Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 15
3
The Phillips-Powderhorn Experience and
the Allina Backyard Project
MAYOR R. T. RYBAK
Mayor R. T. Rybak began his comments by acknowledging the efforts
of Allina chief executive officer Richard Pettingill. It was his decision,
Rybak noted, to move the headquarters of Allina to its current building in
a part of Minneapolis experiencing some very deep challenges.
Looking at a map of the city of Minneapolis, Rybak explained that
health disparities cluster in certain areas of the city. A look at unemploy-
ment rates across the city shows that they cluster in the same places where
health disparities do. The same thing occurs with educational disparities.
What this means, Rybak said, is that reducing health disparities is really
about building holistic communities where a resident is entitled to live in a
place where he or she can be fully sustained.
What does this mean from a public policy standpoint? It must first
be recognized that any one of these issues cannot be tackled in isolation,
but the initial focus needs to be on economic disparities, Rybak said. This
includes a focus on housing, access to healthy food, and the ability to access
health care when it is needed. Access to job training and job placement are
other essential pieces of living a healthy life. Rybak noted that a workforce
center is located only about half a block away from Allina headquarters.
Adequate housing is another major component of reducing health dis-
parities. Mayor Rybak developed a housing trust fund that spends $10 mil-
lion each year on affordable housing efforts. The city also uses the fund to
purchase foreclosed homes and place new residents into those homes. The
city offers foreclosure prevention sessions as well. He further noted that the
15
OCR for page 16
16 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
foreclosure problem across the United States is a huge human tragedy that
requires policy makers to be actively involved in these issues.
Juvenile justice is another focus point in efforts to reduce health dispari-
ties. By launching a public health approach to youth violence, the entire
community was brought together and a comprehensive approach focusing
on prevention was created. This approach involves four key values. First,
every young person in Minneapolis is supported by at least one trusted
adult in his or her family or community. Second, intervene at the first sign
that young people are at risk for violence. The city has stepped up efforts
to enforce truancy and curfew laws. A curfew-truancy center where youth
are sent also provides family support services; 80 percent of those youth
sent to the curfew-truancy center never return. Third, refocus young people
who have gone down the wrong path. Lastly, unlearn the culture of violence
in the community. The outcome of these programs is that juvenile crime is
down 40 percent over the past 2 years in Minneapolis. This is, Rybak said,
an example of the importance of focusing on upstream factors.
Referencing the federal health care reform legislation then being dis-
cussed in the United States, Rybak observed that it is a “national disgrace”
that children and adults in this country lack insurance coverage. At the
same time, he said, the population needs to have dramatically different life-
styles. This means a focus on the physical activity aspects of communities.
For example, Minneapolis has a bike center and hundreds of miles of bike
trails, making the city the number two bicycling city in the United States
(Portland, Oregon, is number one). It is essential to create and maintain
walkable, sustainable communities.
Another example of making the physical aspects of communities friend-
lier is the Safe Routes to School initiative. Safe Routes to School is a
national initiative that identifies ways in which schools and parent groups
can find alternatives to busing to get students to and from school. Designat-
ing safe routes on which children may walk to and from school each day
and including “human school buses” along the route have the added benefit
of helping communities organize. A human school bus consists of parents
and other adults who accompany with kids as they walk to school or who
stand on their front steps and wave to the children as they walk by. Even
a message wishing everyone a good day written in chalk on the sidewalk
along where children walk can be a contribution to the human school bus.
The final frontier, Mayor Rybak said, is food: what people are putting
in their stomachs. He noted that the local food movement is huge in this
country and has led to the launch of a new initiative called Homegrown
Minneapolis. This initiative involves creating more community gardens as
well as increasing access to high-quality, affordable food in neighborhoods
that currently do not have access to such products.
Taking this a step further, Rybak noted his wife’s involvement with an
OCR for page 17
17
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
effort to better connect children to nature. How can parents and kids be
reconnected to the land? How can children be moved from “screen time”
to “green time?” By connecting to the land, people become connected to
their food and children are able to spend time in natural settings. To sum-
marize, Rybak said, this is really about finding a comprehensive, holistic
way to raise a family and thereby find a comprehensive, holistic way to
create a community.
DISCUSSION
Following Mayor Rybak’s presentation, the audience was invited to ask
questions. The first question was from participant Jim Hart of the Univer-
sity of Minnesota, School of Public Health. He asked how the mayor was
being supported in his efforts to create holistic communities by the state
and federal levels of government.
Rybak responded that, not surprisingly, the support is extraordinarily
siloed, in that there is very little discussion across levels of government.
For example, although federal and state support for housing is good, the
support for youth violence prevention is very episodic. He noted that the
current White House has created an urban policy position that is focused
on the comprehensive nature of these issues. The mayor also commented
on the importance of Michelle Obama planting a garden on the White
House grounds.
Workshop participant David Pryor asked whether the city has embraced
the mayor’s approach to change and whether evidence of lifestyle changes
on the part of city residents has been detected. Rybak replied that although
all of these initiatives are based in City Hall, they were created in partner-
ship with the community itself. He noted that this is a two-way approach,
in that community members must themselves participate in the local food
initiative and in exercise. Health care reform cannot be expected to be suc-
cessful without also focusing on changing individual behaviors, he said.
Sanne Magnan, Commissioner of Health for the state of Minnesota,
thanked the mayor for his efforts in helping Minneapolis become one of
the pilot communities for a new statewide effort called Steps to a Healthier
Minnesota. She explained that she wants to expand this program across
the entire state and wondered if lessons learned from the effort could be
applied to the future expansion of the program. Rybak responded that the
way that communities are built and laid out needs to be rethought. In some
cases, this means making access to transit easier; in other cases, this means
greater access to different goods within a community. With the population
aging, Rybak continued, infrastructure issues must be addressed at the level
of Main Street. For example, housing for seniors could be created above a
corner grocery store.
OCR for page 18
18 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
Workshop participant Helen Jackson Lockadell asked about strategies
to involve the media in better covering the positive things happening in
communities. The mayor noted that the media does not always pay atten-
tion to the comprehensive nature of these issues. Furthermore, he said that
efforts to communicate with people are so much easier now because of new
interactive social media such as Facebook and blogging. The need is to stop
thinking only about traditional media and start thinking about communi-
cating with people directly, Mayor Rybak commented.
Another workshop participant asked about provisions to use food
stamps at farmers’ markets. She noted that it is very important for the
HIV-positive people who she works with to eat healthy foods. However, it
is difficult for them to access healthy foods such as grapes or blueberries
because of the restrictions on food stamp usage. Rybak replied that an
initiative is under way for farmers’ markets to accept payments through
electronic benefit transfer. Efforts are also under way to work with grocery
store chains to get them to sell more locally grown foods.
When another workshop participant asked the mayor about future
efforts to have healthy and sustainable communities, he asked Gretchen
Musicant, Commissioner of Health in Minneapolis, to respond. She
described the broad network of community clinics in place that provide
health care to residents without insurance. She also described a program
that is part of the Allina Backyard Project. Portico Healthnet provides
people help with connecting to care and to paying for that care. This
effort is subsidized by the health care sector, and the hope is to grow this
program throughout Minneapolis. However, Rybak noted, the dramatic
cuts in health care being proposed at the state level will have a number of
consequences for the health department in Minneapolis.
Roundtable chair Nicole Lurie asked the final question. The Allina
Backyard Project has reshaped its neighborhood, and similar efforts are
under way in North Minneapolis. She wondered what lessons have been
learned about the right conditions to make these sorts of changes.
Mayor Rybak replied that good neighborhood capacity, such as local
institutional support, is critical. For example, both Allina and Abbott
Northwestern Hospital play this role in the Phillips-Powderhorn neigh-
borhood. He also noted the need to be explicit about putting dispropor-
tionate help in the areas of the city with disproportionate need. Describing
this as “heavy, heavy lifting,” Rybak emphasized that extraordinarily
broad coalitions must be built and many, many more partners must be
involved. The mayor also acknowledged that these efforts are difficult to
carry out.
OCR for page 19
19
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
GORDON SPRENGER
Gordon Sprenger is former president and chief executive officer of
Allina Health Systems. He presented a historical perspective on efforts that
have taken place in the Phillips-Powderhorn neighborhood and began by
setting the context. In the mid-1990s, a law that was based on the popu-
larity of health maintenance organizations was implemented in Minnesota.
Essentially on the basis of the idea of managing risk, health systems were
told that they needed to accept an integrated payment for a population base
and manage it. Then, in 1995, 19 hospitals and clinics came together with
a major insurance plan into an integrated system that they named “Allina”
on the basis of the premise that they could align incentives. The plan was
to take a single payment and bring it to an organization like Allina that
could then reallocate resources between the provider side and the preven-
tion side. (Although the law was passed, regulations were never approved.
Today, most health care deliverers are not part of an integrated system.)
Allina wanted to be an innovator in improving the health of the com-
munities that the organization served. In 1995, these communities were
facing many challenges: an aging population, homelessness, suicide, homi-
cides, divorce, stress, households led by single parents, and a changing work
environment. All of these challenges led to numerous health and family
problems for community residents.
Sprenger described two “ah ha” moments that he experienced at about
this time. First, he realized that children were coming to the emergency
rooms to be treated for rat bites. No one considered the fact that once
the rat bites were treated in the emergency room, the children were going
directly back to the same rat-infested homes.
Second, Sprenger described visiting a local park where he spoke to a
young mother about whether she had immunized her child. The mother
reported that what she was worried about was whether her child would
be gunned down in the park, not whether her child was immunized. She
was thinking of survival, in other words, and he was thinking about long-
term health. This disconnect led to Allina’s efforts to solve some of these
problems.
Although several corporations and other organizations were operat-
ing individual programs within the Phillips-Powderhorn community, no
focused cross-agency effort and no comprehensive plan were in place, so
a joint business-government-neighborhood partnership was created. The
members of the partnership pledged to raise $25 million to improve the
community.
Sprenger emphasized here the importance of working in partnership
with the other organizations and corporations. He quoted Albert Einstein,
saying “The significant problems we face cannot be solved at the same
OCR for page 20
20 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
level of thinking we were at when we created them.” It was not enough
to provide quality health care; what was needed was finding the primary
causes of health care problems (violence, smoking, stress) and then finding
ways to intervene.
One of the first things the partnership did was to engage in discussions
with the police department to find a way in which they could work together
to reduce crime and violence in the neighborhood. This effort led to a
decrease in violent crimes from 1,227 in 1995 to 467 in 2008. At the same
time, housing initiatives were initiated to replace and rehabilitate existing
housing on the 14 most blighted blocks.
Other efforts included violence prevention; the creation of protocols
to treat victims of abuse; and the establishment of an on-site family service
center at a local elementary school that provided health care, social ser-
vices, and mental health services to children and families. Sprenger offered
asthma as an example. Because kids suffering from asthma have high rates
of absenteeism, provision of on-site health care services for treatment of
asthma resulted in decreased rates of absenteeism and improved school
performance.
After realizing that 40 cents of every health care dollar goes to treat a
tobacco-related illness, Sprenger decided to take this issue on as well. By
contributing lobbying muscle, spending political capital, and working with
other health care organizations, those efforts resulted in passage of legisla-
tion restricting where one could access tobacco products.
Many observers wondered what all of these efforts had to do with
health. Many providers also felt that they were already short on resources
to care for their sick patients, let alone to spend their few resources on
upstream factors. Sprenger noted, however, that these social problems that
the neighborhood residents experienced would become medical problems
without some kind of intervention.
Other efforts funded by Allina Systems include
• Creation of the Phillips-Powderhorn Cultural Wellness Center
(which will be described in more detail later in this summary).
• Establishment of a free shuttle service for elderly and Medicaid
patients to reduce cancellation rates at clinics.
• Paramedic promotion of recreation safety through helmet aware-
ness efforts in the parks to reduce rollerblading injuries.
• Free tattoo removal for former gang members.
• Creation of the Day One Project, a centralized call center with
an updated database to help abuse victims find a bed in a shelter,
which meant that an abuse victim needing help could locate a
vacancy by making one rather than multiple telephone calls.
OCR for page 21
21
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
• Efforts to increase the number of children beginning school with
complete immunizations by making shots available throughout the
community in the No Shots, No School program, which led to an
immunization rate of 98 percent, up from a rate of 60 percent 2
years earlier.
• Establishment of Park House, a day care center for HIV/AIDS
patients, where social services as well as health care services are
available, which helped prevent hospital emergency room visits.
A major accomplishment was the creation of a health careers partner-
ship. Since 2000, more than 1,200 students have enrolled in the partnership
and have graduated and gone on to career-track jobs. The Train to Work
program was also created for an important business reason: to provide a
future workforce for local hospitals. The program includes work readiness
training and has a mentoring component.
Sprenger was chair of the American Hospital Association board at
that time, so he had a strong platform from which to describe the program
as he traveled throughout the country. He noted that Allina had invested
$20 million to get many of the programs described above up and running.
Although many were skeptical, Allina believed that their investment in the
community was very much a business decision.
RICHARD PETTINGILL
Richard Pettingill is the chief executive officer of Allina. He used the
ongoing federal debate over health care reform to frame his comments and
began his remarks by stating that the current debate is not about reforming
health; rather, it is about reforming how the nation finances health care.
The nation’s health care system is unaffordable, so a discussion of how to
reallocate scarce resources is needed. It is essential, he said, that the dia-
logue in the debate be changed from one about health care to one about
what health is. He suggested that to see meaningful health care reform, the
32 recommendations from the commissioned paper (Appendix A) need to
be discussed and noted that health care reform needs to be seen as health
promotion and prevention.
Pettingill related a story about the importance of determining what
“health” means to people. Atum Azzahir hosted a community meeting
where residents were asked the question, “How do you define health?”
Having never been asked this question, after a stunned silence, the responses
included “living my life without despair,” “I hope my kids have a future,”
and “I know I am not dead, but I’m not certain I’m alive.” These definitions
are fundamentally different from those of clinicians.
OCR for page 22
22 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
Pettingill likens the current situation to a perfect storm: health care
reform legislation will provide incremental improvements and try to repair
a system that is already broken. What is needed instead is investment in the
design of an entirely new system.
As an integrated delivery system, Allina has a board of directors that
has challenged the organization to, as Pettingill said, “create a revolution in
health care.” It is not enough to tinker around the edges, the board empha-
sized. The organization should be “at the forefront of that revolution.”
Although acute and episodic care will always be an important part of
the Allina system, now the emphasis is more on going upstream to focus
on wellness, prevention, and chronic disease management. An electronic
information system is also an important component of the organization so
that the care received can be measured.
One example of how such an electronic information system can be
used can be seen in a project launched by Allina in New Ulm, Minnesota,
a community of 17,000 residents. The goal is to eliminate heart attacks in
10 years. A community cardiac risk assessment is under way for 10,000 of
those residents. Then, moving upstream, residents at risk of cardiac arrest
will be placed in a model of care that includes prevention, wellness, and
chronic disease management. This is a change in how models of provid-
ing care get rewarded because prior to this, Allina would have been paid
only for providing care to a heart attack patient in the emergency room.
Scarce resources need to be reallocated to focus on social circumstances
and behavioral issues (Figure 3-1). Rather than investing resources solely
on health care access, investments in improving the determinants of health
status are needed.
Pettingill also raised the question of what it means to be a not-for-profit
organization with a tax exemption. He described a meeting of community
leaders where charity health care was discussed, noting that Allina provides
free care in the community worth $135 million. Pettingill noted that the
business community suggested that it, the business community, should be
the one claiming that benefit, because Allina builds the free care into its rate
structure system that then gets passed to the private sector.
This discussion led to the formation in 2008 of Allina’s Center for
Healthcare Innovation. Encompassing three projects—the Heart of New
Ulm, the Backyard Initiative, and the Allina Patient Safety Center—the
center’s purpose is to advance initiatives that improve overall health and
well-being in the communities that Allina serves. These initiatives, in turn,
will lead to the creation of national models that can be replicated locally.
Allina is investing $100 million over a 5-year period in the Center for
Healthcare Innovation. The center will also include a research component,
in conjunction with the University of Minnesota’s School of Public Health.
Pettingill described the neighborhood where the Backyard Initiative
OCR for page 23
23
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
Behavioral Patterns
5%
Behavioral
40% Patterns
What is the ROI
when we align
Social economics with Access
15% Circumstances the determinants
of health status?
95%
30% Genetics
5% Environment
Access
10%
Influence* National Health Expenditures**
FIGURE 3-1 Aligning expenditures with determinants of health (* = McGinnis et
al., 2002; ** = Brown et al., 1992).
Figure 3-1.eps
is based. The neighborhood has a population of 45,000 people and high
rates of unemployment, poverty, and subprime mortgages. At the same
time, 50 not-for-profit organizations are present in the neighborhood, so
resources are available. The real challenge is to get these organizations to
collaborate, not compete, and to direct the limited resources in the same
direction. The Backyard Initiative also has a strong Residents Council and
buy-in from community businesses. The police department and the city
public health department are both partners with the community as well.
The role of Allina is to be a convener of people and to be a collaborator
with the organizations.
The Backyard Initiative has a strong focus on prevention. For example,
a childhood visual acuity screening was held in the neighborhood. Seven
hundred children were screened, and 20 percent of those children needed—
but did not have—corrective lenses. Clearly, this will affect the academic
achievement of that 20 percent. Similarly, it is estimated that 50 percent of
the children in the neighborhood have never had a dental exam. This, too,
will affect learning, Pettingill explained.
Another partner of the Backyard Initiative is the Minnesota Early
OCR for page 24
24 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
Learning Foundation. A new project, the Early Learning Initiative, is being
launched. Its goal is to encourage literacy in prekindergarten children. This,
in turn, will affect graduation rates, incarceration rates, and health status. A
health risk assessment effort is also linked to the Early Learning Initiative so
that preschoolers who need visual and dental care can access it early in life.
Still needed in the neighborhood, Pettingill said, is a medical home as
well as a social home. This will involve further partnering to ensure access
for residents to the medical care delivery system, the public health system,
the educational system, the social system, the social services system, and
the economic system.
SANNE MAGNAN
Sanne Magnan is the Commissioner of Health in Minnesota. Her
presentation focused on (1) health care reform efforts in Minnesota and
how those efforts have affected health disparities; (2) efforts and priorities
at the state level to reduce health disparities via Minnesota’s Eliminating
Health Disparities Initiative (EHDI), launched in 2001; and (3) working
with policy makers to reduce health disparities.
Health Care Reform Efforts
Sanne Magnan began her comments by describing the strengths of the
state of health care in Minnesota. She noted that the health plans in the
state (e.g., Medica, Blue Cross and Blue Shield of Minnesota, HealthPart-
ners, and UCare) are required by law to be nonprofit. The state also has
many integrated health care organizations, as well as a strong community
clinic system and safety net system. In relation to the situations in other
states, Minnesota has some of the highest-quality health care and some of
the lowest health care costs in the nation, Magnan said. At the same time,
every dollar that goes toward health care costs takes dollars away from
other determinants of health, such as prevention, healthy behaviors, educa-
tion, and affordable housing.
Minnesota’s health care reform law, passed in 2008, begins with an
investment in public health and prevention through a statewide health
improvement program. Initially called the Statewide Health Promotion
Program, it built upon the Centers for Disease Control and Prevention’s
(CDC’s) Steps to a Healthier U.S. model. State legislators, however, wanted
to focus on health improvement rather than promotion, so the name was
changed to the Statewide Health Improvement Program (SHIP). SHIP aims
to help reduce the burden of chronic disease by focusing on the two leading
preventable causes of illness and death: tobacco use and obesity. Through
a competitive grant process, funding for SHIP was awarded to local public
OCR for page 25
25
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
health agencies (community health boards) and tribal governments. SHIP
now covers all 87 counties in Minnesota and all tribal regions whose gov-
ernments accept state funding.
SHIP focuses on making upstream changes to policies, systems, and
environments to reduce tobacco use and exposure and to increase physi-
cal activity and good nutrition. Making those upstream changes is critical,
Magnan said. Although improving the health care system is a worthy goal,
if the only thing that happens is that more people enter the health care
system to receive treatment, nothing is really solved. Upstream investments
like those made by SHIP can help prevent disease before it starts.
Other components of Minnesota’s health care reform efforts include
improving transparency about the quality and cost of health care, the
creation of a quality incentive program for providers, and the implemen-
tation across the state of medical homes, which link the primary health
care system with resources available in the community. Another activity
supported at the state level by the health department is implementation of
health information technology. By implementing electronic health records,
Magnan noted, it will be easier to collect race and ethnicity data. Currently,
more focused approaches are needed to collect such data, and those data
are desperately needed to inform the activities needed to address disparities.
By legislative mandate, both SHIP and health care homes will be evaluated
by how well disparities are decreased.
Eliminating Health Disparities Initiative
Efforts and Priorities in Minnesota
One critical aspect of Minnesota’s EHDI is to invest in building leader-
ship capacity within communities of color and Native American popula-
tions. The initial approach focused on the eight key areas listed in Box 3-1.
At the same time, the health department is making a conscious effort
to move toward a focus on upstream factors and the social determinants
of health. This upstream approach—rather than a focus only on the health
care system—should assist with reducing multiple health disparities. Mov-
ing the focus upstream can maximize the funding available to reduce health
disparities by reaching more people because by focusing only on the provi-
sion of services to individuals, only a limited number of individuals can
be reached. For example, Minnesota has approximately 750,000 residents
who are people of color or American Indians, yet the existing funding can
reach only 55,000 individuals with direct services. Working upstream in
policy, systems, and environmental changes to address healthy behaviors,
education, job development, the environment, etc., will allow a greater
impact on more people in the state. Minnesota’s Freedom to Breathe act
is an example of an upstream policy initiative that begins to reduce health
OCR for page 26
26 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
BOX 3-1
Eliminating Health Disparities Initiative (EHDI)
Statewide effort to eliminate disparities in 8 areas:
Infant Mortality Diabetes
Childhood/Adult Immunization HIV/AIDS and STIs
Cardiovascular Disease Breast/Cervical Cancer
Violence/Unintentional Injury Healthy Youth Development
disparities. By mandating clean indoor air for all restaurants, bars, and
institutions, workers and patrons are protected from secondhand smoke.
This is true for people of any race, ethnicity, or socioeconomic status.
Other particular initiatives are essential to reducing health disparities.
For example, in addition to the areas listed in Box 3-1, reducing tubercu-
losis is listed as a priority in the EHDI legislation. Magnan also noted the
importance of building social capital and enhancing social interconnections
as a strategy to eliminate health disparities. One example of this can be seen
in state efforts to improve emergency preparedness. These efforts led to
meetings between public health officials and other community officials, such
as chiefs of fire departments and chairs of school boards. These connec-
tions across organizations can assist in tackling a myriad of problems. The
establishment and use of medical care homes are another way to increase
social capital, link people with cultural resources, and enhance work to
eliminate health disparities.
Working with Policy Makers
Sanne Magnan noted the importance of using language that policy
makers (e.g., legislators) understand. For example, rather than talking
about physical inactivity and unhealthy eating, which is what she called
“public health speak,” talk instead about “obesity.” Discussing the increas-
ing rates of obesity among U.S. children—the children people see on the
streets and playgrounds in their communities every day—is much more
compelling than describing the problem only in public health terms. The
creation of community gardens with the involvement of families and chil-
dren is another example of a compelling story for legislators.
Another important lesson learned about working with legislators is to
focus on solutions that can solve multiple problems. For example, Minne-
sota is discussing using some of the same infrastructure for both SHIP and
OCR for page 27
27
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
emergency preparedness programs. Treating obesity as a disaster event or
incident, like any other emergency, is an approach that could address many
problems, Magnan explained. In addition, an infrastructure like that used
for SHIP that focuses on policies, systems, and environmental interventions
could be used to tackle other issues, such as alcohol abuse.
Finally, Magnan indicated that the use of economic data is also help-
ful when working with the legislature. She used the example of sharing
with the legislature the economic consequences of tobacco use and obesity,
explaining that unless these two health care issues are addressed, the annual
cost of health care for the state could be as much as $3.4 billion.
DISCUSSION AND QUESTIONS
All of the morning speakers (Cohen, Iton, Rybak, Sprenger, Pettingill,
and Magnan) responded to questions. Jeff Levi asked the first question,
which referenced the health care reform efforts going on at the federal
level. He asked how the federal government could best support the posi-
tive efforts under way in Minnesota. He followed up by asking Magnan to
address the role of prevention in Minnesota’s health programs.
Sanne Magnan responded by referring first to the American Recovery
and Reinvestment Act, passed by the U.S. Congress in early 2009. That
legislation included approximately $650 million for community-level health
and wellness programs. She noted the importance of ensuring that those
funds get to the local level for use in programs like the Steps to a Healthier
U.S. program currently funded by the CDC.
Sanne Magnan also described the perception that the federal efforts
in health care reform address only access to care and not the overuse and
inefficiencies in the health care system. The National Priorities Partnership
is one organization trying to bring to bear a framework that focuses on the
problem of overuse. Palliative care and safety issues must also be addressed.
Reforming Medicare payment models is another piece of the federal
effort that Magnan believes needs to be addressed. States like Minnesota,
she said, are actually disadvantaged because of the way that Medicare pays
providers.
Richard Pettingill suggested that the public health community needs to
show some outrage to become actively involved in the health care debate.
He noted that the book Freakonomics, in describing how people ascer-
tain risks, describes a trade-off between hazards and outrage that must
be balanced. The number of people who die each year of heart disease,
for example, is an example of a risk with a high hazard but low levels of
outrage. High levels of outrage (and a low level of hazards), on the other
hand, occurs when a child dies because of a gunshot wound. What is
needed, Pettingill said, is greater levels of outrage on the part of the public
OCR for page 28
28 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
health community. This outrage needs to be brought to the federal health
care reform debate.
A representative from the Minneapolis Urban League asked the panel
about the problem of the very small amount of resources available to com-
munities of color. For example, she said, many children in Minneapolis eat
hot Cheetos or other junk foods for breakfast. Is there a way, she wondered,
to provide incentives to communities to encourage healthier eating? Will
SHIP have a role in providing communities of color with incentives for
living a healthier lifestyle? Magnan responded that one of the strengths
of SHIP is that local communities will have a menu of interventions from
which to choose.
A participant from the Association for Nonsmokers described her expe-
rience attending the state’s SHIP conference. She noted that some members
of the audience see health care reform efforts to be a move toward social-
ism. Additionally, some participants at the conference expressed negative
feelings about using taxpayer dollars to try to change individual behavior.
In fact, some participants at the conference believed that attempting to
change this behavior is not an appropriate role for government at all.
Magnan replied that this is an example of “democracy in action.”
Consideration of community health requires both individual responsibility
and community responsibility. For example, if a person wants to go walk-
ing outdoors, it is his or her responsibility to put on shoes and go out the
front door. At the same time, however, if the community has no sidewalks,
no streetlights, or high levels of crime, the responsibility becomes that of
the community. Rather than seeing this as socialism, Magnan commented,
this is just good public policy.
Joel Weissman, an afternoon speaker, offered his own examples of the
critical link between individual responsibility and community responsibil-
ity. People will not go out walking, he said, unless the community makes it
possible to go out walking. Weissman noted that many elderly people move
to Florida because in their home states snow does not get shoveled from the
sidewalks and they end up feeling trapped in their homes. It is possible, he
said, to combine a focus on individual behavior with public policy.
Weissman is a backyard gardener, growing cherry tomatoes, blueber-
ries, and raspberries, and discovered that his children and their friends were
snacking from the garden. At the same time, he noted, they still like pizza
and Cheetos as much as ever. So, only so much can be done to encourage
individual responsibility without ensuring that opportunities exist as well.
A person cannot eat healthy food without access to gardens, farmers’ mar-
kets, or good grocery stores.
Sarah Greenfield, a community organizer with Take Action Minnesota
and Make Health Happen, asked about access to high-quality, affordable
health care. Commenting that this was only one recommendation out of 32
OCR for page 29
29
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
in the commissioned paper by Larry Cohen, Anthony Iton, Rachel Davis,
and Sharon Rodriguez, she asked if the changes that occur nationally or in
the state because of health care reform would affect the public delivery of
health care to the poor, the elderly, and other groups with limited resources.
Anthony Iton responded that it is imperative to consider health care
an important social good. The goal is to align the incentives so that people
understand that their own personal interests are inextricably tied to the
health issues of others in their community. He noted that the current health
care reform debate is really about payment reform rather than health care
reform and that this is a frightening distraction from the real issues. It is
essential, Iton said, to ensure that community-based prevention efforts are
at the core of health care reform.
Larry Cohen noted that not everyone shares the perspective that pre-
vention should be the centerpiece of health care reform. Other advocates
feel that the emphasis on prevention is a distraction. Clearly, he said, one
is not going to work without the other; the two groups of advocates must
learn to work together.
Richard Pettingill, in response to Sarah Greenfield’s question, com-
mented that it is essential to bring the mainstream health care delivery sys-
tem into the debate as a collaborator with communities and public health
officials. Rather than seeing the current efforts as either health reform or
health care reform, it should be a dialogue that includes both health reform
and health care reform.
Sam Nussbaum asked Sanne Magnan about the role of reducing waste
and inefficiency in the health care system. He proposed that Minnesota
could be a model for other states looking to reduce the cost of care, and
asked Magnan to talk about efforts within the state to get costs under
control.
In response, Magnan stated that Minnesota’s health reform efforts
have three goals: first, to improve population health; second, to improve
the health care experience for the consumer; and third, to improve afford-
ability. As an example, she described the state’s efforts to create a system for
high-tech diagnostic imaging (magnetic resonance imaging and computed
tomography scans) across communities and health plans. Any patient who
is given a high-tech diagnostic imaging test should have this information
embedded in that patient’s electronic medical records. In this way, a system
has been put into place to ensure that this valuable but expensive resource
is being used wisely across communities.
Richard Pettingill offered a second response to Nussbaum’s question.
Although Minnesota is ranked at the top of all states in terms of health sta-
tus and educational achievement, it is also true that the state has a high tax
rate. In comparison, Georgia has a very low tax rate but among the worst
high school graduation rates in the country. Also, Medicare reimbursement
OCR for page 30
30 POLICY INITIATIVES TO REDUCE HEALTH DISPARITIES
rates are higher in Georgia than in Minnesota. At the same time, the quality
of health care is lower in Georgia than in Minnesota.
Nicole Lurie noted that the federal stimulus funding contains invest-
ments in areas that directly affect health outcomes, such as early childhood
education and housing. Her perspective is that these should be considered
important health investments.
Joel Weissman asked about the role of evaluation in establishing medi-
cal homes. Magnan explained that they relied upon a very participatory
process that first involved setting up criteria and outcomes. She noted that
it is essential to look at outcomes because of the need to be held account-
able for better health and improved affordability.
Roundtable chair Nicole Lurie asked the final question, which was
whether health care organizations such as health insurers and hospital sys-
tems should be allowed to have nonprofit status. She explained that there
is a national movement among public health leaders to request evidence for
the community benefits that a health care organization provides in order
to determine that it is providing an adequate amount of community care.
Thus, the organization must provide concrete evidence in order to maintain
its nonprofit status.
Gordon Sprenger said that his view is that the difference between for-
profit and nonprofit systems is what the organization does with the profits.
In a for-profit organization, those profits go back to the shareholders; in
a nonprofit organization, those profits should be invested back into the
organization itself and into the community that it serves. He noted the
importance of national leadership on the question of how resources are
allocated and said that this is at the core of health care reform.
Sprenger also mentioned the role of philanthropic organizations.
Explaining that philanthropies have few constraints on how funding is
allocated, he said that as health care reform continues to be evaluated, the
private foundation environment also needs to be examined.
Mike Christensen, a member of Mayor Rybak’s staff, also responded
by saying that public health leadership needs to adopt a new “fundamental-
ism” about reducing health disparities in Minnesota. He noted that of the
health disparities that Sanne Magnan described in her presentation, many
involve sex or violence behaviors. These behaviors, in turn, can lead to
despair, hopelessness, and a lack of future orientation. Low-income urban
populations need more than a new brochure, Christensen said; they need
career ladders and affordable housing. Society needs to “get real about the
interventions,” he commented. He also explained that Allina had tripled
the amount of hiring that it does from the surrounding neighborhoods,
and that Wells Fargo Mortgage had invested $35 million in housing in the
surrounding area. In conclusion, Christensen said, these are the kinds of
interventions that need to happen.
OCR for page 31
31
PHILLIPS-POWDERHORN EXPERIENCE AND ALLINA BACKYARD PROJECT
REFERENCES
Brown, R., J. Corea, B. Luce, A. Elixhauser, and S. Sheingold. 1992. Effectiveness in disease
and injury prevention estimated national spending on prevention—United States, 1988.
Morbidity and Mortality Weekly Report 41(29):529–531.
McGinnis, J. M., P. Williams-Russo, and J. R Knickman. 2002. The case for more active policy
attention to health promotion. Health Affairs 21(2):78–93.
OCR for page 32
