Healthy People 2030: A National Blueprint for Health Improvement

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, a must-read for every public health official, Healthy People 2030, makes a much-anticipated debut with a new set of science-based, 10-year objectives—an outline for improving the health of all Americans.

DR. PAUL HALVERSON:
I hope that practitioners in particular will find Healthy People 2030 to be useful and inspirational because both are important. And, you know, at the end of the day, if people don't open the document—if they're not looking at it, if they're not using it—then, you know, all of that work is for naught.

Because it really needs to be a living document to inspire change and to increase the likelihood that we'll actually make a difference in creating the action necessary to achieve these goals.

JILL HUNSAKER RYAN:
I think the most valuable thing about this document is it provides a north star for the public health field, and it helps get public health practitioners rowing in the same direction so that we have a very aligned response as a nation for some of these really critical issues.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the fifth edition of the 10-year plan to improve public health is now available. Healthy People 2030 is out, ready to help guide the next decade of public health agency planning at the state, territorial, freely associated state, and local level.

Subject matter experts, organizations, and members of the public spent years developing the Healthy People 2030 plan, a slimmed-down update that offers a more streamlined set of measurable goals, better organizes objectives by type, and puts the focus on the social determinants of health. We examine Healthy People 2030 with two experts.

Jill Hunsaker Ryan is executive director of the Colorado department of public health and environment. She'll be along shortly to tell us how the report helps her department and the state's 55 local public health agencies coordinate their work. But first, we hear from Dr. Paul Halverson, who was among those helping write The Healthy People 2030 Report. He spent eight years as director and state health officer for the Arkansas department of health. Today, he's founding dean and professor of the Fairbanks School of Public Health at Indiana University.

HALVERSON:
Well, the Healthy People process—actually, this is its fifth edition, and we're really very proud of the fact that this creates national goals for health. Again, it was started with the idea in mind that if everything's a priority, then nothing's a priority.

The idea here was to create a consensus around what are the important strategies for the nation. And the Healthy People process was started with the idea that everyone should be able to live a healthy, full, productive life, and having goals for the nation create the means by which we actually could accomplish that goal.

And so, this fifth edition, if you will, the fifth time this has come out. It's an every-10-years process. It's a massive process of both the government and private sector working together to create these goals.

This edition we believe, again, strikes an important balance between practicality and important aspirational goals for the nation.

JOHNSON:
Are there any big changes?

HALVERSON:
Well, yes, a couple of changes.

First of all, we have substantially reduced the number of goals. You may have known that over the last several editions, the Healthy People process has expanded greatly, and that is in large part because of the popularity of the program.

People saw it as an opportunity to really get their important issue in front of the nation and getting it in the Healthy People process was a really important thing, and part of that was the linkage to funding.

So, the two things that are really different in this edition of the Healthy People 2030 document was the way it was organized and its decoupling from funding.

So, this was not about what should be funded. This is really about what are those things that are most important as it relates to the national goals to achieve a healthier nation.

And the biggest issue, frankly, was the fact that we had a mandate from the health and human services to reduce by over 50% the number of specific goals in the Healthy People document. And that was a major, major task.

Because again, we're not saying that if your issue is not in Healthy People, it's not important. It's just that the Healthy People process had gotten to the point where we had so many goals, it was like looking at the New York phonebook, and then it's hard to say that anything is a priority when there were so many goals.

So, this was an opportunity to skinny down the number of goals, but at the same time to recognize that all of these goals come together to support a healthier people and the opportunity for everyone to live a healthy and productive life.

There is also a strong emphasis this time, in particular, on reducing disparities and increasing the likelihood that everyone could live a full and productive life with the recognition—the important recognition—of the social determinants of health as a driver of much of the background, if you will, related to each of these goals.

JOHNSON:
With the pandemic upon us, we've spent a lot more money on public health lately. We hope that will continue, but we'll find out in time, I suppose.

How does the decoupling of the funding in this report impact our approach to the work we do?

HALVERSON:
Well, I'm glad that you brought this up because it's an important time in our nation.

And I think what we've seen, particularly in our response to COVID, is a public health system that has been systematically undervalued and under-resourced. And its remarkable, frankly, that we've done as well as we have, but you don't have to look too far in most states and local health departments to see really the ravages of the de-investment in public health. And it's predictable, frankly, and I think we've seen a couple of commentaries to this effect.

Public health will rise to the occasion in a national emergency, as we have on several occasions before. Money will come. We'll increase the capacity to do that specific thing—whether it's H1N1, the anthrax issues after 9/11, now with COVID—we put more money in. And then, the immediate problem is over, and then we started de-investing in public health. And we really, frankly, lose the interest of the public in maintaining the strong public health infrastructure that we need.

The problem is—and think of it as a bridge. If we think about public health infrastructure as a bridge that we all drive over, what we do every time we have a crisis is we take out and we put more boards and more concrete to strengthen the bridge. We never really fix the bridge, we just put a Band-Aid on it. And then, when the crisis is over and everybody's thinking everything's fine, we let the bridge fall again.

And so, what we really need to do is to recognize that the infrastructure of public health requires substantial investment over time on a consistent basis.

We really are still in the midst of a crisis. Our workforce in public health is aging and many people are retiring—we've got terrible statistics around people that are planning to leave public health through retirement and other reasons. We've got technology which we are not up to speed on; in particular, we see the problems with technology and public health as it relates to our response to COVID. But all of these things, frankly, remind us of the importance of making a long-term investment in public health.

So, the question is, "How does that relate to 2030?" Well, again, we've decoupled the goals from financing, but that doesn't mean that we're not interested in funding public health. It just means that we don't want to set goals that are solely based upon funding.

So, the funding of public health is still a major issue. It is not a specific goal of Healthy People 2030, it's an implicit assumption that the goals that are provided in Healthy People 2030 need sufficient funding at the federal state and local level in order to be accomplished.

JOHNSON:
What kind of feedback has the report received so far?

Are you aware of any comments in favor or against the changes that are coming out?

HALVERSON:
Well, I've had the same pleasure, really, of presenting and talking a little bit with folks from the American Public Health Association, with the Association of State and Territorial Health Officials, and with a number of local governance boards around Healthy People 2030 and some of the changes that are coming out and so forth. And, frankly, I've seen a tremendous reception to the 2030 approach.

And, you know, it's a plus-minus on the issue around—on one hand, people are very grateful for the fact that we've actually reduced the number of goals because, as I've said, the Healthy People process had gotten to be so popular and so successful that everyone wanted their particular thing in the Healthy People document 2020, 2010, whatever. The point of it is is that we really skinnied it down so that it actually could represent the priorities of the nation. And so, that reduction caused some angst for people that didn't have their issue prominently highlighted in the Healthy People document.

On the other hand, from a policy perspective, people are very relieved and they're grateful for the fact that there actually is now some priority to the Healthy People process, and that we are approaching this from a health equity perspective, and we acknowledge the important factors that the social determinants play in the accomplishment of these goals.

So, I think overall, sort of the preview audiences that I've had a chance to speak to and, I think, colleagues that are on the committee have had likewise experience where people have been pretty positive. So, I'm hoping that, as this is revealed publicly, we'll begin to see really some excitement around moving forward with this new approach.

JOHNSON:
We've heard more data is coming as a part of this newest document.

HALVERSON:
Yeah, so, there will be additional data in it.

As you may know, the National Center for Health Statistics is tasked with actually doing the measurement. They are relieved, by the way, because it had become a major task for them to try—as the number of Healthy People goals had increased substantially, it was difficult in order to keep track of all of these.

So, we have fewer goals, but we will have continued support from the National Center for Health Statistics in gathering the information and reporting on the progress. And all of that, I think, will be an important addition to the Healthy People process.

JOHNSON:
Is that data going to be available to public health professionals around the country?

HALVERSON:
Yes, and the policymakers.

The idea here is that the Healthy People 2030 document will be useful not only to public health people but to policymakers as well. There really needs to be a connection between what public health people think is important and then what policy makers can use to help guide public investment decisions, creating doable and measurable goals for public health.

So, all of this, I think, helps move us in the right direction, and I believe that the new Healthy People document goes a long way to helping to support improved public health policymaking.

JOHNSON:
Is that the number one goal for this piece of work?

HALVERSON:
I really think so. I think the issue that the committee was pretty strong on was it's great to have good goals, but we need to have goals that are actionable. We need to see progress.

Sadly, there are some things that, you know, of course we all agree that it's important to reduce disparities and to improve life expectancy, but we haven't seen the progress that we need to see. And again, by choosing goals that have specific measurable outcomes and by looking at ways in which to be more encompassing of all industries—one of the issues that we really stressed was the importance of all sectors and being involved.

It's not simply what public health thinks of itself—it's how public health interacts with the healthcare sector, with the education sector, with transportation, with education, with commerce, with all sectors.

And so, one of the major focal areas really is in terms of trying to engage all of society and coming up with health goals that are meaningful to, you know, the stock market people, to the people in transportation, in aeronautics, in education, and farming.

It's amazing—I mean, every industry has important goals that are health-related, and that if we all could recognize how we fit together to support important health goals and how health supports the economy and how health is important to our daily living—all of those things really are an important part of what Healthy People 2030 is about.

JOHNSON:
If you're a state or territorial health official getting this report, what do you do with it?

HALVERSON:
Well, I think this is the important thing, and when I was health officer in Arkansas, that was always my issue—so what do I do with this thing?

Well, I mean, the reality is—and what we hope will happen, and has happened in past iterations, and we hope will happen even more now with 2030—would be state health officers would take this and work to develop a Healthy People process for their state.

So, I know for example, when I was in North Carolina, we had a Healthy Carolinians process—it was an excellent process—and we've seen that play out in the states all over the country.

So, the question is, "Okay, so we have goals for the nation—what about goals for our state? What are the goals that we're going to take, and what are those measurable milestones that we're going to set for our state?" And having a smaller number of goals at a national level allows for a more manageable process at the state and local level.

So, again, we would hope that states would embrace the Healthy People process so much that they would create for their own state a Healthy People process, working with the legislature and with local health departments to come up with something that's meaningful to the state, and to the local health departments, and local policymakers.

I mean, it would be really, really important, for example, for states to adopt their own goals related to infant mortality, for example, or low birth weight, or people that have their hypertension under control. If we look at specific things, it's important for states to say, "Okay, here's the national goal—how do we fare right now? What's our reference point and where are we going in the future?" And being able to say, "Okay, well, the Healthy People National goal is 12.3. We're already at, you know, 18. So, what's reasonable for us to achieve in the next two years? What should be our goal?"

So, in other words, we want to personalize the goals to each of the states and then begin to think about action plans that will allow us to get there. Because, at the end of the day, the Healthy People process is about creating impetus for action and recognizing that health is really important in all aspects.

But having priorities for the nation then should translate into being priorities for the state, priorities for the local, and, ultimately, we wind up with something that we can actually see improvement in the nation.

It's nice for us to have a national plan, but unless and until state and local health departments adopt these as their own, we're really not going to see the level of action and improvement that we really need to see.

And, again, by decoupling funding from these goals, it essentially says, "Let's work towards this because they're important goals, not just because we have funding sources to support it."

Now, again, would it be important for state and local health departments to find funding to support these goals? Absolutely. And should the federal government support health goals? Absolutely.

So, it's not to say that we don't need funding. It's just trying to say, "Let's not only choose goals that are supported by funding. Let's talk about what's really important, what's driving—or what should be driving—the success of the health of the nation."

JOHNSON:
You helped write this latest version of the report.

HALVERSON:
Yes.

JOHNSON:
You are on the committee that created it.

HALVERSON:
Right.

JOHNSON:
How do you rank this version against the others?

Can you judge that independently?

HALVERSON:
You know, when I was at CDC on the federal response committee, as we were writing, for example, the infrastructure chapter—that was one of my responsibilities back, I don't know, three versions ago—I've been involved with this process forever. And my dear friend, Jonathan Fielding, I think has been involved from the very beginning, and I just have so much admiration for Jonathan.

I think this process has evolved and there have been wonderful people that have been engaged in the leadership of the Healthy People process, including all of the terrific staff at the office of disease prevention and health promotion at HHS.

So, I think what we have seen in the Healthy People 2030 process is learning over the years of how to make this process better, and I personally have seen this process see substantial improvements: we streamlined some things; we've increased the likelihood of engagement by other sectors; we've allowed for substantial public comment; a lot of these things that we had hoped to do in previous editions—and, in fact, have been successful in many ways—but we've learned ways in which to make it even better. So, I think the definition of a learning environment is very applicable here.

I think this was our best edition yet. Again, I wasn't as involved on the steering committee and all. This was my first time on the official, you know, secretary's advisory committee. I would say the process went very, very well. I've been involved in the periphery and other editions, but my observation is that this process worked very well—and it's actually taken us three years in the making to get to this point.

I couldn't be more proud of the great work the committee has done, and the staff has been terrific. And the real work happens at the federal working group level where they take our recommendations and actually make it work, and they've done a tremendous job.

So, I have to say that the process has really been very smooth and I think very effective. It's been terrific. So, my hat's off to a good process.

I really do credit the staff tremendously for that because they've taken note of what we could do better, and every time in every previous process, and I think we've endeavored to try to make it better. And I think it's been great.

JOHNSON:
If you're in public health, this is a document you should be looking forward to.

HALVERSON:
Oh, absolutely.

Frankly, I will tell you that over the years, the process has improved. I think a really legitimate concern that had arisen over the years is that, as the process grew, the number of goals grew. And, again, these thousands of goals became almost as if it was, like I said, the phone book.

And now, we've reprioritized it. We now have, I think, a different framework, which I think is easier to understand—it's more inclusive, it's more supportive. All of these things, I think, make for a more meaningful document.

But again, if you're a health officer at a state or a local level, or if you're working in the federal government and administering grant funding and so forth, the Healthy People goals is a bedrock document.

It really, really, I think, should represent what we ought to be, as a nation, focused on achieving. It really does create that framework that we all need to understand and know.

JOHNSON:
The Healthy People 2030 Report sets national health goals, but it also helps guide local public health plans.

Jill Hunsaker Ryan is executive director of the Colorado department of public health and environment. She says her team will make good use of its recommendations.

RYAN:
I have seen the report and I'm really excited for its release. It's the fifth report in the Healthy People series. I think that it's a great planning tool and it really helps the public health system get into alignment in terms of objectives, what the federal government is focusing on.

And, in Colorado, we're actually required to complete a public health improvement plan every five years. So, it's our version of Healthy People and we consult the document to do that in order to be in alignment with the direction that the field is headed at the federal level.

JOHNSON:
So, Colorado will be looking to this new document for guidance on its own plan.

RYAN:
That's correct.

You know, the Healthy People always has priorities, and they have many in Colorado. We just have a few, but for example, improving air quality around ozone and greenhouse gas emissions, reducing suicide, helping people maintain a healthy weight, reducing HIV, prevention, increasing immunizations around measles or the flu—those are topics that are priorities for Colorado, but they're also in Healthy People 2030.

JOHNSON:
Have you been looking forward to this revision? I mean, the last report is now 10 years old—it's probably time to update some things.

RYAN:
Yeah, that's right. I mean, I think that it's always sort of the latest thinking around health outcomes, how to impact them, you know, to sort of take inventory on whether things are going in the wrong direction in some areas.

There are a lot of priorities to choose from and, of course, I think every state health department focuses probably on all of the priorities in Healthy People 2030, and then we always pick a few, you know, to really focus on and sort of culminate our resources around.

You know, I might also mention that in Colorado—and I think this is different from other states—we have a whole local public health system too, so we have 55 local public health agencies. They're also required to write county level public health improvement plans, and then their plans roll up to the state plan.

So, you've got the health departments that cover every county in Colorado, and, of course, they're also using this as a guiding document when they're creating their plans.

JOHNSON:
So, it's that useful, then, even at the most local level of public health. It's a document you can work from.

RYAN:
Well, it is. And I think it's—you know, because there are so many topic areas—that it's very cross-cutting. And, you know, if there are particular health issues that a community is dealing with, you'll find them in Healthy People 2030.

And then, of course, there's the underpinnings of health equity that we really struggle with in public health. And you know, what that means is if you look at health outcomes—so, you say, you know, what are the leading causes of disease or injury or death, and who's most likely to be impacted by those—you know, you start to see patterns and you see them by lower income, you see them by race and ethnicity sometimes even regardless of income, sometimes you see them in rural communities.

So, you have to pay attention to what role demographics plays in population health outcomes and why the data looks the way it does. And it's something that Healthy People 2030 has a whole framework for.

JOHNSON:
And we've heard there's more focus this time around on data. Is that what you're referring to?

RYAN:
Yes. There's more focus on data, but I think also just, you know, sort of the structural underpinnings—the inequities in society that create conditions in which people don't have the same level of health, and the fact that you can measure that based on race/ethnicity when we know there's very little underpinnings for genetics here.

So, for example, car crash deaths are higher among racial and ethnic groups. Infectious disease is higher among racial and ethnic groups. Things that don't really have a genetic underpinning, and yet these folks still have higher rates. And it really does come down to the inequities in society around economics, and education, and access to healthcare, and access to goods and services.

And you can measure those inequities, unfortunately, based on race, ethnicity. Or then you look at the rural areas and you have access issues in terms of services, and that shows up in the health outcome data of rural communities.

JOHNSON:
You have mentioned to me previously that the objectives are of interest to you in that you even worked on those.

Tell us what we can expect for those of us who have not seen it about the objectives this time around.

RYAN:
Sure.

So, for example, I mentioned air quality. They have objectives around, you know, reducing greenhouse gas emissions, reducing ground-level ozone, you know, even in Colorado—and our state health department is different from other state health departments in that we have a whole section on environmental health.

And so, when I go to the section on environmental health in Healthy People 2030, I see, "Wow, they have listed all of the areas we're working on." Like, not only air quality, but surfacing ground water, and contamination of infectious agents, or chemicals. There's a new chemical called—well, it's not new, but it's been recently discovered in higher quantities in drinking water supplies—that's called PFOS. They've got toxic substances and hazardous wastes in here.

So, it's really a very comprehensive document of things that we're working on as well, and it provides us the opportunity as we're planning to look at: what are the metrics they're looking at? How much do they think, as a nation, we can decrease by? It influences us there.

It's a good reference for just comprehensive information about all the myriad of topics that we tackle in the public health field.

JOHNSON:
Does a report like this help you when it's time to ask your legislature for policy changes or funding?

RYAN:
Yeah, I think absolutely it helps with that, and it helps when we're doing grant writing as well just to show that there is a national focus on some of these areas to our legislators. But also, you know, if we're writing federal grants—because if we get all of the public health agency sort of rowing in the same direction in these areas, then I think that it will have a larger impact overall.

I'll give you a good example. So, Health People 2030—if you look at their objectives around healthy weight, I mean, they have all sorts of objectives in here. They have things like, you know, increased fruit consumption or vegetable consumption in the population, increased consumption of whole grains, reduced consumption of saturated fat.

One of the areas that we are really focused on—and we think this is very important—is to reduce the consumption of calories from added sugars in the population ages two and older. And so, you know, for example, you go into a restaurant and a lot of times kids are offered pop—it's really the default beverage. Well, that's like eating a liquid candy bar. Or parents don't know and they just give their children juice all day, when really it's more healthy to give them water.

So, they've got objectives around all these areas, and it's kind of a menu for everything that you could target in a behavior-change strategy.

JOHNSON:
It sounds kind of like a reference guide. If you're working on an issue—maybe you haven't looked it up in the document before—you go to that and see where you are, and get the benchmarks, and then go forward.

RYAN:
Yeah, that's absolutely right. That's a great way to put it.

I think it is a very good reference document, and particularly as we're doing our own planning. You know, reducing HIV is another priority for us. We've seen the HIV rate in Colorado go up over the last few years. And so, they have several areas around HIV in terms of reducing the number of new HIV diagnoses. And then, they also have, you know, some measurements around making sure that people with HIV get the care they need when they need it. Well, we get dollars from the federal government to implement wraparound services for people who have HIV.

And so, I think that's a good example where, you know, we're getting funding from the federal government, we are elevating HIV in our plan, and then we go to Healthy People and they've also got several objectives around the exact things we're doing. So, you know, we can look to Healthy People 2030 as a source and say, "Is there anything we're missing in our strategies to be able to mount an effective response against HIV?"

JOHNSON:
Can you imagine doing your job without this document?

RYAN:
I think the most valuable thing about this document is it provides a north star for the public health field, and it helps get public health practitioners growing in the same direction so that we have a very aligned response, as a nation, for some of these really critical issues.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.