Another issue raised is where additional Federal investments in overarching issues be made? This could point to two levels of priority setting, with one being relatively simple, and the other being more politically and logistically complex. On the one hand, there is the utility of ensuring that every person can find an entry point and have a voice; on the other hand, there is the opportunity for collective movement when people focus on common issues. It's not necessarily an either/or choice. Another aspect is the social determinants, which would likely have the greatest impact on disparities and inequalities, and should therefore be factored into priority-setting.
Dr. King approved of the idea of two levels of priority-setting, and suggested two foci for the process: 1) the gap between evidence and practice for each topic area, and 2) the overarching Federal investment in areas that will have a pervasive effect. She said the Ad Hoc group on Evidence may need to grapple with how to operationalize social determinants from a public health perspective so that the Committee can make concrete recommendations for the types of interventions that will have an impact. If the recommendations are too nebulous, there is a risk that nothing will happen on this.
Dr. Fielding agreed that examples are needed, but this can become tricky. At the margin, one could say that more investment is needed in education than in health care. But there is not a one-to-one relationship between investment and results. Some states spend more on education and still have worse outcomes than those that spend less. Each social determinant requires specification about what interventions would make a difference, but this is a challenge because the knowledge base is not solid yet. Concrete examples should be given of the type of programs that seem to have an impact.
Dr. Kumanyika introduced several ideas into the discussion. First, she recommended incorporating the concept of "collective risk" that is being used in relation to climate change to advance the social determinants approach. The concept explains how to assess investments that are of benefit to the population, but not necessarily the individual. Second, the Health in all Policies approach falls in line with the Committee's recommendation to address social and physical environmental determinants. In cases where the points of intervention do not fall under the purview of HHS, health-relevant social and physical environmental determinants may be better addressed in policy areas pertaining to other key non-health domains (e.g., housing, agriculture, transportation) as well as the health care system domains.
Dr. Fielding noted that the intent of Health Impact Assessment (HIA) is to look at some of the longer-term, indirect effects of changes in other sectors on health. He suggested that members review the materials on HIA that have been compiled at UCLA (http://www.ph.ucla.edu/hs/health-impact/ ), which summarize the HIAs that have been done in this country. Another member recommended that the World Health Organization's Commission on Social Determinants report should serve as a key reference for the Healthy People 2020 recommendations once they have been finalized. The report of the Robert Wood Johnson Foundation's Commission to Build a Healthier America was also mentioned as a resource. Dr. King requested that NORC distribute the resources mentioned during this discussion to the Committee.
V. Recommendations of the Subcommittee on Data and IT
Dr. Ronald Manderscheid, Chair of the Subcommittee on Data and IT, provided a brief update on the subcommittee's progress. He acknowledged the contributions of the subcommittee members, including Lisa Iezonni as well as representatives from the National Center for Health Statistics (NCHS), SAHMSA, HRSA, and AHRQ. There are three main issues being explored by this subcommittee: 1) How HHS' epidemiology services and services cost data can be used as part of Healthy People 2020; 2) how key Federal data sources on the social and physical determinants of health can be utilized to meet the data needs of Healthy People 2020; and 3) how information technology can be used to develop the public health infrastructure of the nation.
Dr. Manderscheid said the Subcommittee is interested in setting in motion efforts to create an online Healthy People community that all Americans can use to improve their health. It could be used to compare Healthy People 2020 indicators across counties or states, or to compare national data to local benchmark data. The Subcommittee will present its recommendations in time for the Advisory Committee's next public meeting. The two foci for this presentation will pertain to building the public health IT infrastructure and enhancing the capacity to share data.
VI. Wrap-Up and Next Steps
Dr. Fielding addressed the question of whether the Committee's charter would be renewed and when the Department would make a final decision on that issue. Ms. Blakey explained that they were seeking this information and that a decision about the timing of an in-person meeting would need to be made by early August, so that it could be announced in the Federal Register. She added that the Committee's feedback on issues related to both implementation strategies and priority-setting were extremely valuable. Dr. Fielding expressed his sincere thanks to Howard Koh for his leadership and also thanked the members of the public who had signed into the meeting for their interest and engagement in Healthy People 2020.