Evaluation of The Commission to Build a Healthier America
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The document summarizes a review of the Commission to Build a Healthier America. It discusses the commission's creation, theory of change, impact, and opportunities for future impact. Key points include that the commission aimed to promote health beyond clinical services by influencing policies and environments. It had some success in sparking national conversations around social determinants of health and influencing policies like the Affordable Care Act. There are opportunities to further increase the commission's durability and impact by creating urgency, building an implementation plan, strengthening partnerships, and advocating for additional policy changes.
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Evaluation of The Commission to Build a Healthier America
- 1. Commission to Build a Healthier America: A Fourth Year Review April 2013 Paul Light Nerissa Clarke 4/18/2013 1
- 2. “If you really want to move the needle on life expectancy, quality of life, the kinds of things that the commission focused on, it’s not going to happen through traditional healthcare reform alone. It’s only going to happen through the kind of changes in behavior supported by the changes in policies, and other steps to change the environment that the commission talks about in its report. Obviously we haven’t succeeded in doing all of that yet.” 4/18/2013 2
- 3. Project Questions I. History: Why was the commission created and how was it structured? II. Theory of Change: What was the commission’s framework and theory of change? III. Footprint and Impact: How did the commission create its mark on history? IV. Opportunity: Where is there 4/18/2013 room for impact in the future? 3
- 4. Methodology - Literature review - Document review - Internet searches - Citations - Media coverage - Congressional publications - Public Health curricula - 30 interviews - Data analysis 4/18/2013 4
- 5. The Charge • Raise awareness among policy-makers and the public about the substantial shortfalls in health experienced by many Americans • Identify interventions beyond clinical services that demonstrate promise for improving overall health and reducing disparities • Recommend to the Foundation and the nation’s leaders key actions outside medical care that communities, businesses, unions, philanthropies, faith-based organizations, civic groups, local governments, the states and the federal government can take to create greater opportunities for long and healthy lives for all Americans 4/18/2013 5
- 6. I. Theory of Change Inputs Activities Outputs Outcome • Existing Research • Hearings • Think • A healthier nation • Staff Expertise • Site Visits • Agenda setting for all Americans • Commissioners • Research/ • Reframing • Public Health Publications definition Demonstrations • Outreach • RWJF funding • Media Production • Talk • Stakeholder • Events • Enhance national receptivity • Interactive Tool visibility Development • Foster cross- sector dialogue • Act • Leverage limited resources • Optimize impact 4/18/2013 6
- 7. Framework The Commission’s work promoted a healthier America for all Americans by changing the way we think, talk, and act THINK: “We need to take a look beyond medical care to other factors that can improve America’s health” TALK: “We hope to spark a national conversation [across sectors] about committing to health and wellness for everyone” ACT: We must “focus on those [interventions] with the strongest potential to leverage limited resources and optimize the impact of federal investments” 4/18/2013 7
- 8. Think • Expand traditional definitions of health • Support evidence-based research • Invest in tough measurement techniques 4/18/2013 8
- 9. Talk • Foster collaboration • Develop common language around social determinants – ―Health is more than healthcare‖ – ―Health starts where you live, learn, work, and play‖ 4/18/2013 9
- 10. Act Leverage scarce resources: • Target vulnerable populations (children) • Replicate success (innovation, partnerships) • Measure, measure, measure 4/18/2013 10
- 11. II. Footprint & Impact Footprint is a measure of the ―good commission‖ • Focus on process of ―doing it right‖ • Work horses, not show horses • Some lightweights have high impact; some heavyweights have little or none 4/18/2013 11
- 12. “I do feel that the commission helped. Obviously the momentum was there, the ideas were there, and the receptivity to this kind of stuff was there. But my feeling is that the commission just helped… all of it helped to drive it forward. Of course at the end it’s hard to pin down exactly what one thing was the most influential.” 4/18/2013 12
- 13. Scoring Footprints Eleven Weights: 1. Length 2. Breadth 3. Complexity 4. Leadership 5. Freedom to Investigate 6. Visibility 7. Seriousness 8. Thoroughness 9. Leverage 10. Durability 11. Bipartisanship 4/18/2013 13
- 14. Comparing Footprints Footprin Name Launch t Date Commission 11 11 9/11 Attack Social Security Financing Crisis 2002 1981 received 8 out of 10 10 10 Base Closing and Realignment Government Reorganization Preventing Terrorist Attacks 1988 1947 1998 possible 11 with 10 10 Quality of Care for Wounded Warriors Space Shuttle Challenger Accident 2007 1986 zeroes for: 9 9 Conduct of Iraq War Defense Department Fraud, Waste, and Abuse 2003 1985 9 Deficit Reduction 2010 9 Urban Riots 1967 8+ HEALTHIER AMERICA 2008 • Visibility (can’t be 8 8 Internal Revenue Service Abuse John F. Kennedy Assassination 1996 1963 recovered) 8 7 U.S. Intelligence Agencies Airport Safety 1994 1952 • Leverage to policy 7 Aviation Security and Safety 1996 7 Crime in America 1965 7 Executive Branch Reorganization 1969 (can be debated) 7 6 Stimulus Oversight Educational Quality 2009 1981 • Durability (can be 6 5 5 Strategic Missile Basing Government Response to the HIV/AIDS Epidemic Gulf War Syndrome 1983 1987 1995 enhanced) 4 4 Central America Policy Three Mile Island Nuclear Accident 1983 1979 3 Space Shuttle Columbia Accident 2003 2 Kent State Campus Unrest 1970 1 Central Intelligence Agency Financing of Private 1967 Organizations 4/18/2013 14
- 15. III. Impact Impact is a measure of ultimate success—doing it right is not enough Two measures of impact: 1. Head-to-Head with other blue ribbons 2. Sum of the parts on its own 4/18/2013 15
- 16. 1. Head to Head Impact Name Launch Date 4 9/11 Attack 2002 4 4 4 Base Closing and Realignment Crime in America Defense Department Fraud, Waste, and Abuse 1988 1965 1985 Four-point measure: 4 Government Reorganization 1947 4 Preventing Terrorist Attacks 1998 4 Social Security Financing Crisis 1981 3 3 Airport Safety Conduct of Iraq War 1952 2003 1. Little or none 3 Educational Quality 1981 3 Executive Branch Reorganization 1969 2. Moderate 3 John F. Kennedy Assassination 1963 3 3 Quality of Care for Wounded Warriors Space Shuttle Challenger Accident 2007 1986 3. Large amount 3 3 Stimulus Oversight Strategic Missile Basing 2009 1983 4. Great deal 2 Aviation Security and Safety 1996 2 Central America Policy 1983 2 Deficit Reduction 2010 2* HEALTHIER AMERICA 2008 2 2 Internal Revenue Service Abuse U.S. Intelligence Agencies 1996 1994 Commission received a 2 Urban Riots 1967 1 Central Intelligence Agency Financing of Private Organizations 1967 2-point score (for now) 1 Government Response to the HIV/AIDS Epidemic 1987 1 Gulf War Syndrome 1995 1 Kent State Campus Unrest 1970 1 Space Shuttle Columbia Accident 2003 1 Three Mile Island Nuclear Accident 1979 4/18/2013 16
- 17. 2. Sum of the Parts 1. Commissioners 2. RWJF 3. Community Development 4. Health Field 5. Policy Agenda 4/18/2013 17
- 18. Impact on the Commissioners • On knowledge • On application • On future engagement • On health not being healthcare 4/18/2013 18
- 19. Impact on Robert Wood Johnson Foundation “The Commission’s lesson was not a funding strategy for RWJF, it was a framework. One of the biggest things that came from it was that it altered the way RWJF's top leadership was thinking about social determinants of health.” 4/18/2013 19
- 20. Impact on Community Development “Seeing the foundation take something and move it and spread it into places where we probably couldn't have gone; to see the Federal Reserve Bank so owning expanded notions of health and vitality. That’s huge.” 4/18/2013 20
- 21. Impact on Health Field “From where I sit, I watched the conversation about health really be focused on healthcare across the health policy world, which is really our world, and to see now that so many organizations are really beginning to shift their focus toward the social factors that impact health. I think the commission started a new dialogue on health. I think they were really effective at doing that.” 4/18/2013 21
- 22. Impact on Policy • Healthy Food Financing Initiative • Affordable Care Act • Healthy Hunger-Free Kids Act 4/18/2013 22
- 23. IV. Opportunities Goal: 1. Raise durability – Of commission – Of framework 2. Support advancement in the field 4/18/2013 23
- 24. Specific Strategies 1. Create a sense of urgency 2. Build an implementation plan 3. Deeper Environmental Scan: Partnerships 4. Press the case for policy change 4/18/2013 24
- 25. 1. Create Urgency 4/18/2013 25
- 26. 2. Build Implementation Plan 4/18/2013 26
- 27. 3. Scan the environment 4/18/2013 27
- 28. 4. Press the case for policy change 4/18/2013 28
- 29. Conclusion Where Next? 4/18/2013 29
Editor's Notes
- Robin MockinghauphtReunion Plus: 2/3rd of original commissioners. Its going to be a 1 time meeting for a couple days, education, catch up on the past 4 years, site visit, public hearing, and then ask them to give some ideas for moving forwardIdea behind the commission:Where are we now? what has happened in the past four years (what progress has been made)? Where can we push forward that we haven’t been able to before?Impact of what happened (various perspective), data anything to update, what are the opportunity 4 years later? Progress/where have we fallen back?Not thinking particularly about what RWJF could do? What is it that can be done within the US (RWJF as one of the players)
- “This commission wasn’t about healthcare. It was about lifestyle, it was about exercise, it was about nutrition. Those are the things that dominate the health of the country, much more than healthcare.”
- “Decision-makers at national, state and local levels must have reliable data on health status, disparities and the effects of social determinants of health. Approaches to monitor these data at the local level must be developed by, for example, adapting ongoing tracking systems. Funding must be available to promote research to understand these health effects and to promote the application of findings to decision-makers. “
- The good commission must take enough time to complete its inquiry, but comes to closure without dissipating the urgency associated with its launch. Most of my commissions did just that by finishing within two years of their launch. The Commission to Build a Healthier America crossed the one-year threshold needed to earn a one-point score on this measure. The good commission must examine the widest range of potential causes and consequences of the crisis at hand. Setting an aggressive agenda for exploring their issue was typical among the 28 commissions analyzed. The Commission to Build a Healthier America also took a broad approach, and earned a one-point score on this measure. The good commission embraces the complexity of the issue at hand, thereby avoiding the reductionist temptation to reduce a crisis to a simple event or technical flaw. Like most of the other commissions, the Commission to Build a Healthier America adopted a complex definition of the health problem, and earned a one-point score on this measure. The good commission attracts well-known leadership as a source of ideas, credibility, and future leverage in promoting its findings. Two-fifths of the examined blue-ribbon commissions chose subject-matter experts as their chairs, while the rest recruited visible leaders. The Commission to Build a Healthier America recruited visible leaders as well, and earned a one-point score on this measure. The good commission is free to investigate every lead and examine any angle without interference from its sponsors, stakeholders, and even future readers. Once again, two-fifths of the commissions were tightly limited in their freedom to investigate, while the rest set their agenda without interference. The Commission to Build a Healthier America had full freedom to investigate, and earned a one-point score on this measure. The good commission generates enough visibility to create public interest in its issue, and advance pressure for its recommendations. Roughly two fifths of my commissions received little coverage, while the rest used the urgency of their issue and to generate heavy coverage and create best-selling reports. Despite an aggressive and well-executed communication strategy, the Commission to Build a Healthier America was crowded out of the news hole by the economy, the 2008 election campaign, and rising unemployment. It therefore received a zero on this measure. Its visibility within the health community may support a one-point score, but the lack of visibility of either the commission or its message among opinion-leaders, policymakers, and the public gives it a zero compared to the other 28 commissions. The good commission is serious about honoring its commitment to a broad and complex investigation, assuming, of course, that it has enough resources and freedom to act. All but three of the 28 commissions followed through on their promise, and pursued their answers and recommendations with maximum rigor. The Commission to Build a Healthier America followed through, as well, and earned a one-point score on this measure. The good commission is not just serious about its work, but is also thorough in diving below the easy, often superficial answers into the contested issues that might explain the crisis at hand. All but seven of the 28 commissions completed a thorough inquiry, including 11 that did so in under a year. The Commission to Build a Healthier America did so, too, and earned a one-point score on this measure. The good commission builds leverage for implementation by creating strong linkages with advocates, promoting early commitments to action, targeting its recommendations to specific actors, and even drafting possible legislation and regulations. All but nine of the examined commissions created this sense that they could not be ignored. However, as much as the Commission to Build a Healthier American worked to create this sense of inevitability, the external environment provided little room for engagement. It received a zero on this measure. The good commission produces a body of work that can withstand the test of time. Two-fifths of the commissions were largely forgotten soon after their final meeting, while the rest were central to the debate far into the future. Although RWJF’s commission made every effort to set the stage for durability through its many efforts to penetrate the environment of potential adopters, it nonetheless received a zero on this measure, too. If not yet forgotten, it is fading quickly. This score is not set in concrete, however. As noted later in this report, a renewed investment in promulgating its message could earn a higher score, if not for its name, then at the very least for its think, talk, and act approach. The good commission makes every effort to maintain a bipartisan position as it pursues its inquiry. It may take place in a highly partisan environment, but it tends to wall itself off from the rancor to concentrate on its work. Only three of the 28 commissions were divided by partisanship, while the rest had no discernible party lines. The Commission to Build a Healthier America more than meets this test and earned a one-point score on this measure. “Defined as a summarymeasure of investigatory prominence and a predictor of impact, footprints involve simpleindicators of length, breadth, complexity, leadership, freedom to investigate, visibility,seriousness, thoroughness, prominence, and durable influence.As the next chapter shows, each investigation leaves a footprint on history. Some investigationsare largely invisible, while others are rarely off camera. Some are serious and thorough, whileothers are mostly for show. And some establish their prominence in a sea of competinginvestigations and produce lasting influence on future investigations through their work, whileothers are eclipsed by bigger issues and end up on the proverbial dusty shelf.The challenge is to measure the elements of this implied “good investigation” with enoughprecision to show how footprints vary and why they matter. “ Light, Government by Investigation, page 38“MEASURING INVESTIGATORY FOOTPRINTSEvery investigation leaves its own footprint on investigatory history. This footprint is not asurrogate for historical significance, though it is tempting to argue that “heavier” investigationsare more significant that their lighter peers on my list. Nor is footprint a measure of impact,though many of the measures discussed below do affect eventual impact, albeit through a chainof cause-and-effect that begins with investigatory characteristics such as trigger, breakdown,purpose, and investigatory method.Rather, footprint is an indicator of an investigation’s overall weight in claiming and consumingresources such as time, expertise, and staff; recruiting and deploying energy in a broad, serious,thorough, and bipartisan search for answers a complex issue; operating with full freedom tofollow every lead in a serious, thorough inquiry; establishing its prominence among thecompeting investigations of its era; and creating durable influence on future inquiries. In short, afootprint reveals the overall weight of the investigation using many of the attributes of thepurported good investigation.Again, just because an investigation creates a heavy footprint does not mean it will produce agreat deal of impact. Although Chapter Three shows a very strong relationship with impact, therelationship is not perfect. Eight of the 32 heavy weight investigations (25 percent) on my listcreated relatively low impact, as did 22 of the 38 middleweights. At the same time, none of the30 lightweight investigations created high impact, thereby confirming that footprints do shapeimpact, albeit driven by investigatory characteristics.Impact is not the issue for this chapter, however. It is footprint, and the measures that sum to an11-point score. Before turning to the rating of each investigation and the ranking of my full list,it is important to understand the basic components of the measure.” (p 55-56)
- Robin MockinghauphtReunion Plus: 2/3rd of original commissioners. Its going to be a 1 time meeting for a couple days, education, catch up on the past 4 years, site visit, public hearing, and then ask them to give some ideas for moving forwardIdea behind the commission:Where are we now? what has happened in the past four years (what progress has been made)? Where can we push forward that we haven’t been able to before?Impact of what happened (various perspective), data anything to update, what are the opportunity 4 years later? Progress/where have we fallen back?Not thinking particularly about what RWJF could do? What is it that can be done within the US (RWJF as one of the players)
- Deductions Possible Upgrade
- Assessed by:LegislationExecutive ordersReorganizationsProcess or policy proposalsBudget initiativesMajor addressesEndorsementsPublic statementsOther initiatives
- Substantial partnership with the Federal Reserve BankHealthy Community Conference SeriesArticle contributions to Investing in What Works for America’s Communities RWJF grant with U.S. Green Business CouncilCDFI’s incorporating health as a core objective“LIIF is a community development financial institution (CDFI) that provides innovative capital solutions that support healthy families and communities.” “Seeing the foundation take something and move it and spread it into places where we probably couldn't have gone; to see the Federal Reserve Bank so owning the expanded notions of health and vitality. That’s huge. When you do something and it takes on a life of its own; that’s success. When nobody is saying ‘yeah, that was my idea.’ or nobody saying ‘oh yeah, I funded that.’ but entities begin to own it, embrace it, and move it. That's huge.”National Healthy Community Conference in DC (2010)Ongoing regional Healthy Community Conference Series (LA, New York city, Las Vegas, Houston, Boston, etc)IndirectbookAIGA GAIN Design for Social Value conferenceSocial Capital Markets (SOCAP) Conference workshop led by David Erickson
- “My impression is that the commission made a huge contribution. Mostly within the health community…Before this period social determinants of health seemed to be academic/abstract, not something that was immediately relevant for public health professionals. That's different now. I think now they’re beginning to get it.”
- Add more quotes to reference here“One of the things that this foundation can do is provide the resources and environment for people to test strategies that could end up leading to improved health outcomes. You provide a margin of safety that makes it possible to go out and experiment. I don’t think you can ever tell whether any report has had an impact unless you have made the commitment to put the report into action. So don’t ask me “Has the report made an impact?” Ask, “What has the commission and RWJF done based on this report to try to increase the likelihood that it will have an impact? What have others done?”