Behavior Change In The Era Of Health Reform


Editor’s note: This article is part of a series of blog posts by leaders in health and health care who participated in Spotlight Health from June 25-28, the opening segment of the Aspen Ideas Festival. This year’s theme was Smart Solutions to the World’s Toughest Challenges. Stayed tuned for more.

At the recent 2015 Aspen Ideas Festival, a panel vigorously discussed the potential of behavior change to be the blockbuster drug of the 21st century. While no firm conclusions were reached, all agreed that need is enormous. Currently, too few Americans meet their full potential for health and only about half receive recommended care, including high-value preventive services. Scientists and policymakers have long explored better ways to improve the public’s health knowledge, attitudes, and beliefs to heighten the sense of self-efficacy that could ultimately trigger positive behavior change.

But changing behavior is never easy. Barriers always seem to stand in the way. They include the ongoing challenges of accessing preventive services affordably and conveniently in the current environment, as well as overcoming entrenched societal norms that seem to make healthy choices difficult.

New Opportunities

Now, the era of health reform is bringing new opportunities to overcome some of these barriers. By seizing these opportunities, we can build systems that regularly encourage everyone to make the healthier choice the easier choice — a major goal in facilitating behavior change. Moving toward what the Robert Wood Johnson Foundation calls a true “culture of health,” we can also work to make healthy behaviors the norm, not the exception. To do so we can, among other things, enlist non-traditional partners to help build healthy cultures throughout our daily lives. We especially need such partners since health is much more than what happens in a doctor’s office; rather it starts where people live, labor, learn, play, and pray.

We currently have before us many new ways to encourage behavior change to advance health. All of these approaches present opportunities and challenges. One prime example is the 2010 Affordable Care Act (ACA), which offers a major opportunity to remove cost as a barrier to using preventive services.

The ACA requires all private health plans created after Fall 2010 to offer beneficiaries access to high-value preventive services (eg, those ranked as “A” or “B” by the US Preventive Services Task Force) with no cost sharing. This requirement means that 137 million Americans in private plans can now receive services like tobacco cessation counseling, colorectal cancer screening (such as colonoscopy), and vaccinations without added cost. Although it is still unclear how many providers and patients are now aware of and utilizing this benefit, if millions more do so, we can expect healthier Americans.

Pharmacies, too, are steadily becoming a favored site for the public to access preventive services. With the vast majority of Americans living within five miles of a pharmacy, which are often open round-the-clock, these establishments have become convenient places for people to receive services such as vaccinations, hypertension screening, HIV testing, and counseling.

For example, adults are increasingly seeking sites for immunization other than doctors’ offices, and pharmacies are working to meet this demand. In fact, a full quarter of adults now receive their annual flu shot in pharmacies, compared to only 7 percent seven years ago — although with only about half of all Americans (46 percent) receiving flu immunization last year, we still need to find better ways to improve overall rates.

Early Support Builds Healthy Habits For A Lifetime

With one-third of American children overweight or obese, new support strategies could also help them reset the stage for a lifetime of healthier nutrition choices. In this regard, the 2010 Healthy, Hunger-Free Kids Act offers healthier food options for a range of initiatives for the first time in 30 years, including the National School Lunch and School Breakfast programs. New standards now impact at least 21 million low-income kids for lunch and 11 million for breakfast, with school meal options including more fruits, vegetables, whole grains, and low-fat dairy servings.

The premise here is simple: if children learn to view such food options as the new “normal,” they will make healthier nutritional choices that could last into the future. However, change of this magnitude is never simple, and many debates have emerged about goals, implementation, and specifics of the new standards. As the current law is set to expire in September 2015, ongoing national debate has now centered on the dynamics of reauthorization.

De-Normalizing Tobacco

A final example involves tobacco, still the leading preventable cause of death in the US and, indeed, worldwide. For years, the tobacco industry has successfully normalized and glamorized what we now understand to be a drug addiction. As a result, tobacco causes more than half a million deaths a year in the US, while lung cancer, which should be uncommon, remains the country’s leading cause of cancer death.

Public health practitioners have promoted and advanced strategies to deglamorize and de-normalize tobacco use to promote behavior change. Already about 30 states have taken this approach, reclaiming clean air as the social norm by requiring public places, including restaurants and bars, to be 100 percent smoke-free. Such strategies, combined with a series of other key interventions, have dropped adult smoking prevalence by more than half (from 42 percent to 18 percent) in the last 50 years.

With progress in tobacco control, however, comes the threat of complacency. Most public health attention has now turned elsewhere. Meanwhile, the rapid rise of e-cigarettes, while possibly an innovative form of harm reduction for smokers, also threatens to renormalize smoking behavior while serving as a potential new source of addiction for youth. A vigorous public health debate has erupted about the appropriate role of e-cigarettes in our society. Meanwhile, we all await final rules from the Food and Drug Administration (FDA) regarding “deeming” that for the first time would extend the agency’s regulatory authority to e-cigarettes (as well as to cigars and dissolvable tobacco products).

Looking Ahead

In short, despite recent progress and great opportunities in national strategies to promote prevention and other healthy behaviors, much more needs to be done. Our good health is a gift, and one that is always fragile. In the era of health reform, further unleashing and solidifying the potential for behavior change can protect health. We await further progress to fulfill its promise to be the blockbuster drug we all hope it can be.


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