Prevention Institute

Prevention leaders from across California gathered in Sacramento to explain the critical role of prevention in shaping a healthier and more equitable California -  and describe how California's prevention policies will, in turn, influence the nation's prevention agenda. Read PI's Executive Director, Larry Cohen's written testimony.

Expert Testimony
Larry Cohen
Founder and Executive Director, Prevention Institute
See hearing agenda.
Download a PDF of Larry Cohen's testimony.

Thank you Assemblymember Monning and Senator Hernandez for creating this forum on prevention. Last week I was in Oklahoma speaking at a large meeting on workplace health including many state officials. Now, Oklahoma isn't the first place most people think of when they think about innovation in prevention, but the governor described how she would be turning the smoking room in their capitol into an exercise room, and even more importantly that she had just signed an executive order banning tobacco in all state buildings. I am quite sure this would never have happened without our pioneering work and commitment here in California. When we think about the task before us today, we shouldn't underestimate California's role as a bellwether - a place where innovation can shape the nation. And of course it's not just tobacco; in my career I have been involved in traffic injury and drowning prevention, violence prevention, changing our food and activity environment and in every one of these efforts, groundbreaking work has been done here in California to prevent illness and injury in the first place. When I look around the room today, I see many of the nation's most creative and effective prevention leaders. California has a history of leadership and we are poised to do much more: Prevention is perfectly aligned with California's spirit of innovation and leadership. Today I will highlight reasons that prevention makes economic sense, but this is not just about doing what's cost effective. We do prevention here not just because it is necessary to save money by saving lives, but because it is the right thing to do.

Prevention is deeply personal.  It's about whether our friends, our families, and our communities suffer from illnesses and injuries that could have been prevented in the first place.  Each of us can think of people we care about who are suffering from avoidable illnesses and injuries. Prevention is particularly about investing in health and safety in the places where the need is greatest-low-income populations, people of color , disabled people, and other groups that experience discrimination have the same health problems for the most part, only more so and sooner. Prevention matters.

Why Community Prevention
When I talk about prevention I am talking primarily about community-wide change efforts. Communities, norms and environments broadly shape the ways we behave, which are key determinants of our well-being. Researchers who have looked closely at what shapes health and safety have consistently concluded that the strongest determinants are environment and behavior, which comprise 70% of the factors that influence health; medical care plays a much smaller role, at just 10%. Yet, we direct 96% of our national health expenditures to medical services, and just 4% to prevention.

This is not to say that treatment isn't important: we're all going to need it and when we do, it should be affordable, accessible and high quality. And with effective prevention, we can lessen the onslaught of demand for treatment so the quality can more easily improve.

We need to reframe the way we think about health. If we think about the problem as diabetes, then we're going to solve the problem with health care services like screenings and insulin. If we think about the problems underlying diabetes-poor nutrition and a lack of physical activity-then we'll be thinking about far more people and we'll begin looking at the landscape of opportunities for people to make decisions about what to eat and whether to be active. As the IOM has said, "It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change." Prevention science and practice tells us that changing the conditions where people live, work and play is far more efficient and effective than waiting for people to be sick or injured.

The Impact on California
The health of Californians is vital to our businesses, our economy-our children's future depends on healthy, thriving communities. Preventable illnesses and injuries are currently undermining government, business, communities, and families.

Over 16 million Californians live with at least one of seven preventable conditions: cancer, diabetes, heart disease, hypertension, stroke, mental disorders or pulmonary conditions. This results in over $26 billion in treatment costs and over $100 billion in terms of lost productivity annually. Whether businesses want to come to California and stay here has a lot to do with the quality of communities and the health of the workforce.

Motor vehicle crashes cost the state over $4 billion in health care costs and lost productivity. Asthma cost the state roughly $700 million annually in health care costs and is among the leading reasons children miss school and adults miss work. In 2005 the city of Los Angeles spent more than $56 million dollars on medical treatment for violence.

The economic case for prevention
Investing in prevention is a smart use of resources, from which we all benefit. Prevention Institute's economic analysis of community prevention efforts found an expected return of 4.8:1 after just 5 years in California. That means an investment of $10 per person per year to increase physical activity, improve nutrition, and prevent tobacco use could save the state more than $1.7 billion in annual health care costs within five years. In discussions with the economists we worked with it was clear that, while 4.8:1 is an impressive return, the greatest potential return on investment would come by investing in communities that are most impacted. These savings would accrue to Medicare to the tune of $468 million and MediCal to about $86 million, while private payors could save the lion's share: $1.1 billion.

This is why many businesses already invest in health. Businesses investing in workplace wellness programs showed a $3.48 average return-on-investment for every dollar spent; $2.73 less in absenteeism costs for every dollar spent and a 26% average reduction in health care costs.

But businesses can't do it alone. Building health outside the workplace makes businesses stronger, too. In Lancaster, California, outside of Los Angeles, a $10 million investment in new lighting, landscaping, and trees spurred $125 million in investment in the downtown area, with 40 new businesses opening and 800 new jobs. Sales tax revenue grew by 26 percent, and traffic crashes plummeted.

State Controller John Chiang examined the outlook for state workers and retirees and is now an outspoken proponent of prevention. As he has pointed out, reducing the rate of health care inflation by 1 percent could cut the State's unfunded liability by $7.4 billion over ten years. He is looking at innovative ways to improve the health status of state employees and retirees through prevention.

Building on Innovation in California
California is known throughout the country as an innovator and leader in prevention efforts. Thanks to California's groundbreaking tobacco control policies, more than one million lives have been saved, among both smokers who quit and young people who chose not to start smoking. These efforts have saved $86 billion dollars in health care costs. Lung cancer is declining more than three-times faster in California than in the rest of the nation-and we haven't done all we can do, or saved all the lives we can, particularly in our poorest, rural, LGBT, and communities of color.

Each $30 car seat is estimated to save $2,000 in health care and other costs, and in California, a comprehensive set of policies and practices has pushed car seat compliance over 95%. Seat belts saved almost 13,000 California lives in 2009 alone.

We are in the midst of spurring the same kinds of comprehensive, norms changing prevention successes for diet and inactivity-related chronic diseases, as our state leads efforts to improve access to fresh, healthy food and beverages, and safe places for physical activity.

In 2003, California was the first state in the country to pass a bill that used policy to promote healthier eating in schools. SB 677, sponsored by the California Center for Public Health Advocacy, permitted only the sale of specified healthy beverages and prohibited the sale of sodas in elementary and middle schools. California has gone on to pass some of the most innovative prevention policies in the country.

In this year's legislative season alone, there have been a number of statewide policy successes, including increased breastfeeding support (SB 502), efforts to increase access to the CalFresh program (AB 6 and AB 69), the establishment of a Healthy Food Financing Initiative fund in California (AB 581), bringing Safe Routes to School programs to underserved communities (AB 516), and a requirement for cities and counties to address disadvantaged, unincorporated communities in their general plans (SB 244).

It's happening on a community level, too. At Asian Health Services in Oakland, just a few blocks from Prevention Institute's office, providers recognized that traffic safety was extremely important among their largely immigrant and elderly patient population. They identified the wide busy intersections in Oakland's Chinatown as a serious hazard, and worked with the city and other civic organizations to implement ‘scramble' intersections, with attractive tiles and multilingual signage. They saw an immediate reduction in injuries and fatalities and a reduction in health care costs. What is really striking about this is that they couldn't pay for that work out of health care funds even though it was a smart, creative and efficient way to improve health. We need to figure out how to align our spending on health with the most effective ways to keep people healthy.

Our state has an opportunity to lead the nation in reducing chronic diseases and health inequities, just as we have led the nation in reducing tobacco consumption and eliminating unhealthy food and soda in schools. Legislative and administrative actions can support workplaces, small businesses, hospitals, and government to shift their practices to create a healthier environment for staff and visitors.

Maintaining an innovative edge in California also makes good economic sense because it is this innovation that can help us draw down Federal funds for programs and projects that show promise. We can and do bring in significant resources for WIC, Food Stamps, for Communities Putting Prevention to Work, and most recently, California represented 20% of all funds awarded for federally funded Community Transformation Grants. When California leads with vision, we set ourselves up to be a smart place for the rest of the country to invest.

Recommendations
Prevention is perfectly aligned with California's spirit of innovation and leadership: saving money and lives. Here are a few things that we should work on together:

• Establish a clear, ambitious strategy for prevention in CA: This should include goals for improving community environments and benchmarks that tell us that environments are becoming safer and healthier for all Californians. In addition to chronic disease prevention, community safety (traffic safety, violence prevention) are critical elements of community prevention strategy.
• Ensure that decision making in and across all sectors of government contributes to improved health and safety: Every policy, funding, or administrative decision impacts our health-from transit to education to new technology investments. In many cases, prevention isn't about finding new funds; it's about directing existing funds strategically in order to provide children and families with the opportunities to make healthy decisions. The Health in All Policies Task Force of the Strategic Growth Council's recommendations and the California Obesity Prevention Plan provide frameworks for action. Additional intersectoral work, of the kind advanced through Prevention Institute's Collaboration Multiplier framework, is necessary to better align funding and decisions with health and safety.
• Reflect a commitment to prevention in government's own organizational practices: Implementing model practices that promote health, safety and equity, including state building design and purchasing agreements, would serve to positively affect state employees and those who use state facilities and also signals a commitment to healthy workplaces and communities that attract business.
• Expand investment and maximize its impact of investments in low income underserved communities: There are currently a number of unprecedented investments in prevention in California communities, most notably the federal Community Transformation Grants and The California Endowment's Building Healthy Communities initiative. These efforts will create a wealth of practice-based information that can be applied in communities across the state and there are also many ways to focus state resources in support. Creating an infrastructure that can promulgate best practices and bring efforts to scale will maximize each investment. California will be stronger, more resilient, and more innovative if all have access to opportunities and are able to participate in the life of our state.
• Move clinical care and prevention into closer alignment: There is a wide gap between where our health dollars go and the strategies that are most effective in improving health and safety. Barriers need to be addressed that keep clinical institutions, public health agencies, and community organizations from working together to address the health needs of the population. The Community Centered Health Homes approach is a roadmap for ensuring that clinical care organizations engage effectively in community prevention. As the Affordable Care Act is implemented, it is time for new training, new ways of measuring effectiveness, new payment schemes that bring together the best thinking on how to keep people healthy and safe.

Moving Forward
While prevention has strong, bi-partisan support among the public, and there is unprecedented support including from all of you here, the work is far from done. We've made great strides over the past few decades-with virtually every infant in a car seat and dramatically reduced smoking rates-but we must keep the drumbeat for prevention strong. Health matters. The people in this room today are changing the way our communities think about health, and we're beginning to change the ways our delivery system and our leadership thinks about health. In California, that's because we have innovative funders, innovative approaches, and leaders who are willing to put into action a common sense solution like community prevention. Political will is particularly important, and we have that kind of leadership in this room right now, the kind of leadership to take the next steps in bettering the health of all of our people, in all our communities across the state. We need to invest in prevention because it's the smart thing to do. We need to invest in prevention, because it's the right thing to do.