The workshop’s final session featured an open discussion among the Roundtable members and other workshop attendees about the ideas presented over the course of the day. Session moderator George Isham from HealthPartners remarked that one point of view that he had heard over the course of the day was that instead of finding a way to get health and education working together for common goals—the title of this workshop—the two communities should be working with a common purpose to meet divergent goals. He commended Peter Orszag for pointing out in his presentation that, in Isham’s words, “Health care is eating the socioeconomic heart and soul of the country through its costs,” and Isham noted that several of the presentations emphasized the need to break down silos in both the government and private sectors.
Isham then commented that he would like to see a serious examination of what conditions are necessary to improve the health of students and enhance their learning. He added that he would like the health care sector to understand more clearly the needs, objectives, and issues in the education sector. He also commented on the lack of curriculum content that could be used to teach health literacy and life skills in order to create healthier lifestyles, and he wondered if the case could be made for including health literacy content at every level of primary and secondary education curriculum, from kindergarten through grade 12. He then reminded the workshop participants of the tremendous impact that education has on morbidity and mortality, and he made particular note of the maps that Kent McGuire presented that showed that the areas in the United States
with the largest disparities in education outcomes overlapped considerably with those parts of the country with the largest disparities in health outcomes, with both types of disparities being most prominent in the southern and western parts of the United States.
Having noted once again the seven health priorities that Charles Basch presented (vision, asthma, teen pregnancy, aggression and violence, physical activity, skipping breakfast, and attention deficit hyperactivity disorder [ADHD]), Isham asked the workshop participants to consider how that list could serve as a foundation for coordinated efforts between the health and education sectors. He also suggested to the Roundtable members that when they make their comments, they should think about what awareness they came to in this workshop and what insights they found particularly useful for informing action that the Roundtable—or the country as a whole—might take.
David Kindig of the University of Wisconsin School of Medicine and Public Health reminded the workshop participants that research shows that environmental and social context plays a critical role in poor health and education outcomes, and he noted that the information that Orszag presented demonstrates that the contextual gap is growing. He then said that while there is not a great deal of overlap between education policy and health policy, the two do overlap to a certain degree and that this overlap offers fertile ground for the health and education communities to work with one another, both from a joint policy advocacy perspective and from a programmatic perspective. Referring to McGuire’s disparity maps, Kindig wondered if understanding how those disparities developed might help inform approaches for addressing them.
Robert Kaplan of the Agency for Healthcare Research and Quality commented that the effect of education on health outcomes is “just so remarkably large that we have to address it.” He said that it is time to develop a strategic plan to make progress. He also wondered what the appropriate manner is to deal with community input when community input may be in conflict with the goal of promoting health.
Captain Stephanie Zaza, director of the Division of Adolescent School Health at the Centers for Disease Control and Prevention (CDC), informed the workshop that her division not only focuses on sexual health in adolescents, but also operates all of the elements of school-based health surveillance. She said that data from those surveillance efforts are publicly available, with the 2013 data available on June 12, 2014. She encouraged the research community to make use of these data.
Zaza then commented on the recent recommendation from the Community Preventive Services Task Force to build a portfolio of educational interventions that includes full-day kindergarten for children in poverty, out-of-school enrichment programs, and high school completion pro-
grams. “The real innovation in this work is that [the task force] allowed educational attainment outcomes to be their measure of success and not requiring specific health outcomes as measures,” Zaza said. This step, she said, reflects the compelling evidence that educational attainment, in and of itself, is strongly correlated with long-term health outcomes. She said that she believes the acceptance of that evidence allowed the task force to move forward despite an inability to identify specific health outcomes to measure. She also said that she now believes, based on the presentations at the workshop, that high school completion programs may be one of the most important actions that the health care sector can support for changing the trajectories that lead to poor health in adulthood.
Zaza then spoke about the need for the health care sector to better understand the infrastructure that is available to students in this country and what needs to be done to fix that infrastructure as long as it is not providing school nurses and school-based health centers at every school. She noted that an evaluation of a school nursing program conducted by staff of CDC and the National Association of School Nurses provided the first cost–benefit analysis of school nursing that showed a clear beneficial ratio to having school nurses versus not having school nurses (Wang et al., 2014).
Sanne Magnan of the Institute for Clinical Systems Improvement made two points. First, she said that she is worried—a concern she shared in a side conversation with one of the speakers—that the transition from a fee-for-service model to an outcomes-based model is stalled, even though the outcomes-based model is good for population health and provides better value. She reported that in her side conversation with the speaker, he had told her that the problem is that there is no obvious path for people to see how to get from where we are to where we need to be. “I want us to think, as the Institute of Medicine and the Roundtable on Population Health Improvement, what role we can play in helping create and support an infrastructure to help with that glide path, to help with figuring out how to get from the kind of payment world and medical infrastructure that we live in now to a different kind,” Magnan said. She also voiced her support for the idea that the health care community needs to develop principles to guide communication efforts between its members and those in the education community.
José Montero of the New Hampshire Division of Public Health Services said that while research can often help identify those areas that are ripe for progress, the nation cannot afford to spend the time to take a purely academic approach to the problem, with researchers trying to answer all questions conclusively through data and experimentation. His suggestion was to use the natural experiments that are already occurring to inform the agenda for moving the nation forward. He also
stressed the importance of representatives of different sectors becoming advocates for research and action beyond the health care field. “If we are at a place where we can use our pulpit for any pieces of the spectrum that will help us with health outcomes,” Montero said, “we should do that.”
Montero said that accountable care organizations (ACOs) present a great opportunity to study how to mix the community health outreach workers and health coaches that the new ACO models are developing with the workforce in school health clinics in order to advance the nation’s health outcomes goals. He also said that the Roundtable, as the representative of a wide range of interests in the health sector, needs to help identify the key points for advocacy.
Rear Admiral Sarah Linde of the Health Resources and Services Administration said that the National Prevention Strategy identifies education as an important component and an important sector to participate in that strategy, but it does not offer many concrete action items for linking the health and education sectors. She recommended reviewing the National Prevention Strategy as a starting point for developing a strategic action plan, particularly given that it attempts to address so many of the overarching themes that were discussed in this workshop.
Mary Pittman of the Public Health Institute said that this workshop and the previous day’s workshop sponsored by the National Institutes of Health highlighted the interdependence of biology, health, and education. This interdependence needs to be reflected in a more sophisticated way in the interventions that are developed, particularly those for early childhood. She also remarked that it is clear that both the health and education sectors are concerned about addressing inequities and that equity can be a driving factor in every conversation between the health and education sectors. Pittman continued, “We are going to have to raise awareness about these issues, and we are going to have to talk about the complexity of these issues and identify ways to highlight the contextual gaps so that we can target our communications at multiple levels and stimulate the political will.” Pittman added that there is also a need to communicate the fact that some of these interventions are not expensive and that they have been shown to work.
Debbie Chang of Nemours said that the two workshops got her to think more about intervention strategies and about the importance of developing a small set of metrics that are germane to both health and education. She said that the 2 days of presentations and discussions would prompt her to look at the effects of her obesity programs on a child’s readiness to enter kindergarten and to look at metrics that will identify co-benefits. Chang also asked where the Roundtable can add value to these discussions. Her suggestion was that the Roundtable can play an
important role in breaking down silos, facilitating conversations, and working on collective impact at the national level as well as in advocating for payment reforms and developing a glide path for those reforms.
Chang was not enthusiastic about the idea of producing a strategic plan, but she said that if it is needed, it should be very targeted in its goals. Peggy Honoré of the U.S. Department of Health and Human Services said that the Roundtable should heed Orszag’s comment about being cautious about setting big lofty goals, such as having a specific goal for mortality. “I think a lot of times we wind up with a portfolio of recommendations that don’t go anywhere because they are not realistic,” Honoré said. Marthe Gold of the City College of New York suggested that the U.S. Preventive Services Task Force should look at the evidence base discussed at this workshop. It should then use that evidence base to make recommendations that will lead to major changes and that will inform the medical care system that there are learning experiences in different social environments that impact the plasticity of the brain and future health. Jeffrey Levi of Trust for America’s Health said that the Bright Futures program as it functions under the Affordable Care Act could serve as a template for the sort of approach that Gold suggested. Gold added that a simple metric for success could be high school graduation rates, which, as the evidence presented at the workshop shows, are closely related to such health outcomes as life expectancy and morbidity.
Isham then read a few of the comments that came in from individuals who observed the workshop via the Web. Georges Flores of The California Endowment asked, “What remedies exist for poor performance of educational systems in preparing sufficient numbers of African American and Hispanic children to become qualified to apply for training as health professionals?”
Ann Armstrong in Omaha, Nebraska, wrote,
Here in Omaha we are addressing oral health for various school-based initiatives within schools with high rates of poverty. If you could spend 1 hour going out into the field with us, you would be shocked to see the state of oral health and the impact that alleviating dental pain can have on a child’s ability to concentrate and focus. While educators are often concerned with vision and hearing, oral health is equally as important as children often adapt to the increasing levels of pain that come with oral decay, which is the leading cause of chronic disease among children.
She then asked, “From a holistic perspective, how can we improve the status quo to incorporate oral health as part of comprehensive school health?”
The final comments came from Pamela Russo of the Robert Wood Johnson Foundation, who reiterated that there are many possible intervention points throughout the life course that are critical for improv-
ing both educational attainment and health. She expressed surprise that among all the promising programs and interventions discussed at the workshop, Head Start was not mentioned despite its extensive national presence. She also noted that one statistic that McGuire did not present in his talk is that the same states where educational disparities are the highest are also the areas with the highest rates of infant mortality. “In other words, even from the very start, you get the sense that we are allowing all of these young brains to be damaged and are creating an epidemic of damaged brains,” she said. “We have to find the interventions to stop that.” In closing the discussion, Kindig said that the first 1,000 days are critical in the life course. “I think we have to pay attention earlier than in the school situation,” he said, “though we need to do that as well.”