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Yes SSIR: Letter to the Editor, Stanford Social Innovation Review


There were a number of good insights and promising strategies described in the Healthy Eating, Active Living special supplement of SSIR Summer 2019.  Yet the authors also admitted that child obesity and adult chronic diseases continue to grow.

One key weakness of the social determinants of health (SDOH) framework is that there are so many challenging “determinants,” that scarce resources for change can get spread and diluted.  So we end up with good SDOH change anecdotes—while actual state & national health statistics worsen.

To maximize impact, especially to reach the tipping point of actually reversing 40+ years of worsening health habits, we need to prioritize.  One highly promising “80/20” (and, yes, SDOH) strategy is through K-12 schools—literally with 20% of the US population, for 13 years, at just the right developmental stage to learn and change.  There are scalable, low cost, school-based strategies that dramatically increase fitness & activity, improve nutrition habits, develop social-emotional strengths, and reduce child obesity.  And school wellness policies and health advisory councils (SHACs) can help address many other social determinants.

But schools understandably resist “unfunded mandates” to make them scale these approaches.  The sustainable answer is to have those who benefit financially pay:  the health sector.  And to give schools incentives to be a proactive part of the solution.

Health plans & providers can reduce per capita costs, by $1000s during childhood and $10,000s to $100,000s in adulthood, by improving K-12 students’ health habits.  They can invest in schools to realize these savings, including using part of the school day.  But they need performance-based guarantees, that their investments will be utilized only for agreed evidence-based strategies, implemented with the necessary fidelity—then confirming with outcomes data that they are successfully achieving ROIs.  And school administrators need to see the value.

In Arizona, we are putting in place a self-reinforcing, self-funding combination of partners, policies, programs and payments to make this happen.  For example, we are making progress on:

-          - Reforming the state school accountability system, so that school superintendents can improve their schools’ state A-F letter grade, by improving physical & health education—as assessed with students’ fitness, activity & nutrition outcomes.  School leaders have clearly stated that this gives them a strong incentive to restore time, attention & resources to these neglected areas—which have been slashed by 2/3 in recent decades.

-          - Implementing a state recess law, which mandates 2 daily recesses K-5—thereby increasing physical activity for most 6-12 year olds by 50%—yet with local control of the details, and at no required cost to schools.

-          - Getting sustainable, performance-based funding from Medicaid plans and social impact investors, to scale a proven whole-school program with key PE & nutrition ed components. This is expected to save $30-50/student/year, at a cost of $10/student/year at-scale—by dramatically increasing activity and healthy eating, and thereby reducing child obesity, ADHD, depression, etc.

This is not an easy process.  But given the lack of other affordable, scalable, move-the-needle alternatives, this type of approach is worth serious consideration.

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