President Barack Obama's health care reform law will spend more than $1 trillion over the next decade to extend health coverage to millions of people -- and about $20 billion actually trying to make us healthier.
The money supporting these initiatives is tucked inside the Affordable Care Act in the form of the Prevention and Public Health Fund, a pot of money to finance efforts in hundreds of communities to curtail obesity, promote exercise and better nutrition, and reduce tobacco use.
Improving the health of Americans and reducing preventable deaths wouldn't just benefit those individuals. Better health could prove key to reversing decades of skyrocketing health care spending. And the prevention fund is Obamacare's primary means of making inroads on these problems, one community at a time.
“If we removed the barriers to healthy living, we would bend the cost curve in health care spending. In order to do that, we had to target communities," Sen. Tom Harkin (D-Iowa), who created the fund, said in a written statement.
Up to 40 percent of deaths each year from the five leading causes in America -- heart disease, cancer, chronic lower respiratory diseases, stroke and unintentional injuries -- are preventable, the Centers for Disease Control and Prevention reported in May. And medical treatments for the half of the population with chronic health conditions such as cardiovascular disease, diabetes and tobacco-related illnesses account for 84 percent of health care spending, according to a 2010 report from the Robert Wood Johnson Foundation in Princeton, New Jersey.
The Affordable Care Act called for the prevention fund to receive $18.8 billion from 2010 to 2022, then $2 billion annually in future years. But that supply of money has diminished since Obama enacted the law in 2010.
Congress has taken more than $6 billion out of the fund since 2012. Also, the main source of dollars for local initiatives, the Community Transformation Grants program, is ending Sept. 30, two years early, because Congress reallocated the funding to other Centers for Disease Control and Prevention programs. In addition, the Department of Health and Human Services diverted $453.8 million of the money to help finance the implementation of Obamacare's health insurance exchanges.
Perhaps the highest-profile use of the prevention fund is the CDC's $162 million anti-tobacco advertising campaign called "Tips From Former Smokers." The medical journal The Lancet credited these ads with prompting 1.6 million people to attempt to quit smoking and 100,000 people actually to do so in 2012.
The spots feature graphic accounts from individuals with serious tobacco-related ailments, such as a cancer patient from North Carolina who had her larynx removed.
Most of the projects financed by the prevention fund are smaller in scale and cost and based in individual communities, however. These aim to address the underlying cultural and behavioral factors that lead to poor nutrition, inactivity, obesity and tobacco use, and they have the potential to make measurable improvements in health, said Georges Benjamin, executive director of the American Public Health Association in Washington.
"We think that there's evidence that communities have begun talking about those problems, identifying the root causes, trying to use these monies to leverage other funding and other things that they're already doing to begin to make a difference," Benjamin said.
In San Diego County, California, the local government and the Chula Vista Elementary School District used federal grants to make an immediate impact on students' weight, said Nick Macchione, the director of the county Health and Human Services Agency.
School administrators approached county officials in 2010, concerned that unhealthy weight was holding back their students, Macchione said. In partnership with the county's Live Well San Diego initiative, they conducted voluntary body mass index screenings of 25,000 kids in 44 schools. The findings confirmed the leaders' fears: Almost 40 percent of the children were either overweight or obese. "This was shockingly alarming," Macchione said.
Using some of the $8.2 million the county received from the prevention fund, the health agency and the school started making changes, Macchione said. The cafeteria started offering healthier food and local farmers visited to talk about agriculture and provide fresh produce. Math teachers incorporated physical activity into counting lessons. And students and parents received information about nutrition and exercise.
Two years later, Chula Vista schools already could boast gains: a 3.2 percent reduction in the share of students who were obese or overweight. The county has since started spreading this program to 300 schools serving 650,000 children, Macchione said.
Programs in Indiana also focused on children brought home the challenges faced by those working to address health in their communities, said Andrea Hays, the project director overseeing the $3 million in Community Transformation Grants managed by the Healthy Communities Partnership of Southwest Indiana in Evansville.
As in San Diego County, they worked with local schools to incorporate healthier food and physical activity in students' daily routines. Under one pilot program, Healthy Communities Partnership of Southwest Indiana joined with a local hospital to deliver fresh fruits and vegetables to a school, where Hays saw firsthand how deeply rooted the problem was.
"We had kids that had never tried a banana before," Hays said. "It's culture shock for these kids."
In Iowa, the Department of Public Health tapped into $8.2 million in prevention funding to link patients to more medical providers. As part of the Iowa Community Referral Project, a partnership with local health boards and the Urbandale-based Iowa Primary Care Association, dentists received training to take blood pressure measurements and ask patients about tobacco use.
Four of the dental clinics participating in this program provided blood pressure tests to more than 4,000 people and discovered that 6 percent had hypertension, more than 70 percent of whom visited a medical doctor for further care, said Kala Shipley, the executive officer for health promotion at the Des Moines-based department.
Results like these won't reverse years of rising obesity rates and worsening health, but they're a good place to start, Macchione said.
"Culture change takes time," he said. "If we just look back 30 years ago on smoking, can you imagine in our first year and we started our campaign and we showed probably little-to-no impact, if we would've given up?"