAC, with the help of Kaiser policies in these communities, including new parks, input into Permanente, training health care providers to incorporate city general plans, healthier food marketing in local stores, more prevention and health promotion into clinical practice, healthier foods in hospital, public health department, and and engaging physician champions to advocate for improving public park vending machines, and increased physical activity access to healthy foods and physical activity. opportunities in schools and after school programs. I In Marketing and Advertising -- such as eliminating the mar- keting of unhealthy products to children in and around Within 6 California communities HEAC focuses on forming a schools, and via television, internet and other media. partnership between a community-based organization, school districts and a public health department to implement strategies HEAC aims to effect policy change that will improve environ- to improve nutrition and physical activity environments. In each ments for healthy eating and active living. Also, in January community the partnership works in 5 sectors including: 2007, HEAC participated in the first California Convergence I In Schools-by improving the quality of foods sold and avail- meeting, which aims to promote statewide improvements in able on campus, and advocating for increased compulsory food and physical activity environments, and is a core partner within the emerging ongoing work of Convergence. GO BOULDER61 Greater Options in Transportation, better known as GO and Bike Week and commuter awards, to encourage people Boulder, is a program in Boulder, Colorado, aimed at provid- to walk, bike, or take the bus. ing residents with more transportation options than cars. From 1990 to 1994, Boulder showed a 3.5 percent increase in the Through the multi-sectoral program that works with resi- number of pedestrian trips and a 2.2 percent rise in bike trips. dents, intergovernmental agencies and businesses in the com- Also, unlike the nearby city of Denver where population as well as munity Boulder has been able to develop a sustainable trans- single occupancy vehicle use increased, the population in Boulder portation system. GO Boulder uses incentives, such as Walk continued to grow without a rise in single occupancy vehicle use. 42 YMCA’S PIONEERING HEALTHIER COMMUNITIES62 The YMCA has a Pioneering Healthier Communities Program national policy debate, and 2) encouraging and supporting in more than 64 communities across the country that focus local communities to develop more effective strategies to on: 1) raising the visibility of lifestyle health issues in the promote healthy lifestyles. Sample Results from YMCA Pioneering Des Moines -- Trim Kids (A proven, multidisciplinary Healthier Communities Sites Programs 12-week plan that gives parents and children a healthy Impacting Children’s Health and Well-Being 63 approach to lifetime weight management) Attleboro, Massachusetts -- Physical Activity Club 750 individuals (kids, siblings and parents / for overweight/obese (A 10-week physical activity and healthy eating program kids). Expanded across Iowa, trained 12 other sites for children and their caregivers) I Average weight loss is 5 lbs for elementary, 10 lbs for 100 kids in a pilot with statewide expansion with state funding secondary I 17 percent increase in daily physical activity Pittsburgh -- ASAP (Afterschool with Activate Pittsburgh -- I Decrease in BMI from 30.3 to 28.5 evidence-based curriculum and program to develop I Increase in fruit consumption by 6 percent; reduction in lifelong healthy habits) fast food and vending machine use. 6,500 low-income diverse kids I 76 percent of kids increased muscular strength Dallas -- CATCH (Coordinated Approach to Child Health -- an evidenced-based healthy eating I 56 percent increased muscular endurance and physical activity curriculum) I 69 percent increased flexibility 3,100 kids in 100 after school child care sites Grand Rapids, Michigan -- Healthy U (A proven health I Increased fruit consumption and wellness program for children) I Decreased dessert/candy consumption 3,400 low-income, diverse kids in dozens of sites I Increase in physical activity from 4 to 7 times a week I Dramatic decrease in blood pressure and increase in I Decreased TV time strength and flexibility I More than 90 percent improved school attendance, com- pleted homework, chose not to smoke, drink or use drugs Case Study: Activate West Michigan and Case Study: Attleboro, Massachusetts and Healthy U 64 Rapid City, South Dakota 65 In 2003, the YMCA of Greater Grand Rapids, Michigan creat- Attleboro, Massachusetts and Rapid City, South Dakota looked ed the Activate West Michigan coalition in partnership with at ways to promote increased physical activity through local government, community organizations, schools, and Pioneering Healthier Communities projects. The YMCA’s part- healthcare, corporate, and non-profit leaders. They initiated nered with local leaders, schools, hospitals, public health offi- a “Healthy U” health and wellness program, which included cials, health care providers, business leaders, and the media. physical fitness and nutrition education for elementary and In Attleboro, the coalition focused on a walking school bus pro- middle-school students after school hours both at schools and gram, a pedometer steps challenge among fourth and fifth graders, community centers. In addition, students exercised at the a healthy kids day, and building a bike trail and non-motorized con- YMCA gym at least once a week. After a year, the children nections to commuter rail stations. It also sponsored healthy eat- made improvements on strength and flexibility tests. ing through improving the nutrition of foods in schools and recruit- In addition, the community helped support the program. For ing a local supermarket to provide a “Healthy Snack of the Week” example, school children started gardens at various sites in to school and hospital cafeterias. Zoning laws were also changed the community. Two inner city farmers’ market programs to allow for more sidewalks and streetscapes. provided access to healthy foods, samples of vegetables, and In Rapid City, civic leaders required that new building include education about cooking vegetables. According to a survey, sidewalks and smarter development practices, such as build- 90 percent of people who attended the markets wanted addi- ing bike lanes, wider sidewalks, and adding trees, benches, tional markets and had learned from this experience. and walk signals in downtown areas. 43 TOGETHER, LET’S PREVENT CHILDHOOD OBESITY-COMMUNITY BASED PREVENTION IN FRANCE (EPODE)66 In 2005, the French government launched the EPODE campaign with the goal of lowering childhood obesity rates in 5-12 year olds through a 5-year plan of intervention in 10 towns situated across the country. The plan takes a multi-sectoral approach by involving parents and families, general practi- tioners, school nurses, teachers, towns, businesses, and the medical community. The 3 fun- damental steps are: I Informing All Sectors of the Community about the Problem -- All those involved are informed through public meetings, brochures, posters, and media coverage. I Training Participants -- General practitioners and school nurses are trained on how to diagnose and treat obese children. I Taking Action in Schools and Towns -- Schools integrate nutritional education and physical education into the school day. Also, school menu planning is targeted and children are taught how cook with fresh fruits and vegetables and be given access to food tasting workshops. In order to track progress, the BMI of each child is calculated, recorded, and sent to his or her parents. Parents of those who are overweight or obese will be encouraged to consult their family physician. Anecdotal evidence suggests that obesity has (at least) remained constant in the interven- tion towns while it doubled in control areas. Mothers of children participating in the inter- vention have reported weight loss as well. The complete results will be available in 2009 upon completion of the 5-year plan. NORWAY COMMUNITY INTERVENTION67 In Oslo, Norway a group of researchers sought to test the effects of a community-based intervention to increase physical activity among low-income individuals, according to a 2006 study. A comprehensive intervention program was implemented, at a reported cost of 0.59 Euros per capita (approximately $0.93 US dollars), in an effort to change the behaviors of individuals. The intervention efforts included: I Information Distribution -- Leaflets were designed and distributed that included health reminders such as the benefit of using stairs instead of elevators, and stands with health information were set up as well as mass media activities. I Individual Counseling -- Health counseling was provided during the biannual fitness test. I Walking Groups -- Various walking groups were organized, as well as indoor activity sessions at no cost during the intervention. I Environmental Change -- In order to increase accessibility to areas for physical activity, walking trails were labeled within the district, lighting on streets improved and trails were maintained during the winter to keep them safe. The follow up after 3 years showed that compared to the control community, the intervention group reported an 8-9 percent increase in physical activity, 14 percent fewer individuals gained weight, 3 percent more quit smoking, and there were significant decreases in blood pressure. 44 B. RETURN ON INVESTMENT MODEL The Urban Institute researchers developed a heart disease, stroke, arthritis, and kidney dis- model to estimate how investing in communi- ease. None of these diseases can be prevent- ty-based disease prevention could lead to ed entirely; some individuals develop these lower health care costs. This model is based conditions due to genetics or other factors on the literature review led by NYAM and data unrelated to activity, nutrition, or smoking. on disease rates and associated medical expen- The report relies on a 2004 Health Affairs study ditures. The model addressed 3 questions: by Thorpe, et. al. to determine the most expen- 1. How much do people with selected pre- sive diseases, and then a review by NYAM of the ventable diseases spend on medical care? literature to determine which of the most 2. If the rates of these conditions were expensive diseases respond to physical activity, reduced, how much of these expenditures nutrition, and smoking interventions.68 could be saved? The Urban Institute used data from the 3. How would these savings be distributed Medical Expenditure Panel Survey (MEPS) across payers? from 2003 to 2005 (adults only, excluding Based on the review of the literature, the people in nursing homes or other institu- researchers considered 1) the costs of the tions) to estimate the health care costs of most expensive diseases related to physical the diseases nationally. inactivity, poor nutrition, and smoking; 2) pro- Based on the literature review and consultation gram cost assumptions; 3) disease rate reduc- with a medical advisor, the diseases were tion assumptions; 4) cost savings estimates; grouped into categories, using 3 broad groups and, 5) limitations and notes about the model. of conditions: 1) uncomplicated diabetes The model is used to compare costs of a given and/or high blood pressure 2) diabetes and/or intervention with its expected effects on med- high blood pressure with complications (heart ical care expenditures to assess the potential disease, stroke, and/or kidney disease); and 3) return on investment in community-based dis- selected cancers (those amenable to communi- ease prevention programs. As an example of ty-based prevention), arthritis, and chronic potential return, the model looks at an invest- obstructive pulmonary disease (COPD). ment of $10 per person per year for successful community-based disease prevention pro- DISEASE GROUPINGS USED grams related to improving physical inactivity IN THE MODEL and nutrition, and preventing smoking and other tobacco use. Based on findings report- I Uncomplicated Diabetes and/or High ed in the literature, the researchers assumed Blood Pressure that such strategic interventions could reduce L Diabetes alone uncomplicated diabetes and high blood pres- L High blood pressure alone sure rates by 5 percent in one to 2 years; heart, L Diabetes and high blood pressure stroke, and kidney disease by 5 percent within I Complicated Diabetes and/or High 5 years, and cancer, arthritis, and COPD by 2.5 Blood Pressure percent within 10 to 20 years. L Diabetes with heart disease, kidney disease, and/or stroke 1. Current Costs of Most Expensive Diseases: L High blood pressure with heart dis- The researchers at NYAM and the Urban ease, kidney disease and/or stroke Institute determined the most expensive set I Non-diabetic, Non-hypertensive Heart of diseases that have shown potential to be Disease, Kidney Disease, and/or Stroke reduced through physical activity, nutrition, I Cancer and smoking interventions. These include: I Arthritis heart disease, selected types of cancers, select- I COPD ed lung diseases, diabetes, hypertension, 45 FINANCIAL BURDEN OF SPECIFIC DISEASES The Urban Institute researchers conducted regression analyses to estimate the percent of health care costs attributable to each disease group. Diabetes, high blood pressure, heart disease, stroke, kidney disease, cancer, arthritis, and COPD account for almost 38 percent of America’s health care costs. Significant numbers of cases of these diseases could be pre- vented or delayed with increases in physical activity, good nutrition, and smoking cessation. Percent of U.S. Health Care Costs By Top Diseases That Can Be Impacted By Physical Activity, Nutrition, and Smoking (Based on current disease rates, including all insurance payers, does not include people in institutionalized care) Health Conditions Percent of Health Care Costs in the U.S. Diabetes, high blood pressure, or a combination of 9.4 percent the 2 diseases Diabetes or high blood pressure who also have heart 16.0 percent disease or stroke and/or kidney disease Heart disease or stroke and/or kidney disease who do 6.2 percent not have diabetes or high blood pressure Cancer 3.1 percent Arthritis 1.1 percent COPD 2.0 percent Source: Urban Institute calculations using data from the 2003-2005 Medical Expenditure Panel Survey (MEPS) 2. Building Estimates for Costs of Programs: small group counseling where administra- Of the studies that outlined potential costs tive costs were higher and evaluations and or where project staff contacted researchers measurements were intensive. to determine costs, most had costs estimated In order to determine an estimate, in addi- to be in the range of $3-$8 per person. tion to reviewing the available literature, I A few programs were found where costs TFAH and Prevention Institute consulted a exceeded $10. Those identified were pri- set of experts who agreed that $10 is a high, marily interventions that focused on and therefore, a conservative assumption intensive coaching and one-on-one or for the costs of community-based programs. 46 Sample Interventions Study Target Condition(s) Intervention Information Intervention Effect Population and Age Carleton Cardiovascular Disease Mass media campaign, At 5 years: 2,925 men and women (1995) (CVD), Coronary Heart community programs aimed Risk for both 18-64 [control (1,665); Disease (CHD), Stroke at 71,000 people. Intervention CVD and CHD intervention (1,260)] population randomly down 16 percent generated, compared to a reference community. Cost: $15 per person per year. Farquhar CVD, CHD, Stroke Mass media campaign, At 5 years: 971 men and women 25-74 (1990) community programs aimed at CHD risk down 16 percent; [control (480); 122,800 people. Intervention CVD mortality risk down intervention (491)] population randomly 15 percent; generated, compared to a Prevalence of smoking reference community. The down 13 percent; organizational and educational Blood pressure down program was delivered at a 4 percent; per capita cost of about $4 Pulse down 3 percent; per year. Cholesterol down 2 percent. Fichtenberg CVD, CHD, Stroke Cigarette tax: $0.25 increase At 3 Years: California population (2000) on the price of cigarettes CHD mortality down with $0.05 of the net tax for 2.93 deaths/yr/100,000 an antitobacco educational population per year; campaign. Amount smoked down 2.72 packs/person/yr. CVD Mass media campaign, At 4 years: 2,206 men and women community programs aimed amount of tobacco grams/ 16-69 [control (1,358); at 56,000 people. Intervention day decreased 8 percent; intervention (848)] population randomly 11 percent fewer generated, compared to a people smoked. reference community. Cost: $10 per year per adult over the age of 16. Gutzwiller CVD, CHD, Stroke Mass media campaign, At 4 years: 481 men and women (1985) community programs aimed Hypertension down 16-69 with hypertension at 56,000 people. Intervention 7 percent. (>160/95 mm Hg) [control population randomly (117); intervention (364)] generated, compared to a reference community. Cost: $10 per year per adult over the age of 16. Haines, CVD, CHD, Stroke 12-week employee walking At 3 months: 60 women in their forties et. al. program on a college campus. 1 percent decrease in BMI; (2007) No cost information available, 3.4 percent decrease in but such programs are hypertension; extremely low cost and often 3 percent decrease in have positive ROIs. cholesterol; 5.5 percent decrease in glucose 47 Sample Interventions Study Target Condition(s) Intervention Information Intervention Effect Population and Age Herman CVD, Nutrition Improving access to fruits and At 6 months: 451 low income minority (2008) vegetables among women who +1.4 servings per 4,186 kJ women 18 years and enrolled for postpartum services (1,000 kcal) of fruits and older [control (143); at 3 Women, Infants, and vegetables intervention (308)] Children program (WIC) sites in Los Angeles. Participants were assigned either to an intervention (farmers’ market or supermarket, both with redeemable food vouchers) or control condition (a minimal nonfood incentive). Interventions were carried out for 6 months, and participants’ diets were followed for an additional 6 months. No cost information, but minimal administrative costs to assign and track participation. Osler and CVD Mass media campaign, At year one: 1,196 men and women Jespersen community programs aimed 39 percent eating less fat; 20-65 [control (629); (1993) at 8,000 people. Intervention 10 percent decrease intervention (567)] population randomly generated in smoking; and compared to a reference 28 percent increase in community. Cost: $6 per capita. physical activity. Prior CVD Worksite health promotion, At 3.7 years: 808 high-risk smokers (2005) 15 minute cardiovascular risk 12.6 percent decrease in 16-76 years old factor screening, individualized amount smoked; counseling to high-risk 3.3 percent decrease in employees. Cost: $20 per diastolic BP; employee (note this is a 7.8 percent decrease high risk population). in cholesterol. Rossouw CVD Mass media campaign, At 4 years: 4,087 men and women (1993) community programs aimed Men decreased tobacco 15-64 [control (1305); at 122,800 people. Intervention intake per day by 0.7 percent, intervention (2,782; high population randomly generated, women by 0.3 percent; Men risk; 1,198 (43 percent)] compared to a reference decreased smoking prevalence community (separate high risk by 1.1 percent, women by group also). Cost: $5-$22 2.5 percent; Men decreased per capita. diastolic BP by 2.5 percent, women by 3 percent; Men decreased systolic BP by 2.5 percent, women by 3.0 percent. High risk at 4 years: Men decreased tobacco intake per day by one percent, women by 0.8 percent; Men decreased smoking prevalence by 2 percent, women by 8.2 percent; Men decreased diastolic BP by 3 percent, women by 2.8 percent; Men decreased systolic BP by 1.3 percent, women by 1.7 percent. 48 Sample Interventions Study Target Condition(s) Intervention Information Intervention Effect Population and Age Economos, Nutrition, “Shape Up Somerville” -- After one year, on average First to third grade et. al. Physical activity comprehensive effort to prevent the program reduced one children in Somerville (2007) obesity in high-risk children in pound of weight gain over first to third grade in Somerville, 8 months for an 8 year old MA. Improved nutrition in child. schools, health curriculum, after-school curriculum, parent and community outreach, worked with community restaurants, school nurse education, safe routes to school program. Cost: Between $3-$4 per person. EPODE Nutrition Multisectorial 5-year plan Obesity has at least 5-12 year olds in 10 (2004) involving parents and families, remained consistent in towns in France medical providers, school nurses, targeted towns while it teachers, towns, businesses, and doubled in control areas. media campaigns. Estimated Mothers have reported cost: Approximately 2 Euros weight loss as well. ($3.17 USD) per person. Jenum, Physical activity Provided information through After 3 years, compared to Low-income adults et. al. leaflets and mass media, the control group, the in Oslo, Norway (2006) individual counseling, walking intervention group had an groups, and increased accessible 8-9 percent increase in areas for safe recreation. physical activity, 14 percent Estimated cost of 0.59 Euros fewer individuals gained ($0.93 US dollars) per person weight, 3 percent more quit smoking, and significant decreases in blood pressure rates were reported. Hu et al Smoking cessation California Proposition 99 -- After 3 years, cigarette sales Population of California (1994) increased taxes on cigarettes and dropped 9 percent and other tobacco products from smoking among adults 10 cents to 35 cents. decreased from 26.7 percent in 1988 to 22.2 percent in 1992. 49 SOME PREVENTION EFFORTS HAVE NO DIRECT COST WHILE HAVING BIG HEALTH BENEFITS Not all community-based disease prevention programs have direct costs. In fact, some strategies, like tobacco taxes, can generate revenue. I Studies have shown that increases in tobacco taxes result in significant drops in smoking rates, which lead to improved health and lower health care costs. Specifically, research indi- cates that every 10 percent increase in the real price of cigarettes reduces overall cigarette consumption by approximately 3 to 5 percent, reduces the number of young-adult smokers by 3.5 percent, and reduces the number of kids and pregnant women who smoke by 6 or 7 percent.69 For example, Texas recently increased its cigarette tax by $1.00 per pack, and consumption over the following year dropped by more than 20 percent.70 I Smoke-free laws also have a positive impact on the health of communities with no real cost.71 The cigarette companies acknowledged the power of smoking restrictions to reduce smoking rates years ago (in internal company documents revealed in anti-smoking lawsuits), stating, for example, that “if our consumers have fewer opportunities to enjoy our products, they will use them less frequently.”72 I Local zoning laws can improve the walkability of a community, supporting increased physical activity. For example, in Davis, California, a carefully designed bike network, which includes a dedicated traffic lane for bikers, has led to 25 percent of all trips in the city being by bike (compared to one percent nationally), and a decision by the city to stop busing children to school, having them bike instead.73 I Experts believe menu labeling at fast food restaurants (showing caloric and nutrition information) contributes to reducing obesity. One study has suggested that menu label- ing in Los Angeles could significantly slow the rate of weight increases in the population, thus saving health care costs associated with obesity.74 3. Building Disease Rate Reduction In order to determine the effect on diseases, Assumptions: Based on findings from the lit- the researchers translated the results of pro- erature review and consultations with a physi- grams as presented in articles into the effect cian, the Urban Institute researchers made these changes could have on diseases or lim- assumptions about the length of time it could iting disease progression. The literature take for community-based disease prevention outlines the connections between changes programs focusing on increasing physical in behavior and the impact on health. For activity, improving nutrition, and reducing instance, increased physical activity, reduced smoking to have an impact on health. Body Mass Index (BMI), or lowering systolic blood pressure have been shown to delay or Building on estimates from a range of stud- prevent types of disease development. In ies, the researchers modeled an investment addition, studies describe how different dis- of only $10 per person into effective pro- eases progress. Results can be seen in grams to increase physical activity and good reducing type 2 diabetes, for example, in nutrition and prevent smoking, and a reduc- just one to 2 years. This reduction would tion in rates of uncomplicated diabetes and inevitably have an effect on the complica- high blood pressure of 5 percent in one to 2 tions of diabetes, most notably heart disease, years; complicated diabetes and high blood kidney disease, and stroke, although reduc- pressure as well as non-diabetic, non-hyper- tions or delays in these conditions would tensive heart disease, stroke and/or kidney take longer to be realized than reductions in disease of 5 percent within 5 years; and can- uncomplicated diabetes or high blood pres- cer, arthritis, and COPD of 2.5 percent with- sure (an estimated 5 years as opposed to one in 10 to 20 years. to 2 years). Cancers, arthritis, and COPD 50 would take the longest to be affected, taking ed in the model could likely result in greater 10 to 20 years before disease prevention pro- declines. The researchers acknowledge that grams could help bring about reductions in all of these diseases may develop unrelated disease rates. The model assumes a one- to physical inactivity, poor nutrition, or time reduction in diabetes and/or high smoking. The model focuses on the esti- blood pressure, even though the sustained mated share of these disease rates that could investment in prevention programs includ- be affected by these factors. Examples of Studies Showing Intervention Impact on Disease or Behavior Rates Study Target Behavior Target Condition Finding Brownson Physical Activity Cardiovascular Disease Of people who had access to walking trails, 38.3 percent (2000) used them. Of these users, 55.2 percent increased their amount of walking. CDC Physical Activity, Diabetes By losing 5 to 7 percent of body weight and getting (2005) Weight Loss just 2 1/2 hours of physical activity a week, people with pre-diabetes can cut their risk for developing type 2 dia- betes by about 60 percent. Dauchet Nutrition Cerebrovascular Disease Risk of stroke was decreased by 11 percent for each (2005) additional portion per day of fruit and 3 percent for each additional portion per day of vegetables. Felson Weight Loss Arthritis 40 percent increase in risk per 10-lb weight gain and (1997) 60 percent increase in risk per 5-unit BMI increase. HHS Nutrition Cardiovascular Disease, A 10 percent decrease in cholesterol levels may result (2003) Cholesterol in an estimated 30 percent reduction in the incidence of coronary heart disease. Joshipura, Nutrition Cardiovascular Disease Each additional serving of fruits or vegetables per day et. al. was associated with a 4 percent lower risk for coronary (2001) heart disease. Nutrition Cardiovascular Disease 22 to 30 percent of CHD deaths are due to dietary factors, especially increased consumption of cholesterol McGinnis and saturated fat and a decreased consumption of fiber. & Foege Nutrition Cancer The proportion of all cancer deaths attributable to diet is (1993) 35 percent. Nutrition Diabetes 45 percent of diagnosed cases are due to poor diet, inac- tivity, and obesity. Nanchahal Weight Loss CVD Every kilogram of weight gain after high school increased (2005) risk of congenital heart disease by 3.1 percent in men. Hamman Weight Loss Diabetes 16 percent reduction in diabetes risk per kilogram of (2006) weight lost. SMALL CHANGES CAN HAVE A BIG IMPACT ON HEALTH The research shows that even small changes in behavior can have a major impact on health. For example: I For individuals, a 5 to 10 percent reduction in total weight can lead to positive health benefits, such as reducing risk for type 2 diabetes.75 I An increase in physical activity, even without any accompanying weight loss, can mean significant health improvements for many individuals. A physically active lifestyle plays an important role in preventing many chronic diseases, including coronary heart disease, hypertension, and type 2 diabetes.76, 77, 78, 79 51 4. Cost Savings Estimates: Using the share of from implementation of such an interven- costs estimated in the regression analyses and tion. They then applied this formula to the the size of the effects of prevention programs example of a program that reduces the preva- reported in the literature, the Urban lence of uncomplicated diabetes and high Institute researchers estimated the medical blood pressure by 5 percent in the short run. care expenditure savings that would result Medical Savings Calculations Short Run Savings Example (Preliminary Estimates) The savings (S) from reduction of condition j: The savings from 5% reduction in Sj = (ej) * (share of costsj) * expenditures uncomplicated diabetes and Where: hypertension in the U.S.: Sj is savings from the intervention Sdiab_HBP = (ediab_HBP) * (share of costsdiab_HBP) * ej is the effect of the intervention on expendituresUS disease cluster j = (0.05) * (0.094) * $1,235 billion Share of costs refers to estimated costs = $5.8 billion annually attributable to disease cluster j Expenditures is total medical expenses Because the model is based on adults only excludes spending on nursing homes and is and excludes nursing home expenditures, adjusted to account for spending on children. the expenditure number used in this example 5. Limitations and Notes on the Model account trends in prevalence. For exam- ple, diabetes is increasing while heart dis- The researchers note that the estimates are ease is declining, but the model estimates likely to be conservative. As noted above, the savings based on the current prevalence. model assumes costs in the higher range and benefits in the low range. Furthermore, the I While the model does take into account model does not take into account any costs of competing morbidity risks, it does not institutional care. Chronic disease often leads take into account changes in mortality. to disability or frailty that may necessitate However, in the short (one to 2 years) nursing home care, so exclusion of these costs and medium run (5 years), changes in may underestimate the return on investment mortality are likely to be small. in reduction of disease. I The model calculates all savings in 2004 While the model is still being elaborated to dollars. Thus, it does not take into account address many of these issues, some known lim- any rise in medical care expenditures or itations of the model as reported here include: changes in medical technology. I The model assumes a sustained reduction I The model incorporates only the margin- in the prevalence of diabetes and hyper- al cost of the interventions and does not tension over time. The literature on the reflect the cost of the basic infrastructure duration of the effects of intervention is required to implement such programs. small, with effects usually reported over I The intervention effects do not account for no more than 3 to 5 years. variations in community demographics such I The model assumes a steady state popula- as distribution of race/ethnicity, age, gen- tion. This model is based on current dis- der, geography, or income. The intervention ease prevalence and does not take into effect is treated as constant across groups. 52 EXAMPLES OF CURRENT EFFECTIVE PREVENTION PROGRAMS SUPPORTED BY THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) I The REACH for Wellness program in Fulton County, Georgia, designed REACH OUT, a campaign to promote cardiovascular disease education. In two years, the program led to an increase in the percentage of regular adult participants in moderate-to-vigorous physical activity from 25 percent to 29 percent. During this period, the percentage of adults who reported checking total blood cholesterol levels increased from 69 percent to 80 percent, and the percentage of adults who smoked decreased from 26 percent to 21 percent.80 I In Broome County, New York, more than three of every five adults are either overweight or obese, according to the Behavioral Risk Factor Surveillance System (BRFSS). With a CDC grant from the Steps to a Healthier US (now Healthier Communities) program, the Broome County Steps Program implemented: L A walking program for families in rural areas, BC Walks, where within one year, the percentage of people who walked for 30 minutes or more five days a week increased from 51 percent to 61 percent; L Supporting a consolidated bid for 15 school districts to purchase healthy foods at lower costs; which resulted in a 14 percent increase in fruit and vegetable consumption; and L Expanded a diabetes prevention program, Mission Meltaway, in conjunction with the local YMCA and Office of Aging, to reach 3000 people. Participants in the program lost more than five pounds on average, and, as one example, in one program, 91 of the 100 participants lost weight, 65 increased their physical activity levels, and all 100 improved their knowledge of proper nutrition and exercise after only four weeks in the program.81 I Nearly 30 percent of children ages two to five who participate in Minnesota’s Women, Infant, and Children (WIC) supplemental nutrition program are overweight or are at-risk for becom- ing overweight. The Rochester, Minnesota Steps Program implemented a Fit WIC program to help parents and their children become more physically active through a series of play, recre- ation, physical activity, and structured skill building activities. They also worked with the Rochester YMCA to give WIC parents free access to the YMCA programs. Participants’ activi- ty levels increased an average of 50 minutes of physical activity per day per preschool child, and parents reported a 10 percent increase in moderate activity level in addition to increasing the time spent playing with their children.82 53 Conclusions T he nation’s economic future demands we find ways to reduce health care costs. Preventing people from getting sick is one of the most important ways we can drive costs down. 5 SECTION This study shows that the country could save I All individuals and families should have a substantial amounts on health care costs if high level of health, health care, and pub- we invest strategically in community-based lic health services, regardless of who they disease prevention programs. We could see are or where they live. significant returns for as little as a $10 For America to become a healthier nation, investment per person into evidence-based prevention must become a driving force in programs that improve physical activity and our health care strategy and become central nutrition and lower smoking rates in com- to discussions about how to reform health munities. Not only could we save money, care in the U.S. For too long, disease pre- many more Americans would have the vention has been considered too difficult to opportunity to live healthier lives. implement programs on a wide-scale basis. Physical activity, nutrition, and smoking are 3 One challenge has been to get policymakers of the most important areas to target for pre- to invest, given the already high health care vention, and as this study shows, community- costs and difficulties in showing the impact based programs can generate a significant of many community-based prevention pro- return both in terms of health and financial grams. Understanding the return on invest- savings. There is a wide range of other dis- ment is an important step to help determine ease prevention efforts that target these and what types of programs to invest in, how other health problems and have a beneficial much should be invested, and how the pro- impact on the health of Americans. grams could be funded. Until the country starts making a sustained This study identified a range of community- investment into disease prevention programs, based programs that have been shown to we will not realize the potential savings. We have a positive impact on improving the need to make the investment to see the returns. health of communities by increasing physi- TFAH and RWJF launched the Healthier cal activity, improving nutrition, or prevent- America Project in 2007 to find ways to ing or helping people quit smoking. These improve the health of the nation. The proj- programs are designed to help improve the ect has set a number of goals, including: health and well-being of large segments of the population without direct medical treat- I America should strive to be the healthiest ment. Instead, community disease rates are country in the world; decreasing and health is improving through I Every American should have the opportu- increased access to safe places to be active, nity to be as healthy as he or she can be; affordable nutritious foods, and support to help prevent or quit smoking. I Every community should be safe from threats to its health; and 55 Insurance providers, including Medicare, ing the health of Americans in addition to Medicaid, and private payers, would directly saving health care costs, it is important to benefit from investments made in commu- gain an increased understanding about what nity-based prevention. In addition, commu- programs are most effective and how to best nities would benefit from improved health target efforts in communities, including eval- and productivity of the workforce and citi- uating costs and outcomes. This research is zens in those communities. important to help policymakers determine the most effective ways to invest for the high- In addition, the country must make improv- est returns in health and savings. ing research into community-based disease prevention programs a priority. Since these Investing in prevention is investing in the programs hold so much potential for improv- future health and wealth of the nation. 56 Literature Review Bibliography American Cancer Society. “Colorectal Cancer shown to be a Smoking-Related Screening.” Journal of the National Cancer Institute 96, no. 10 (May 19, 2004): 770-780. A APPENDIX Cancer.” Press Release, Dec 5, 2000. Collins, R., J. Armitage, S. Parish, P. American Heart Association. “Risk Factors Sleight, R. Peto, and Heart Protection and Coronary Heart Disease.” American Study Collaborative Group. “Effects of Heart Association. http://www.american Cholesterol-Lowering with Simvastatin on heart.org/presenter.jhtml?identifier=235 Stroke and Other Major Vascular Events in (accessed June 24, 2008). 20536 People with Cerebrovascular Disease Or Other High-Risk Conditions.” Lancet American Heart Association. “Risk Factors 363, no. 9411 (Mar 6, 2004): 757-767. and Coronary Heart Disease and Stroke.” American Heart Association. Collins, R., R. Peto, S. MacMahon, P. http://www.americanheart.org/presenter.jht Hebert, N. H. Fiebach, K. A. Eberlein, J. ml?identifier=539 (accessed June 24, 2008). Godwin, N. Qizilbash, J. O. Taylor, and C. H. Hennekens. “Blood Pressure, Stroke, Bogers, R. P., W. J. Bemelmans, R. T. and Coronary Heart Disease. Part 2, Short- Hoogenveen, H. C. Boshuizen, M. Term Reductions in Blood Pressure: Woodward, P. Knekt, R. M. van Dam, et al. Overview of Randomised Drug Trials in “Association of Overweight with Increased their Epidemiological Context.” Lancet 335, Risk of Coronary Heart Disease Partly no. 8693 (Apr 7, 1990): 827-838. Independent of Blood Pressure and Cholesterol Levels: A Meta-Analysis of 21 Dauchet, L., P. Amouyel, and J. Dallongeville. Cohort Studies Including More than 300 “Fruit and Vegetable Consumption and Risk 000 Persons.” Archives of Internal Medicine of Stroke: A Meta-Analysis of Cohort Studies.” 167, no. 16 (Sep 10, 2007): 1720-1728. Neurology 65, no. 8 (Oct 25, 2005): 1193-1197. Brownson, R. C., R. A. Housemann, D. R. Davis, N. A., E. Nash, C. Bailey, M. J. Lewis, Brown, J. Jackson-Thompson, A. C. King, B. B. K. Rimer, and J. P. Koplan. “Evaluation R. Malone, and J. F. Sallis. “Promoting of Three Methods for Improving Physical Activity in Rural Communities: Mammography Rates in a Managed Care Walking Trail Access, use, and Effects.” Plan.” American Journal of Preventive Medicine American Journal of Preventive Medicine 18, 13, no. 4 (Jul-Aug, 1997): 298-302. no. 3 (Apr, 2000): 235-241. Economos, C. D., R. R. Hyatt, J. P. Goldberg, Carleton, R. A., T. M. Lasater, A. R. Assaf, H. A. Must, E. N. Naumova, J. J. Collins, and M. A. Feldman, and S. McKinlay. “The Pawtucket E. Nelson. “A Community Intervention Heart Health Program: Community Changes Reduces BMI z-Score in Children: Shape Up in Cardiovascular Risk Factors and Projected Somerville First Year Results.” Obesity (Silver Disease Risk.” American Journal of Public Health Spring, Md.) 15, no. 5 (May, 2007): 1325-1336. 85, no. 6 (Jun, 1995): 777-785. Edelstein, S. L., W. C. Knowler, R. P. Bain, R. Church, T. R., M. W. Yeazel, R. M. Jones, L. Andres, E. L. Barrett-Connor, G. K. Dowse, S. K. Kochevar, G. D. Watt, S. J. Mongin, J. E. M. Haffner, et al. “Predictors of Progression Cordes, and D. Engelhard. “A Randomized from Impaired Glucose Tolerance to NIDDM: Trial of Direct Mailing of Fecal Occult An Analysis of Six Prospective Studies.” Blood Tests to Increase Colorectal Cancer Diabetes 46, no. 4 (Apr, 1997): 701-710. 57 Egger, G., W. Fitzgerald, G. Frape, A. Fichtenberg, C. M. and S. A. Glantz. Monaem, P. Rubinstein, C. Tyler, and B. “Association of the California Tobacco McKay. “Results of Large Scale Media Control Program with Declines in Cigarette Antismoking Campaign in Australia: North Consumption and Mortality from Heart Coast “Quit for Life” Programme.” British Disease.” The New England Journal of Medicine Medical Journal (Clinical Research Ed.) 287, 343, no. 24 (Dec 14, 2000): 1772-1777. no. 6399 (Oct 15, 1983): 1125-1128. Finkelstein, E. A., O. Khavjou, and J. C. Englert, H. S., H. A. Diehl, R. L. Greenlaw, Will. “Cost-Effectiveness of WISEWOMAN, S. N. Willich, and S. Aldana. “The Effect of a Program Aimed at Reducing Heart a Community-Based Coronary Risk Disease Risk among Low-Income Women.” Reduction: The Rockford CHIP.” Preventive Journal of Women’s Health (2002) 15, no. 4 Medicine 44, no. 6 (Jun, 2007): 513-519. (May, 2006): 379-389. Ensemble Prevenons L’Obesite Des Enfants Fujimoto, W. Y., K. A. Jablonski, G. A. Bray, (EPODE). Together, we can Prevent Obesity in A. Kriska, E. Barrett-Connor, S. Haffner, R. Children. Paris, France: French Ministry of Hanson, et al. “Body Size and Shape Health, 2004, http://ec.europa.eu/health/ Changes and the Risk of Diabetes in the ph_determinants/life_style/nutrition/ Diabetes Prevention Program.” Diabetes 56, documents/ev_20041029_co07_en.pdf no. 6 (Jun, 2007): 1680-1685. (accessed June 24, 2008). Goodman, R. M., F. C. Wheeler, and P. R. Evans, R.,3rd, P. J. Gergen, H. Mitchell, M. Lee. “Evaluation of the Heart to Heart Kattan, C. Kercsmar, E. Crain, J. Anderson, P. Project: Lessons from a Community-Based Eggleston, F. J. Malveaux, and H. J. Wedner. Chronic Disease Prevention Project.” “A Randomized Clinical Trial to Reduce American Journal of Health Promotion : AJHP Asthma Morbidity among Inner-City 9, no. 6 (Jul-Aug, 1995): 443-455. Children: Results of the National Cooperative Guo, J. J., R. Jang, K. N. Keller, A. L. Inner-City Asthma Study.” The Journal of McCracken, W. Pan, and R. J. Cluxton. Pediatrics 135, no. 3 (Sep, 1999): 332-338. “Impact of School-Based Health Centers on Farquhar, J. W., S. P. Fortmann, J. A. Flora, Children with Asthma.” The Journal of C. B. Taylor, W. L. Haskell, P. T. Williams, Adolescent Health : Official Publication of the N. Maccoby, and P. D. Wood. “Effects of Society for Adolescent Medicine 37, no. 4 (Oct, Communitywide Education on 2005): 266-274. Cardiovascular Disease Risk Factors. the Gutzwiller, F., B. Nater, and J. Martin. Stanford Five-City Project.” JAMA : The “Community-Based Primary Prevention of Journal of the American Medical Association Cardiovascular Disease in Switzerland: 264, no. 3 (Jul 18, 1990): 359-365. Methods and Results of the National Farquhar, J. W., N. Maccoby, P. D. Wood, J. Research Program (NRP 1A).” Preventive K. Alexander, H. Breitrose, B. W. Brown Jr, Medicine 14, no. 4 (Jul, 1985): 482-491. W. L. Haskell, et al. “Community Education Haines, D. J., L. Davis, P. Rancour, M. for Cardiovascular Health.” Lancet 1, no. Robinson, T. Neel-Wilson, and S. Wagner. 8023 (Jun 4, 1977): 1192-1195. “A Pilot Intervention to Promote Walking Felson, D. T., Y. Zhang, M. T. Hannan, A. and Wellness and to Improve the Health of Naimark, B. Weissman, P. Aliabadi, and D. College Faculty and Staff.” Journal of Levy. “Risk Factors for Incident Radiographic American College Health : J of ACH 55, no. 4 Knee Osteoarthritis in the Elderly: The (Jan-Feb, 2007): 219-225. Framingham Study.” Arthritis and Rheumatism 40, no. 4 (Apr, 1997): 728-733. 58 Hamman, R. F., R. R. Wing, S. L. Edelstein, J. Tobacco Smoke Exposure Reduction in M. Lachin, G. A. Bray, L. Delahanty, M. Latino Children: A Controlled Trial.” Hoskin, et al. “Effect of Weight Loss with Pediatrics 110, no. 5 (Nov, 2002): 946-956. Lifestyle Intervention on Risk of Diabetes.” Hu, T. W., J. Bai, T. E. Keeler, P. G. Barnett, Diabetes Care 29, no. 9 (Sep, 2006): 2102-2107. and H. Y. Sung. “The Impact of California Hardcastle, J. D., J. O. Chamberlain, M. H. Proposition 99, a Major Anti-Smoking Law, Robinson, S. M. Moss, S. S. Amar, T. W. on Cigarette Consumption.” Journal of Public Balfour, P. D. James, and C. M. Mangham. Health Policy 15, no. 1 (Spring, 1994): 26-36. “Randomised Controlled Trial of Faecal- Humphrey, L. L., M. Helfand, B. K. Chan, Occult-Blood Screening for Colorectal and S. H. Woolf. “Breast Cancer Screening: Cancer.” Lancet 348, no. 9040 (Nov 30, A Summary of the Evidence for the U.S. 1996): 1472-1477. Preventive Services Task Force.” Annals of Hart, A. R. “Pancreatic Cancer: Any Prospects Internal Medicine 137, no. 5 Part 1 (Sep 3, for Prevention?” Postgraduate Medical Journal 2002): 347-360. 75, no. 887 (Sep, 1999): 521-526. Jenum, A. K., S. A. Anderssen, K. I. Healthy Eating Active Communities. Birkeland, I. Holme, S. Graff-Iversen, C. “Background on the Program.” Healthy Lorentzen, Y. Ommundsen, T. Raastad, A. K. Eating Active Communities. Odegaard, and R. Bahr. “Promoting Physical http://www.healthyeatingactive Activity in a Low-Income Multiethnic District: communities.org/background.php Effects of a Community Intervention Study to (accessed June 24, 2008, 2008). Reduce Risk Factors for Type 2 Diabetes and Cardiovascular Disease: A Community Herman, D. R., G. G. Harrison, A. A. Afifi, Intervention Reducing Inactivity.” Diabetes and E. Jenks. “Effect of a Targeted Subsidy on Care 29, no. 7 (Jul, 2006): 1605-1612. Intake of Fruits and Vegetables among Low- Income Women in the Special Supplemental Joshipura, K. J., F. B. Hu, J. E. Manson, M. Nutrition Program for Women, Infants, and J. Stampfer, E. B. Rimm, F. E. Speizer, G. Children.” American Journal of Public Health 98, Colditz, et al. “The Effect of Fruit and no. 1 (Jan, 2008): 98-105. Vegetable Intake on Risk for Coronary Heart Disease.” Annals of Internal Medicine Herman, W. H., T. J. Hoerger, M. Brandle, K. 134, no. 12 (Jun 19, 2001): 1106-1114. Hicks, S. Sorensen, P. Zhang, R. F. Hamman, et al. “The Cost-Effectiveness of Lifestyle Knowler, W. C., E. Barrett-Connor, S. E. Modification Or Metformin in Preventing Fowler, R. F. Hamman, J. M. Lachin, E. A. Type 2 Diabetes in Adults with Impaired Walker, D. M. Nathan, and Diabetes Glucose Tolerance.” Annals of Internal Prevention Program Research Group. Medicine 142, no. 5 (Mar 1, 2005): 323-332. “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention Or Hoffmeister, H., G. B. Mensink, H. Metformin.” The New England Journal of Stolzenberg, J. Hoeltz, H. Kreuter, U. Medicine 346, no. 6 (Feb 7, 2002): 393-403. Laaser, E. Nussel, K. D. Hullemann, and J. V. Troschke. “Reduction of Coronary Heart Lee, I. M. and R. S. Paffenbarger Jr. “Physical Disease Risk Factors in the German Activity and Stroke Incidence: The Harvard Cardiovascular Prevention Study.” Preventive Alumni Health Study.” Stroke; a Journal of Medicine 25, no. 2 (Mar-Apr, 1996): 135-145. Cerebral Circulation 29, no. 10 (Oct, 1998): 2049-2054. Hovell, M. F., S. B. Meltzer, D. R. Wahlgren, G. E. Matt, C. R. Hofstetter, J. A. Jones, E. O. Meltzer, J. T. Bernert, and J. L. Pirkle. “Asthma Management and Environmental 59 Lin, S., M. I. Gomez, S. A. Hwang, E. M. Children with Asthma.” The New England Franko, and J. K. Bobier. “An Evaluation of Journal of Medicine 351, no. 11 (Sep 9, the Asthma Intervention of the New York 2004): 1068-1080. State Healthy Neighborhoods Program.” Nafziger, A. N., T. A. Erb, P. L. Jenkins, C. The Journal of Asthma : Official Journal of the Lewis, and T. A. Pearson. “The Otsego- Association for the Care of Asthma 41, no. 5 Schoharie Healthy Heart Program: (Aug, 2004): 583-595. Prevention of Cardiovascular Disease in the Lindstrom, J., P. Ilanne-Parikka, M. Peltonen, Rural US.” Scandinavian Journal of Public S. Aunola, J. G. Eriksson, K. Hemio, H. Health.Supplement 56, (2001): 21-32. Hamalainen, et al. “Sustained Reduction in Nanchahal, K., J. N. Morris, L. M. Sullivan, the Incidence of Type 2 Diabetes by Lifestyle and P. W. Wilson. “Coronary Heart Disease Intervention: Follow-Up of the Finnish Risk in Men and the Epidemic of Overweight Diabetes Prevention Study.” Lancet 368, no. and Obesity.” International Journal of Obesity 9548 (Nov 11, 2006): 1673-1679. (2005) 29, no. 3 (Mar, 2005): 317-323. Loh, N. R., C. C. Kelleher, S. Long, and B. Narayan, K. M., J. P. Boyle, T. J. Thompson, G. Loftus. “Can we Increase Breast Feeding E. W. Gregg, and D. F. Williamson. “Effect Rates?” Irish Medical Journal 90, no. 3 (Apr- of BMI on Lifetime Risk for Diabetes in the May, 1997): 100-101. U.S.” Diabetes Care 30, no. 6 (Jun, 2007): Look AHEAD Research Group, X. Pi-Sunyer, 1562-1566. G. Blackburn, F. L. Brancati, G. A. Bray, R. National Diabetes Information Clearinghouse Bright, J. M. Clark, et al. “Reduction in (NDIC). “Diabetes, Heart Disease, and Weight and Cardiovascular Disease Risk Stroke.” U.S. Department of Health and Factors in Individuals with Type 2 Diabetes: Human Services, National Institutes of One-Year Results of the Look AHEAD Trial.” Health. http://diabetes.niddk.nih.gov/dm/ Diabetes Care 30, no. 6 (Jun, 2007): 1374-1383. pubs/stroke/ (accessed June 24, 2008). Mandel, J. S., J. H. Bond, T. R. Church, D. C. National Kidney Foundation. “Ten Facts Snover, G. M. Bradley, L. M. Schuman, and F. about Diabetes and Chronic Kidney Ederer. “Reducing Mortality from Colorectal Disease.” National Kidney Foundation. Cancer by Screening for Fecal Occult Blood. http://www.kidney.org/news/newsroom/fs Minnesota Colon Cancer Control Study.” The item.cfm?id=3 (accessed June 24, 2008). New England Journal of Medicine 328, no. 19 (May 13, 1993): 1365-1371. National Kidney Foundation. “Ten Facts about High Blood Pressure and Chronic Marsh, S., S. Aldington, P. Shirtcliffe, M. Kidney Disease.” National Kidney Foundation. Weatherall, and R. Beasley. “Smoking and http://www.kidney.org/news/newsroom/fsite COPD: What really are the Risks?” The m.cfm?id=17 (accessed June 24, 2008). European Respiratory Journal : Official Journal of the European Society for Clinical Respiratory Nygard, J. F., G. B. Skare, and S. O. Physiology 28, no. 4 (Oct, 2006): 883-884. Thoresen. “The Cervical Cancer Screening Programme in Norway, 1992-2000: Changes McGinnis, J. M. and W. H. Foege. “Actual in Pap Smear Coverage and Incidence of Causes of Death in the United States.” JAMA Cervical Cancer.” Journal of Medical : The Journal of the American Medical Association Screening 9, no. 2 (2002): 86-91. 270, no. 18 (Nov 10, 1993): 2207-2212. Osler, M. and N. B. Jespersen. “The Effect Morgan, W. J., E. F. Crain, R. S. Gruchalla, of a Community-Based Cardiovascular G. T. O’Connor, M. Kattan, R. Evans 3rd, J. Disease Prevention Project in a Danish Stout, et al. “Results of a Home-Based Municipality.” Danish Medical Bulletin 40, Environmental Intervention among Urban no. 4 (Sep, 1993): 485-489. 60 Pignone, M., M. Rich, S. M. Teutsch, A. O. Schuit, A. J., G. C. Wendel-Vos, W. M. Berg, and K. N. Lohr. “Screening for Verschuren, E. T. Ronckers, A. Ament, P. Colorectal Cancer in Adults at Average Van Assema, J. Van Ree, and E. C. Ruland. Risk: A Summary of the Evidence for the “Effect of 5-Year Community Intervention U.S. Preventive Services Task Force.” Hartslag Limburg on Cardiovascular Risk Annals of Internal Medicine 137, no. 2 (Jul Factors.” American Journal of Preventive 16, 2002): 132-141. Medicine 30, no. 3 (Mar, 2006): 237-242. Prior, J. O., G. van Melle, A. Crisinel, B. Sidney, S., M. Sorel, C. P. Quesenberry Jr, C. Burnand, J. Cornuz, and R. Darioli. DeLuise, S. Lanes, and M. D. Eisner. “Evaluation of a Multicomponent Worksite “COPD and Incident Cardiovascular Health Promotion Program for Disease Hospitalizations and Mortality: Cardiovascular Risk Factors-Correcting for Kaiser Permanente Medical Care Program.” the Regression Towards the Mean Effect.” Chest 128, no. 4 (Oct, 2005): 2068-2075. Preventive Medicine 40, no. 3 (Mar, 2005): Stuebe, A. M., J. W. Rich-Edwards, W. C. 259-267. Willett, J. E. Manson, and K. B. Michels. Puska, P., A. Nissinen, J. T. Salonen, and J. “Duration of Lactation and Incidence of Toumilehto. “Ten Years of the North Type 2 Diabetes.” JAMA : The Journal of the Karelia Project: Results with Community- American Medical Association 294, no. 20 Based Prevention of Coronary Heart (Nov 23, 2005): 2601-2610. Disease.” Scandinavian Journal of Social Tobacco Education and Research Oversight Medicine 11, no. 3 (1983): 65-68. Committee for California. Confronting a Rodgers, A., S. MacMahon, G. Gamble, J. Relentless Adversary - A Plan for Success: Slattery, P. Sandercock, and C. Warlow. Toward a Tobacco Free California 2006-2008. “Blood Pressure and Risk of Stroke in Sacramento, CA: California State, 2006, Patients with Cerebrovascular Disease. the http://www.dhs.ca.gov/ tobac- United Kingdom Transient Ischaemic Attack co/documents/pubs/MasterPlan05.pdf Collaborative Group.” BMJ (Clinical Research (accessed June 24, 2008). Ed.) 313, no. 7050 (Jul 20, 1996): 147. Tuomilehto, J., J. Lindstrom, J. G. Eriksson, Rossouw, J. E., P. L. Jooste, D. O. Chalton, T. T. Valle, H. Hamalainen, P. Ilanne- E. R. Jordaan, M. L. Langenhoven, P. C. Parikka, S. Keinanen-Kiukaanniemi, et al. Jordaan, M. Steyn, A. S. Swanepoel, and L. “Prevention of Type 2 Diabetes Mellitus by J. Rossouw. “Community-Based Changes in Lifestyle among Subjects with Intervention: The Coronary Risk Factor Impaired Glucose Tolerance.” The New Study (CORIS).” International Journal of England Journal of Medicine 344, no. 18 (May Epidemiology 22, no. 3 (Jun, 1993): 428-438. 3, 2001): 1343-1350. Sarnak, M. J., A. S. Levey, A. C. Schoolwerth, U.S. Centers for Disease Control and J. Coresh, B. Culleton, L. L. Hamm, P. A. Prevention. “The Community Guide to McCullough, et al. “Kidney Disease as a Risk Preventive Services.” U.S. Department of Factor for Development of Cardiovascular Health and Human Services. Disease: A Statement from the American http://www.thecommunityguide.org/ Heart Association Councils on Kidney in (accessed June 24, 2008). Cardiovascular Disease, High Blood U.S. Centers for Disease Control and Pressure Research, Clinical Cardiology, and Prevention. “Lung Cancer: Risk Factors.” U.S. Epidemiology and Prevention.” Hypertension Department of Health and Human Services. 42, no. 5 (Nov, 2003): 1050-1065. http://www.cdc.gov/cancer/lung/basic_info /risk_factors.htm (accessed June 24, 2008). 61 U.S. Centers for Disease Control and Veerman, J. L., J. J. Barendregt, J. P. Prevention. “Reduced Secondhand Smoke Mackenbach, and J. Brug. “Using Exposure After Implementation of a Epidemiological Models to Estimate the Comprehensive Statewide Smoking Ban— Health Effects of Diet Behaviour Change: New York, June 26, 2003-June 30, 2004.” The Example of Tailored Fruit and MMWR.Morbidity and Mortality Weekly Report Vegetable Promotion.” Public Health 56, no. 28 (Jul 20, 2007): 705-708. Nutrition 9, no. 4 (Jun, 2006): 415-420. U.S. Centers for Disease Control and Vork, K. L., R. L. Broadwin, and R. J. Prevention. “Stroke: Risk Factors.” U.S. Blaisdell. “Developing Asthma in Childhood Department of Health and Human from Exposure to Secondhand Tobacco Services. http://www.cdc.gov/stroke/ Smoke: Insights from a Meta-Regression.” risk_factors.htm (accessed June 24, 2008). Environmental Health Perspectives 115, no. 10 (Oct, 2007): 1394-1400. U.S. Centers for Disease Control and Prevention. “Chronic Disease Prevention: Webber, M. P., K. E. Carpiniello, T. Preventing Diabetes and its Complications.” Oruwariye, Y. Lo, W. B. Burton, and D. K. U.S. Department of Health and Human Appel. “Burden of Asthma in Inner-City Services. http://www.cdc.gov/nccdphp/ Elementary Schoolchildren: Do School- publications/factsheets/Prevention/diab Based Health Centers make a Difference?” etes.htm (accessed June 24, 2008). Archives of Pediatrics & Adolescent Medicine 157, no. 2 (Feb, 2003): 125-129. U.S. Centers for Disease Control and Prevention. “Chronic Disease Prevention: Wheeler, J. R., N. K. Janz, and J. A. Dodge. Preventing Heart Disease and Stroke.” U.S. “Can a Disease Self-Management Program Department of Health and Human Services. Reduce Health Care Costs? the Case of http://www.cdc.gov/nccdphp/publications Older Women with Heart Disease.” Medical /factsheets/Prevention/cvh.htm (accessed Care 41, no. 6 (Jun, 2003): 706-715. June 24, 2008). Willi, C., P. Bodenmann, W. A. Ghali, P. D. U.S. Centers for Disease Control and Faris, and J. Cornuz. “Active Smoking and Prevention. “Reducing Childhood Asthma the Risk of Type 2 Diabetes: A Systematic through Community-Based Service Review and Meta-Analysis.” JAMA : The Delivery—New York City, 2001-2004.” Journal of the American Medical Association MMWR.Morbidity and Mortality Weekly Report 298, no. 22 (Dec 12, 2007): 2654-2664. 54, no. 1 (Jan 14, 2005): 11-14. World Cancer Research Fund. Food, U.S. Department of Health and Human Nutrition, Physical Activity and the Prevention of Services. The Health Consequences of Involuntary Cancer: A Global Perspective. London, England: Exposure to Tobacco Smoke: A Report of the Surgeon World Cancer Research Fund, 2001. General. Atlanta, GA: U.S. Department of World Health Organization. Health and Human Services, 2006. “Multifactorial Trial in the Prevention of U.S. Centers for Disease Control and Coronary Heart Disease: 2. Risk Factor Prevention. Prevention Makes Common Changes at Two and Four Years.” European “Cents”. Washington, D.C.: U.S. Heart Journal 3, no. 2 (Apr, 1982): 184-190. Department of Health and Human Zaza, S., P. A. Briss, and K. W. Harris, eds. Services, 2003. The Guide to Community Preventive Services: U.S. Preventive Services Task Force. What Works to Promote Health?. New York, “Screening for Cervical Cancer: NY: Oxford University Press, 2005. Recommendations and Rationale.” The American Journal of Nursing 103, no. 11 (Nov, 2003): 101-2, 105-6, 108-9. 62 Total Savings, Costs, and Net Savings NATIONAL RETURN ON INVESTMENT OF $10 PER PERSON (Net Savings) B APPENDIX 1-2 Years 5 Years 10-20 Years Total Care $5,784,081,647 $19,479,731,068 $21,387,802,964 Cost Savings Costs of $2,936,380,000 $2,936,380,000 $2,936,380,000 Interventions U.S. Net $2,847,701,647 $16,543,351,068 $18,451,422,964 Savings ROI 0.96:1 5.60:1 6.20:1 * In 2004 dollars, net savings 63 11 A. Stern. “Horse-and-Buggy Health Endnotes Coverage.” Wall Street Journal, July 17, 2006. <http://online.wsj.com/article/SB11531027 1 KaiserEDU.org. “U.S. Health Care Costs: 5976708341.html> (accessed June 26, 2008). Background Brief.” Kaiser Family Foundation. 12 V. Colliver. “Preventive Health Plan May <http://www.kaiseredu.org/topics_im.asp?imI Prevent Cost Increases: Safeway Program D=1&parentID=61&id=358> (accessed January Includes Hot Line, Lifestyle Advice.” San 10, 2008). Francisco Chronicle, February 11, 2007. 2 U.S. Centers for Disease Control and 13 D. Lazarus. “Costs of Health Care Drag America Prevention. “Annual Smoking-Attributable Down.” San Francisco Chronicle, June 8, 2005. Mortality, Years of Potential Life Lost, and 14 J. Appleby and S. Silke Carty. “Ailing GM Economic Costs -- United States 1997-2001,” looks to scale back generous health benefits.” Morbidity and Mortality Weekly Review 54, no. 25 USA Today, June 24, 2005. (July 1, 2005): 625-28. 15 KaiserEDU.org. “U.S. Health Care Costs: 3 D.N. Lakdawalla, D.P. Goldman, and B Shang. Background Brief.” Kaiser Family Foundation. “The Health and Cost Consequences Of Obesity <http://www.kaiseredu.org/topics_im.asp?imI Among The Future Elderly.” Health Affairs Web D=1&parentID=61&id=358> exclusive. September 26, 2005. (accessed January 10, 2008). <http://content.healthaffairs.org/cgi/ content/abstract/hlthaff.w5.r30v1?maxtoshow= 16 U.S. Centers for Disease Control and &HITS=10&hits=10&RESULTFORMAT=&autho Prevention, National Center for Health r1=goldman%2C+dana&fulltext=obesity&and Statistics. Health, United States, 2003. Atlanta, orexactfulltext=and&searchid=1&FIRST GA: U.S. Department of Health and Human INDEX=0&resourcetype=HWCIT> (accessed Services, 2003. June 26, 2008). 17 U.S. Centers for Disease Control and 4 Hodgson, TA. “Cigarette Smoking and Prevention. Press Release: Obesity Still a Major Lifetime Medical Expenditures.” Milbank Problem. Atlanta, GA: U.S. Department of Quarterly 70, no. 1 (1992): 81-115. Health and Human Services, April 14, 2006. <http://www.cdc.gov/nchs/pressroom/06fac 5 W. Nusselder, et al. “Smoking and the ts/obesity03_04.htm> (accessed June 26, Compression of Morbidity.” Epidemiology & 2008). Community Health, 2000. 18 S. Jay Olshansky, et. al. “A Potential Decline in 6 H.B. Hubert , D.A. Bloch , J.W. Oehlert, and Life Expectancy in the United States in the 21st J.F. Fries. “Lifestyle Habits and Compression Century.” The New England Journal of Medicine: of Morbidity.” The Journals of Gerontology 57A, Special Report. (March 17, 2005): 1143. no. 6; (June 2002): M347. <http://www.muni.org/iceimages/healthchp/li 7 C. Jagger, R. Matthews, F. Matthews, T. fe%20expectancy1.pdf >(accessed July 1, 2008). Robinson, et al. “The Burden of Diseases on 19 U.S. Centers for Disease Control and Disability-Free Life Expectancy in Later Life.” Prevention, National Center for Health The Journals of Gerontology 62A, no. 4; (April Statistics, 2006 National Health Interview 2007): 408. Survey. Atlanta, GA: U.S. Department of 8 J.T. Cohen, et al. “Does Preventive Care Save Health and Human Services, April 2006. Money? Health Economics and the <http://www.cdc.gov/tobacco/data_statistics Presidential Candidates.” New England Journal /tables/adult/table_2.htm> (accessed June of Medicine 358, no. 7 (2008): 661-663. 26, 2008). 9 Cohen, L. and S. Chehimi. “Beyond 20 U.S. Centers for Disease Control and Brochures: The Imperative for Primary Prevention, National Center for Health Prevention.” Chap. 1 in Prevention is Primary: Statistics, 2005 National Youth Risk Behavior Strategies for Community Well Being, edited by L. Survey. Atlanta, GA: U.S. Department of Cohen, S. Chehimi, and V. Chavez, 3-24. Health and Human Services, April 2005. Oakland, CA: Prevention Institute, 2007. <http://www/.cdc.gov/tobacco/data_statistic s/tables.htm> (accessed June 16, 2008). 10 J.T. Cohen, et al. “Does Preventive Care Save Money? Health Economics and the Presidential Candidates.” New England Journal of Medicine 358, no. 7 (2008): 661-663. 64 21 U.S. Centers for Disease Control and 30 U.S. Centers for Disease Control and Prevention, National Center for Health Prevention. “Obesity in the News: Helping Statistics, 2005 National Youth Risk Behavior Clear the Confusion.” Power Point Survey. Atlanta, GA: U.S. Department of Presentation, May 25, 2005. Health and Human Services, April 2005. 31 D.T. Felson and Y. Zhang. “An Update on the <http://www/.cdc.gov/tobacco/data_statistics Epidemiology of Knee and Hip Osteoarthritis /tables.htm> (accessed June 16, 2008). And with a View to Prevention.” Arthritis and U.S. Centers for Disease Control and Rheumatism 41, no. 8 (1998):1343-1355. Prevention, “Cigarette Use Among High School Students -- United States, 1991 -- 2007,” 32 U.S. Centers for Disease Control and Morbidity and Mortality Weekly Report, 57, no. 25: Prevention. NHIS Arthritis Surveillance. U.S. 689-691 (2008). <http://www.cdc.gov/mmwr/ Department of Health and Human Services, preview/mmwrhtml/mm5725a3.htm> June 15, 2007. http://www.cdc.gov/arthritis/ (accessed June 30, 2008). data_statistics/national_data_nhis.htm#excess (accessed June 26, 2008). 22 E. Nolte. and C. Martin McKee. “Measuring the Health of Nations: Updating an Earlier 33 J. Warner. “Small Weight Loss Takes Big Analysis.” Health Affairs, 27, no. 1 (2008): 58-71. Pressure off Knee.” WebMD Health News. <http://www.webmd.com/osteoarthritis/new 23 American Heart Association and American s/20050629/small-weight-loss-takes-pressure- Stroke Association. Heart Disease and Stroke off-knee> (accessed June 26, 2008). Statistics -- 2008 Update. Dallas, TX: American Heart Association, 2008. 34 U.S. Centers for Disease Control and Prevention. “Preventing Obesity and Chronic 24 U.S. Centers for Disease Control and Diseases through Good Nutrition and Physical Prevention. National Diabetes Fact Sheet: Activity.” U.S. Department of Health and General Information and National Estimates on Human Services, <http://www.cdc.gov/ Diabetes in the United States, 2007. Atlanta, GA: nccdphp/publications/factsheets/Prevention U.S. Department of Health and Human /obesity.htm> (accessed April 14, 2008). Services, 2008. 35 L.H. Anderson, et al. “Health Care Charges 25 E.W. Gregg, J. Yiling, B.L. Cadwell, et al. Associated with Physical Inactivity, Overweight, “Secular Trends in Cardiovascular Disease and Obesity.” Preventing Chronic Disease 2, no. 4 Risk Factors According to Body Mass Index (October 2005):1-12. in US Adults.” Journal of the American Medical Association 293, no. 15 (2005): 1868-1874. 36 E. Ostbye, et al. “Obesity and Workers’ Compensation: Results from the Duke Health 26 National Institute of Diabetes and Digestive and Safety Surveillance System.” Archives of and Kidney Diseases. Do You Know the Health Internal Medicine 167, no. 8 (2004):766-773. Risks of being Overweight? Bethesda, MD: U.S. Department of Health and Human Services, 37 S. Klarenbach, et al. “Population-Based November 2004. <http://win.niddk.nih.gov/ Analysis of Obesity and Workforce publications/health_risks.htm> (accessed Participation.” Obesity 14, no. 5 (May 2006): July 1, 2008). 920-927. 27 American Diabetes Association. “Total 38 Minnesota Department of Health. “Fact Sheet: Prevalence of Diabetes & Pre-diabetes.” Health Care Costs of Physical Inactivity in <http://diabetes.org/diabetes-statis- Minnesota.” tics/prevalence.jsp> (accessed July 1, 2008). <http://www.health.state.mn.us/news/ press- rel/inactivityfs.pdf> (accessed June 25, 2008). 28 Office of the Surgeon General. The Surgeon General’s Call to Action to Prevent and Decrease 39 Nancy Garrett, et al. “Physical Inactivity: Direct Overweight and Obesity. Rockville, MD: U.S. Costs to a Health Plan,” American Journal of Department of Health and Human Services, Preventive Medicine 27, no 4 (2004): 4. Public Health Service, Office of the Surgeon 40 Peter Katzmarzyk, et al. “The Economic Burden General, 2001. of Physical Inactivity in Canada,” Canadian 29 American Obesity Association. “Health Medical Journal 163, no 11 (2000): 787-790. Effects of Obesity.” <http://www.obesity.org/ 41 Trust for America’s Health. F as in Fat: How subs/fastfacts/Health_Effects.shtml> Obesity Policies Are Failing in America. (accessed July 1, 2008). Washington, DC: Trust for America’s Health. To be published August 2008. 65 42 J. Putnam, J. Allshouse and L. S. Kantor. and Human Services, 2007. “U.S. per Capita Food Supply Trends: More 52 Centers for Medicare and Medicaid Services. Calories, Refined Carbohydrates, and Fats.” “U.S. Personal Health Care Expenditures Food Review 25, no. 3 (2002): 1-14. (PHCE), All Payers, State of Residence, 1991- 43 Ibid. 2004. <http://www.cms.hhs.gov/National HealthExpendData/Downloads/res-states.pdf> 44 U.S. Centers for Disease Control and (Accessed July 2, 2008). Prevention, National Center for Health Statistics. “DHHS-USDA Dietary Survey 53 I.B. Ahluwalia et al. “State-Specific Integration -- What We Eat in America.” U.S. Prevalence of Selected Chronic Disease- Department of Health and Human Services, Related Characteristics —- Behavioral Risk <http://www.cdc.gov/nchs/about/major/nh Factor Surveillance System, 2001.” MMWR anes/faqs.htm> (accessed April 18, 2008). Surveillance Summaries. 52, no 8 (2003):1-80. 45 J. Putnam, J. Allshouse and L. S. Kantor. 54 The search was conduced using PubMed. “U.S. per Capita Food Supply Trends: More The search strategies contained the following Calories, Refined Carbohydrates, and Fats.” elements: Food Review 25, no. 3 (2002): 1-14. Diseases: 46 Office of the Surgeon General. The Health The researchers searched for the following Consequences of Smoking: A Report of the Surgeon chronic diseases, cancers, and infectious diseases: General. Washington, D.C.: U.S. Department of Cardiovascular Diseases, Diabetes Mellitus, Health and Human Services, Centers for Cerebrovascular Disorders, Coronary Disease, Disease Control and Prevention, National Brain Ischemia, Heart Diseases, Chronic Center for Chronic Disease Prevention and Obstructive Pulmonary Disease, Asthma, Health Promotion, Office on Smoking and Osteoarthritis, Kidney Diseases, Breast Health, 2004. <http://www.cdc.gov/tobacco/ Neoplasms, Colorectal Neoplasms, Uterine data_statistics/sgr/sgr_2004/index.htm#full> Pancreatic Neoplasms, Cervical Neoplasms, (accessed February 15, 2008). Lung Neoplasms, Communicable Diseases. 47 Office of the Surgeon General. Reducing the Interventions: Health Consequences of Smoking - 25 Years of The researchers searched for the following Progress: A Report of the Surgeon General. Atlanta, terms for public health interventions, modifi- GA: U.S. Department of Health and Human able behavioral changes, or biological risk Services, 1989. http://profiles.nlm.nih.gov/ factors: NN/B/B/X/S/ (accessed February 15, 2008). Public Health, Risk Factors, Risk, Life Style, 48 Office of the Surgeon General. The Health Health Promotion, Exercise, Smoking, Consequences of Smoking: A Report of the Surgeon Smoking Cessation, Sexual Behavior, Food General. Washington, D.C.: U.S. Department Services, Fruit, Mass Screening, Breast of Health and Human Services, Centers for Feeding, Air Pollution, Community Health Disease Control and Prevention, National Services, School Health Services, Healthy Center for Chronic Disease Prevention and People Programs, Cholesterol, Body Mass Health Promotion, Office on Smoking and Index, Blood Pressure, Prevention. Health, 2004. <http://www.cdc.gov/tobacco/ Study Design: data_statistics/sgr/sgr_2004/index.htm#full> The researchers searched for the following (accessed February 15, 2008). epidemiological study design keywords: 49 Campaign for Tobacco Free Kids. “About the Program Evaluation, Intervention Studies, Campaign.” <http://www.tobaccofreekids.org/ Prospective Studies, Case-Control Studies, organization/> (accessed February 15, 2008). Longitudinal Studies, Follow-Up Studies, 50 Campaign for Tobacco Free Kids. “Fact Sheet: Survival Rate, Hospitalization, Proportional Lifetime Health Costs of Smokers vs. Former Hazards Models, Incidence, Data Collection, Smokers vs. Nonsmokers.” Randomized Controlled Trials as Topic, Time <http://www.tobaccofreekids.org/research/fact Factors, Regression Analysis, Diet Surveys, sheets/pdf/0277.pdf> (accessed January 10, Cohort Studies, Outcome Assessment 2008). (Health Care), Workplace, Cross-Sectional Studies, Disease Progression, Risk 51 U.S. Substance Abuse and Mental Health Assessment, Pilot Projects, Effectiveness. Services Administration. Results from the 2006 National Survey on Drug Use and Health. Terms were searched as both keywords and as Washington, DC: U.S. Department of Health Medical Subject Headings (MESH). 66 55 Study quality rankings were ranked A-D based 65 M.O. Casey. Forthcoming “Pioneering Health on study designs of: A) randomized controlled Communities: Development from Programs studies; B) quasi-experiental studies without and Promotion to Policy and Environmental selection bias; C) pre-post studies with no Changes,” Health Promotion Practice. comparison group, or comparison groups 66 EPODE European Network. Together, Let’s with likely selection bias; D) study design of Prevent Childhood Obesity. A Concrete Solution to lower quality than the above. Studies that met This Public Health Issue. Brussels, Belgium: the criteria for A-C were included in final liter- The European Parliament, 2006. ature review. This schema is from Center for http://www.europarl.europa.eu/comparl/en Health Care Strategies, Inc. (2007). The ROI vi/pdf/expert_panels/food_safety_panel/he Evidence Base: Identifying Quality althy-diets-and-physical-activities-guittard.pdf Improvement Strategies with Cost-Saving (accessed July 1, 2008). Potential in Medicaid. Retrieved from <http://www.chcs.org/usr_doc/ROI_Evidenc 67 A.K. Jenum, S.A. Anderssen, K.I. Birkeland, I. e_Base.pdf> (accessed April 23, 2008). Holme, S. Graff-Iversen, C. Lorentzen, et. al. “Promoting Physical Activity in a Low-Income 56 C.D. Economos, et. al., “A Community Multiethnic District: Effects of a Community Intervention Reduces BMI z-score in Children: Intervention Study to Reduce Risk Factors for Shape Up Somerville First Year Results,” Obesity Type 2 Diabetes and Cardiovascular Disease.” 15, no. 5 (May 2007): 1325-1336. Diabetes Care 29 no. 7 (July 2006):1605-1612 57 Based on an interview with Shape Up 68 Thorpe K.E., Florence C.S., and P. Joski. Somerville project researchers. “Which medical conditions account for the rise 58 T. Hu, J. Bai, T.E. Keeler, P.G. Barnett and H. in health care spending?” Health Affairs Web Sung. “The Impact of California Proposition Exclusive (2004): 437-45. These conditions cat- 99, a Major Anti-Smoking Law, on Cigarette egories were constructed using AHRQ’s Consumption.” Journal of Public Health Policy Clinical Classifications Software, which aggre- 15, No. 1 (Spring 1994) 26-36. gates International Classifications of Diseases, Ninth Revision (ICD-9) codes into clinically 59 D.M. Bal, J.C. Lloyd, et. al. “California as a meaningful categories. Clinical Classification Model.” Journal of Clinical Oncology 19, no 18S Software was formerly called Clinical (September 15, 2001 Supplement):69s-73s. Classification for Health Policy Research. See A. 60 Based on information from program staff and Elixhauser, et. al., Clinical Classifications for Healthy Eating, Active Communities. Health Policy Research: Hospital Inpatient Statistics, “Background on the Program.” 2008. 1996, Health Care Utilization Project, HCUP-3 <http://www.healthyeatingactivecommunities.o Research Note. Rockville, Md.: AHRQ, 1998. rg/background.php> (accessed June 24, 2008). 69 See F. Chaloupka. “Macro-Social Influences: 61 Active Living by Design. “Increasing Physical The Effects of Prices and Tobacco Control Activity Through Community Design.” Policies on the Demand for Tobacco <http://www.activelivingbydesign.org/index. Products,” Nicotine and Tobacco Research, 1999; php?id=295> (accessed June 24, 2008). other studies at http://tigger.uic.edu/~fjc/; J. Tauras, “Public Policy and Smoking Cessation 62 YMCA of the USA. “Activate America Fact Among Young adults in the United States,” Sheet.” <http://www.ymca.net/ Health Policy 6 (2004):321-32; S. Emery, et. al., activateamerica/activate_america_leadership. “Does Cigarette Price Influence Adolescent html> 26 July 2008. Experimentation?,” Journal of Health Economics 63 YMCA of the USA provided information to 20 (2001):261-270; J. Harris and S. Chan. “The Trust for America’s Health. Data is not yet Continuum-of-Addiction: Cigarette Smoking in published. Relation to Price Among Americans Aged 15- 29.” Health Economics Letters 2, no. 2 (February 64 D.R. Cyzman, et. al. Forthcoming. 12, 1998):3-12. www.mit.edu/people/jeffrey. “Pioneering Healthy Communities: Increasing Fruit and Vegetable Intake 70 State tax and pack sales data provided by the through a Community Response to the Food Campaign for Tobacco-Free Kids, based on Environment and Social Determinants of state reports and “Campaign for Tobacco- Health,” Health Promotion Practice. Free Kids Fact Sheet.” http://www.tobaccofreekids.org/research/fa ctsheets/pdf/0146.pdf 67 71 Cori E. Uccello. Costs Associated With 77 P.T. Katzmarzyk and I. Janssen. “The Secondhand Smoke. Washington, D.C.: American Economic Costs Associated with Physical Academy of Actuaries, October 2006. Inactivity and Obesity in Canada: An http://www.actuary.org/pdf/health/smoking_ Update.” Canadian Journal of Applied oct06.pdf. (accessed July 1, 2008). Physiology 29 (2004): 90-115. 72 T. Walls, T. CAC Presentation #4. August 8, 78 L.S., Pescatello, B.A. Franklin, R. Fagard, 1994. http://tobaccodocuments.org/pm/ W.B. Farquhar, G.A. Kelley, and C.A. Ray. 2041183751-3790.html. (accessed July 1, 2008). “American College of Sports Medicine See, also J. Heironimus. Interoffice Position Stand: Exercise and Hypertension.” Memorandum to L. Suwarna: Impact of Medicine and Science in Sports and Exercise 36 Workplace Restrictions on Consumption and (2004): 533-553. Incidence. January 22, 1992. 79 O. Alcazar, R.C. Ho, and L.J. Goodyear. http://tobaccodocuments.org/landman/202 “Physical Activity, Fitness and Diabetes 3914280-4284.html. (accessed July 1, 2008). Mellitus.” Chap. 21, In Physical Activity and 73 Active Living by Design. “Case Study: Bicycle Health, edited by C. Bouchard, S. N. Blair Networks in Davis, California Make Active and W. L. Haskell. Vol. 1, 191-204. Transportation Possible.” 2006. Champaign, IL: Human Kinetics, 2007. http://www.activelivingbydesign.org/fileadmin 80 U.S. Centers for Disease Control and /template/documents/case_studies/Davis.pdf Prevention. REACHing Across the Divide: (accessed June 24 2008). Finding Solutions to Health Disparities. Atlanta, 74 P. Simon, C.J. Jarosz , T. Kuo and J.E. Fielding. GA: U.S. Department of Health and Human Menu Labeling as a Potential Strategy for Services, Center for Disease Control and Combating the Obesity Epidemic: A Health Impact Prevention; 2007. Assessment. Los Angeles, CA: Los Angeles County Department of Public Health, 2008. 81 U.S. Centers for Disease Control and Prevention. The Steps Program in Action: Success 75 L. Perreault, Y. Ma, S. Dagogo-Jack, et al. Stories on Community Initiatives to Prevent “Sex Differences in Diabetes Risk and the Chronic Diseases. Atlanta: U.S. Department of Effect of Intensive Lifestyle Modification in Health and Human Services; 2008. the Diabetes Prevention Program.” Diabetes Care (Epub ahead of print, Mar 20, 2008). 82 Ibid. 76 H.W. Kohl. “Physical Activity and Cardiovascular Disease: Evidence for a Dose Response.” Medicine and Science in Sports and Exercise 33, no. Suppl 6 (2001): S472-S483. 68 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871