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March 31, 2020
Population health State health policy
Elizabeth Cuervo Tilson
Mandy K. Cohen
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There is now general consensus that to improve the health and well-being of a population, we need to address all of the factors that drive health, including non-medical as well as medical drivers. This means that people should be able to meet their basic needs, like having enough food to eat, safe and secure housing, and a good paying job. It also means that people should be able to live in healthy neighborhoods and communities that support healthy behaviors.
If we are serious about improving population health to the fullest extent possible, we also need to address the disparities in health and well-being among groups based on race and ethnicity, geography (eg, rural vs. urban), educational attainment, and income. We need to acknowledge the inequities that exist, and have existed, in our society that have led to these disparities. For populations of color, the root cause for health disparities is historical and structural racism—those cultural representations, institutional practices, social norms, and public policies that lead to or reinforce inequities among racial and ethnic groups. Correcting these inequities, and decreasing disparities among populations, requires not just acknowledgment and understanding of these issues, but also accountability and intentional work to change them.
A common set of goals and objectives can mobilize, direct, and focus national, state, and local efforts to do the needed intentional work to improve the health and well-being of all people, and can be used to track progress and accountability of that work. The recently released consensus report from the National Academies of Sciences, Engineering, and Medicine (NASEM) recommends Leading Health Indicators (LHIs) for Healthy People 2030 that have health, equity, and well-being at their core. The report recommends 15 new indicators that add focus to the social determinants of health that we know have the greatest impact on overall health, such as poverty, housing, and adverse childhood experiences. These indicators create shared goals that can mobilize stakeholders across sectors to take action while also creating benchmarks to ensure accountability.
These LHIs mark an important shift from past years to include more measures on overall health, well-being, and upstream factors that drive health, and fewer measures of specific health conditions and health care delivery system capabilities. In addition, the measures of equity “go beyond merely disaggregating data by race, ethnicity, sex, or geography and examine segregation and discrimination for a discussion of poverty, racism, and discrimination as the root causes of health inequities.” The LHIs include indicators of how people live their lives in the United States—shaped by the broad context of policies, systems, social structures, and economic forces.
North Carolina embraced this shift in focus for Healthy People 2030, and used it as an opportunity for alignment in developing Healthy North Carolina 2030 (HNC 2030), our state-level version of the national plan. We also moved away from individual health topics to a population health framework that addresses the full factors of health using the Robert Wood Johnson Foundation’s County Health Rankings Model. The framework emphasizes health equity and drivers of health outcomes, including health behaviors, clinical care, social and economic factors, and the physical environment. A total of 21 goals were identified for 2030, down from 40 last decade, to allow for greater focus, attention, energy, and use of resources on a narrower set of priorities. To further mobilize and harmonize state and local efforts across a wide set of partners and stakeholders, HNC 2030 was informed by, and aligns with, other North Carolina statewide strategic plans and priorities, including the Early Childhood Action Plan, Opioid Action Plan, Perinatal Strategic Plan, and the Medicaid Transformation Quality Strategy that guides our state’s move to Medicaid managed care. The North Carolina Department of Health and Human Services is deeply committed to each of these efforts, as we focus on using our resources to “buy health” and not just health care.
The HNC 2030 indicators have considerable alignment with the LHIs recommended in the NASEM consensus report, including increase life expectancy, reduce infant mortality, reduce the prevalence of adverse childhood experiences, reduce drug overdose deaths, reduce the suicide rate, reduce HIV incidence, reduce tobacco and alcohol use, reduce housing problems, increase reading proficiency, and decrease poverty.
We need to recognize that public health alone cannot achieve these goals. There needs to be dissemination to and engagement of broad multisector partners, including health care systems and provider, education, employment, law enforcement, housing, environmental quality, and other systems. These goals will be achieved by not only understanding the interconnectedness of the underlying drivers, but also operationalizing that interconnectedness across sectors. In North Carolina, we are building and deploying shared infrastructure and tactical strategies as part of our Healthy Opportunities work to expand cross-sectoral collaboration. The tactical strategies include standardized screening questions for key health-related social needs, developing the needed workforce (eg, Community Health Workers), and deploying NCCARE360, the nation’s first statewide coordinated network. NCCARE360 unites health care and human services organizations with a shared technology platform that has a robust resource directory and a closed loop referral platform that tracks outcomes, allowing for a coordinated, community-oriented, person-centered approach to delivering care in North Carolina.
Finally, to be successful, we also need to maintain humility in this work. We need to recognize that we don’t always know what works. We should use the best science and learning available to design interventions, but also continue to build the evidence base around what we don’t know. We need to partner deeply across sectors with agencies and people whose expertise differs from our own. For example, health care organizations need not seek to become experts in housing, but instead work to partner closely with organizations that are. Further, we should be mindful of not being quick to build new infrastructure or delivery systems when we could invest more in existing community infrastructure for social service delivery. And when it comes to fundamental topics like dismantling racism, we all need to come together with profound humility to seek deeper understanding.
We want all North Carolinians to have the opportunity for achieving health, and we have embraced Healthy People 2030 and Healthy North Carolina 2030 as frameworks to guide our work over the next 10 years. These frameworks reflect the growing understanding that we must look upstream and tackle the factors outside the four walls of a doctor’s office that influence our ability to improve population health. We are working in North Carolina to align the efforts of public and private stakeholders across our state around this vision, and we are building the infrastructure necessary for action. Other cities, counties, and states have committed to efforts that focus on overall well-being and health equity, and we hope many more will adopt the goals outlined in Healthy People 2030. This is hard work that requires building trust and coordination across complex systems. But if we can get it right, we will have a real opportunity to improve the health of the nation.
 National Academies of Sciences, Engineering, and Medicine 2020. Leading Health Indicators 2030: Advancing Health, Equity, and Well-Being. Washington, DC: The National Academies Press. https://doi.org/10.17226/25682.
Elizabeth Cuervo Tilson, MD, MPH, serves North Carolina as the state health director and the chief medical officer for the Department of Health and Human Services. In this role, she promotes public health and prevention activities, as well as provides guidance and oversight on a variety of cross-departmental issues including the opioid epidemic, early childhood, Medicaid transformation, and healthy opportunities. Prior roles include serving as the medical director of community care of Wake and Johnston Counties, chief network medical director for community care of North Carolina, and assistant consulting professor and cancer control specialist with Duke University Medical Center. Dr. Tilson practiced primary care pediatrics for 26 years and has been active in leadership roles in many local, state, and national pediatric, public health and preventive medicine organizations. Dr. Tilson is a graduate of Dartmouth College (BA), Johns Hopkins University School of Medicine (MD), and the University of North Carolina – Chapel Hill (MPH). She completed residencies and is board certified in both pediatrics and general preventive medicine/public health.
Michael Leighs is the director of intergovernmental affairs for the North Carolina Department of Health and Human Services. Before joining the department he led government relations for the North Carolina Partnership for Children, a statewide nonprofit focused on early childhood development. Michael has over 15 years of public policy and program management experience in the government and nonprofit sectors, including serving in senior roles at the Los Angeles County Department of Public Health and as the Deputy Director of LA Health Action, a project of The California Endowment. He began his policy career as a staff member in the U.S. Senate.
Leighs holds a Master in Public Policy degree from the UCLA Luskin School of Public Affairs and an undergraduate degree in Business Administration from the University of North Carolina – Chapel Hill.
Mandy K. Cohen, MD, MPH, was appointed to the role of secretary of the North Carolina Department of Health and Human Services (DHHS) in January 2017 by Governor Roy Cooper. Secretary Cohen and her team work tirelessly to improve the health, safety and well-being of all North Carolinians. DHHS has 17,000 employees and an annual budget of $20 billion serving as the home to NC Medicaid, public health, mental health, state-operated hospitals and facilities, economic services, adult and child services, early childhood education, employment services, and health service regulation. Secretary Cohen is an internal medicine physician and has experience leading complex health organizations. Before coming to the NC DHHS, she was the chief operating officer and chief of staff at the Centers for Medicare and Medicaid Services (CMS). She brings a deep understanding of health care to the state and has been responsible for implementing policies for Medicare, Medicaid, the Children’s Health Insurance Program and the Federal Health Insurance Marketplace. Secretary Cohen has been recognized a national leader for her work at DHHS. In February of 2019, Modern Healthcare named Secretary Cohen one of the Top 25 Women Leaders in Healthcare.
A graduate of Cornell University, she received her medical degree from Yale School of Medicine and a Master’s in Public Health from the Harvard School of Public Health. She trained in Internal Medicine at Massachusetts General Hospital.
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