Overall Perspective:
In remembering earlier work of yours that I’ve seen, you’ve continued to focus on the scientific evidence surrounding health promotion and your commitment to the AMSO model. This creates a consistent approach to how you see this work being done which enhances the authority by which you speak. Your focus on the business model is critical and I think you’ve done your usual thorough effort in reviewing the health and financial aspects of health promotion. Targeting Colorado as a pilot is an excellent idea as you’ve found a state, more so than others that would be receptive to the approach
One area that you’ve expanded on, it seems to me, is related to your social mobilization. Perhaps in the past, we’ve thought of it as “marketing” but social mobilization and its associated colleague, social media identifies, early on, these influencers and their importance to the process. Also cautioning about getting elected officials involved too early is probably a smart move as well.
Opportunities
• Protect the Plan: “Protecting the Plan” is what I discuss with clients so that we can identify the pitfalls that have been seen before or what we anticipate will be problems or challenges (expected or unexpected). Of course, I discuss it as a resilience strategy but the important aspect is to make sure that roadblocks are seen and addressed. You mention this in your FSQs but I think they are deserving of a section. One way to approach this is to examine previous efforts that have been taken to put health promotion in place in a city or region or even within corporations. You mention efforts in New York, Minnesota and Ohio but don’t detail them too much. Could be helpful to review these a bit more.
• Health Disparities: I wonder if you broaden the opportunities for impact if you address racial or gender health disparities as they related to health promotion. I have no idea about this topic at all but given the issues around disparities, this could be an important area to consider and may open up other advocacy and funding options.
• ROI: As you have explained it, an important aspect of the investment return relates to how foundation view their role as investors of early stage social change initiatives. Their emphasis is on validating models that have long reach and serve as models for other communities or for the nation as a whole. Given the challenges that health promotion initiatives have faced with the use of the term “ROI” and its many financial promises over the year, you may want to consider other language to describe this aspect of the program such as the “impact investment.” Additionally, I believe that section could be strengthened by a further description of how foundations view this kind of investment.
~ Richard Citrin, President  Citrin Consulting (Jan 8, 2018)

“This is a great idea. Thank you very much for crafting this ambitious yet essential plan, to dramatically improve our whole-population health. Those of us in solidly red-states with limited foundation money and insufficient state leadership interest in this–probably as least 100M+ Americans–are having to be particularly focused and creative–desperation breeds innovation?

Our organization is based in Arizona, but with nationwide goals. We are focusing on one key element that you refer to: school-based approaches. There are many, many complex elements involved in activating and optimizing just this one setting—which you hinted at in your white paper. (More on this at our website, www.healthyfutureus.org, with details in our slide deck there.) But imagine the power of an entire population engaged in health promotion, when they have already been engaged in it comprehensively throughout their most formative years, K-12–entering the workforce well prepared to respond to employee, community, and social network health promotion? Schools can be a uniquely powerful contributor. We are reaching the entire population over 13 years. The main fixed costs are covered: the school facilities, administration, transportation, food services, many of the teaching staff, etc. For schools that still have adequate physical and health education personnel, we have low cost, highly effective, replicable, scalable, evidence-based programs, ready to expand.

In parallel, we are working on strategies, such as communicating the academic benefits of more physical activity and better nutrition to school and state leaders, legislatively mandating more recess time, and adding physical and health education indicators to the statewide school accountability formula–which help incentivize investing in and improving school health. We are also working on bringing new money from the health sector into schools, to pay for high-ROI preventive education. It would be very interesting to see an expanded future version of this white paper, in which the Empower Youth Health Program @$10/student/year (plus a scenario with the Fit Kids of Northern Arizona intervention as well, @$60-70/student/year) were modeled for universal scaling throughout Colorado schools. And to do a sensitivity analysis reflecting the upside of this. In the meantime, in Arizona and probably the vast majority of states, we have lost key school health budget resources, including physical & health education teachers & related instructional time, as well as recess breaks–in the non-evidence-based and ultimately counter-productive pursuit of student achievement by inactive “blue brains” in unhealthy bodies. In doing so, we have unintentionally accelerated the future health and fiscal “apocalypse” that you mentioned.

The vast majority of policy-makers in many states do not know—and do not WANT to know—the implications of 1 out of 3 children with diabetes as adults–of chronic conditions continuing to grow in prevalence, with ever-earlier on-set and increasing severity. But we are spreading the word, hopefully more and more effectively–to the point where our “leaders” will act. Fortunately, we do have a capitated Medicaid system in Arizona—indeed, the state insisted on that as a condition of becoming the last state to implement Medicaid. That provides a powerful incentive for AHCCCS (Arizona Medicaid) plans and providers to seriously consider evidence-based prevention. So you are right on track, mentioning the potential to use CMS monies to fund prevention programs. We are hoping to even get some CMS funding for independently evaluated, high-medical-ROI, school-based moderate-to-vigorous physical activity and behavior-changing nutrition education programs—based on actual health outcomes for Medicaid enrollees—though we see this as a 5-10 year goal to qualify for regular reimbursement. CMS and many others will need to see some compelling evidence, in order to think (and reimburse) “outside the clinic”. 

Medicaid may be the largest area of the state budget in most states, but not all (e.g., not in AZ);  Prevention investments are discussed on p. 9 and elsewhere. I keep wondering if the average ROI/payback ratios of 2.5-4x are much too low to elicit policy-maker excitement and support–especially given skepticism on prevention claims? What if we stop referring to things like early screening and physicals as prevention–when they are really early detection? Also, shouldn’t we drop prevention steps that heavily dilute the ROI and that we would be unlikely to scale in universal health promotion, compared to better choices, and instead focus on true/”pure” effective prevention, such as vaccinations and low-cost evidence-based PA and nutrition programs at school and work? In that more restrictive but arguably more accurate and realistic definition of prevention, the ROI should be much more compelling. For example, we believe that one of our school-based programs has a 40-100x ROI; another is at least 5-10x–even at a whole-population level. They pay themselves back almost immediately—the bad news, due to high child health costs savings because inactive children with poor nutrition are much sicker than they should be. The good news—kids get healthier, and all future savings in long-term impact go “straight to the bottom line.” It is great to see AMSO brought into the discussion alongside social determinants of health in this plan. Too often, we see naïve assumptions that Awareness with Opportunities, without Motivation and Skills, will lead to behavior change. But just providing parks, paths, and fruit and veggies nearby, is far from enough to change behavior. The Therapeutic Dose concept provides key insights. Thanks to 15-20 years of research on moderate-to-vigorous physical activity (MVPA), one can connect MVPA time to health outcomes. We have done some ground-breaking analysis, showing that a $10/child/year investment in MVPA can save $30-50/year in direct medical costs–thanks to prior research by David Katz and many others. One financing opportunity not yet mentioned in the white paper yet, is social impact investing. This could be particularly important in the many states like Arizona, with limited budgets, leadership focused on other areas, etc. With high ROIs, including demonstrable short-term savings, creative social financing options now exist—including social impact bonds, but other approaches may be feasible as well.

Two statements near the end of the white paper, show the hope/upside–and the scary downside, if we continue on our current path: – “It needs to be done right, and we know how to do it right.” – “If we wait even a decade to address this problem, raising taxes, cutting other spending, or borrowing more money will no longer be viable options.” This white paper provides a compelling framework for planning for universal health promotion, in the broadest sense. It helps those of us focused on school settings, to see how what we are doing can be integrated with and followed up effectively in adult settings, and can be part of a comprehensive system for lifelong health. Thank you very much for putting this together. Who else could have? Keep up the great work, you are on to something critical for our future! Looking forward to working with you on this.”
~ Scott Turner, President & CEO  Healthy Future US (Dec 10, 2017)

“The white paper has validity and hopefully the idea will be a reality soon. My only suggestion is to add a solution under the Determinants of Health – How you are planning to address low literacy rate and individuals who does not speak English? This groups usually are not in compliance with their medication/unable to navigate the health system- primary care and/or specialty care/fill prescriptions and are a no-show – barriers lack of transportation. Reminders given to them in a simple language.”
~ Rosa Browne, Community Access/Breast and Cervical Programs Coordinator  Yale New Haven Hospital (Dec 8, 2017)

“Truly a labor of love produced by Dr. O’Donnell. Thank you for starting the process through your willingness to put this – and yourself – out there, as you’ve done your entire career. While there are plenty of discussions ahead to bring key elements to fruition, someone needed to get the ball rolling and we appreciate your willingness to invest the time, energy and personal capital to do exactly that. Kudos!”
~ Brad Cooper, Chief Executive Officer, US Corporate Wellness, Inc. (Dec 7, 2017)

“I think this is a great idea! I am going to look over it again more carefully and will be in touch. I just wanted to say that I think this type of program would be very helpful to so many people. I will be in touch again. Thank you”
~ Robyn Caruso, BA, CHES, pt, Founder, The Stress Management Institute for Health and Fitness Professionals (Dec 6, 2017)

“With disciplinary expertise in exercise psychology, I appreciate the Awareness, Motivation, Skills, Opportunity (AMSO) Framework for health promotion. Even more, proposing that behavioral intervention success when “delivered through worksites, hospitals and clinics, schools and other community settings, supported by a buyer’s coalition and reinforced by local and state policy changes,” required adequate population dose is sound. Thus the costs of health promotion are transferred to organizational consumers who benefit directly and indirectly from populations who adopt healthier lifestyle habits, and expanding the health promotion industry (beyond sub-industries, such as fitness, nutrition, wellness). Unfortunately, this model fails to address the resource deprivation, i.e. local availability, access, and affordability access to environmental supports for healthy lifestyle patterns among diverse populations relative to geographic communities. If healthy lifestyle disparities among population subgroups are to be promoted, the place-based context (physical features, systems/settings, policies/plans) structural resources required for developing, adopting, and maintaining healthy habits across the life course must factored into costs for health, equity and sustainability.”
~ Deborah John, Associate Professor, Extension Health and Place Specialist, Oregon State University (Dec 7, 2017)

“If we are to achieve progress in population health and well-being for our communities, states and the nation we need transformational thinking to change the current trajectory. It will require efforts of many stakeholders, a much more significant focus on upstream, preventive approaches and long term commitment. This paper provides a basis for serious conversation and debate challenging the status quo in search of a better approach.”
~ Catherine Baase, MD, Health Strategy Consultant, Board Chairperson, Michigan Health Improvement Alliance, former Global Director, Health Services and Chief Health Officer, Dow Chemical

“Michael O’Donnell can always be relied upon to push the envelope, think out of the box, and offer creative solutions that are large but make perfect sense. Traditionally, health care has been discussed along the following dimensions: access, cost, and quality. Why not go upstream and consider prevention and health promotion as equally important? If successful, evidence-based health promotion programs will exert a significant impact on the health and well-being of Americans and do so cost-effectively. Why not give it a try – moving money around to pay for expensive illnesses, many of which are preventable, is not smart – and certainly not the long-term solution for ever-increasing healthcare costs.”
~ Ron Z. Goetzel, PhD, Senior Scientist, Johns Hopkins Bloomberg School of Public Health; Vice President, IBM Watson Health; President & CEO, Health Project

“Michael O’Donnell’s strategy is buttressed by the sound science on which he builds the case… his data
and arguments are convincing –the time has come (and there is social urgency) for a ‘health promotion or wellness moonshot’ the chance to dramatically enhance the health of a large population, to build an competitively advantaged workforce for employers.”
~ Mike Roizen, MD, Chief Wellness Officer Cleveland Clinic, & author of 4 #1 NY Times Bestsellers

“Universal access to evidence based health promotion is a vital dimension of public health. With
excellent clinical and cost analyses, Dr O’Donnell has developed a statewide proposal that is both
innovative and practical to implement. Such an effort will serve as a replicable, national model for the
future of a true health care system.”
~ Kenneth R. Pelletier, PhD, MD, Clinical Professor of Medicine, University of California School of Medicine
(UCSF)

“There are countless ways to advance the well-being of communities including job creation, education
and increasing equitable access to medical care. Where some continue to labor over the cost benefit of
investing in health promotion, Dr. O’Donnell’s provocative proposal offers detailed answers along with
lofty insights about the return on investment of wellness. But more decidedly, the argument herein
transcends such debates and instead begs the question of whether we can afford not to find the
collective will to create universal access to health promotion.”
~ Paul Terry, PhD, President and CEO, Health Enhancement Research Organization (HERO); Editor in Chief, American Journal of Health Promotion

“Michael O’Donnell is a leader in health promotion and its central importance for national health and wellbeing. In this paper, he provides a concrete vision for how a state and even the nation can support health promotion as an essential foundation for human thriving – and how that support would pay us all back many times over. This is a blueprint for any leader interested in advancing human flourishing in their community.”
~ Wayne B. Jonas, MD, Executive Director, Samueli Integrative Health Programs, H&S Ventures

“Michael O’Donnell is a fervent champion of the brutal fact that it is is infinitely more desirable to be healthy them sick. And that this choice is not about more drugs or operations or hospitals or doctors but not getting sick in the first place. Prevention is worth tons of cures and Michael is the preeminent spokesperson of this deep truth.”
~ Walter M. Bortz, MD, Professor of Medicine, Stanford University School of Medicine

“Few people are more knowledgeable about the American healthscape- what’s working, what’s not; the perils and opportunities – than Michael O’Donnell. This detailed and well-reasoned plan is the consummate blue print for doing well by doing good, an opportunity to measure gains concurrently in years gained, and dollars saved. A meticulous plan for achieving that win-win at scale is transformative.”
~ David L. Katz, MD, MPH, FACPM, FACP, FACLM, Director, Yale University Prevention Research Center Griffin Hospital, Founder, True Health Initiative