Good and Cheap
By Crystal Conde Texas Medicine April 2011

Public Health Efforts Save Lives, Save Money

Public Health Feature – April 2011

Tex Med. 2011;107(4):29-35.

By Crystal Conde
Associate Editor  

Smoking, obesity, and substance abuse are the primary causes of poor health in Texas, and cost employers and state and local governments billions of dollars a year. So it makes sense that spending little or no money now to curb these preventable conditions could save a lot of money later.

That's why the Texas Medical Association and the Texas Public Health Coalition support bills in this year's budget-conscious session of the legislature that would both reduce health care costs and decrease the burden of disease in the state by curtailing tobacco use and impeding the growth in obesity. TMA is a charter member of the coalition, a collection of organizations that share an interest in advancing core public health principles at the state and community levels.

Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, says one-third of all cancer deaths in Texas link to smoking, and obesity contributes to chronic diseases such as diabetes, cardiovascular disease, stroke, and kidney disease.

And, Dr. Lakey adds, obesity and tobacco use are significant contributors to the state's increasing health care budget and are a drain on economic productivity. The American Lung Association estimates the economic cost of smoking in Texas is $13 billion per year. (See "Tobacco's Toll on Texas.") Plus, a recent report by Texas Comptroller Susan Combs indicates obesity costs Texas businesses $9.5 billion each year and continues to rise.

One initiative TMA supports costs nothing up front and would lead to improved health and long-term savings for the state. TMA again backs House Bill 670 by Rep. Myra Crownover (R-Denton) and Senate Bill 355 by Sen. Rodney Ellis (D-Houston) to prohibit smoking in public and work places.

The Texas Health and Human Services Commission (HHSC) completed an analysis of the effects of comprehensive smoking bans on Medicaid spending. HHSC's examination concludes that comprehensive smoking ordinances will likely reduce annual Medicaid costs of hospitalizations for heart attack, stroke, and respiratory illness in Texas by 9.2 percent in 2012 alone. HHSC found the effect of the ordinances on health outcomes increases over time.

The commission estimates the state could realize Medicaid savings of $6.4 million in general revenue funds for fiscal year 2012, with the potential for higher savings moving forward.

"No one can dispute the mountain of evidence that has proven not only that secondhand smoke kills people, but that it also is costing taxpayers millions of dollars in Medicaid expenditures every year," Representative Crownover said.

The HHSC analysis reveals potential for significant savings increases if a statewide ordinance – when combined with other tobacco control efforts – contributes to a reduction in the rate of smoking among Medicaid clients and their caretakers.

According to the Centers for Disease Control and Prevention's Healthy People Database, in 2008, 32 percent of adults living below the poverty level were smokers compared with 18 percent of middle- to high-income adults. Data compiled by The University of Texas Medical Branch (UTMB) in 2009 indicate about 45 percent of the state's population already lives in cities that have implemented a relatively comprehensive smoking ordinance. 

In the antiobesity campaign, several bills add physical education requirements for schools, which TMA policy strongly supports.

SB 185 by Sen. Jane Nelson (R-Lewisville) increases the required daily physical activity for students in grades 6 through 8 from four to all six semesters.

SB 186 by Senator Nelson, along with HB 280 and HB 281 by Rep. Carol Alvarado (D-Houston), add a half-credit of physical education (PE) and a half-credit of health education to graduation requirements. In 2009, HB 3 reduced required PE credits to one.

Little Cost, Big Benefit

The bills have little to no cost to the state, a nice selling point during a time when Texas state agencies face dramatic budget cuts.

House and Senate budget writers have so far rejected the $20.9 million in state tobacco prevention funding DSHS requested for 2012-13. Additionally, the Senate and House budget bills, SB 1 and HB 1, indicate federal tobacco prevention program funds would drop by $2.13 million for 2012–13. DSHS estimates $3.9 million in federal money still would be available for tobacco prevention for fiscal year 2012–13.

The programs include the Texas Tobacco Quitline (877-YES-QUIT), tobacco cessation services, comprehensive tobacco prevention coalitions, smokeless tobacco prevention, and school-based tobacco prevention activities. (See "Tobacco Prevention Funding.")

In addition, the health department's chronic disease prevention funding could face significant budget cuts. DSHS requested $36.4 million for 2012–13, while lawmakers so far have recommended only $13.5 million.

Funding for chronic disease prevention covers grants to Texas communities for physical fitness initiatives, efforts of the Texas Council on Cardiovascular Disease and Stroke, and other activities related to reducing obesity.

Dr. Lakey says it's too soon to speculate on what the department's budget will look like if all these cuts go through.

"State general revenue funds for tobacco prevention could potentially go from $20.9 million to $0. We'd have $3.9 million in federal funds to work with. To live within that budget would require some significant changes. DSHS will work closely with the legislature to figure out what the new tobacco program would be," Dr. Lakey said.

Failure to pass legislation to reduce obesity and tobacco use in Texas will increase health care costs and disease burden in the long term, says Philip Huang, MD, MPH, medical director and health authority for the Austin/Travis County Health and Human Services Department. He testified before the Senate Finance Committee on behalf of TMA, the Texas Pediatric Society, and the Texas Academy of Family Physicians at press time.

"Tobacco use remains the single most important preventable cause of premature death and disease in Texas; this year, another 24,000 Texans will die from tobacco use. That's more than AIDS, crack, heroin, cocaine, alcohol, car accidents, fire, murder, and suicide combined. And it is entirely preventable," Dr. Huang said.

He appeals to lawmakers to pass SB 355 to eliminate public smoking and reduce the impact of secondhand smoke on Medicaid patients, insured state employees, and other publically insured people.

TMA's 2011 smoke-free and obesity prevention platforms point out that:  

• Making Texas smoke-free is one of the easiest, simplest, and fastest public health interventions the state can undertake.
• The scientific evidence is indisputable: Secondhand smoke is not just an annoyance; it is a serious health hazard that can sicken and kill children and nonsmoking adults.
• The average price for a pack of cigarettes in Texas is $5.52. But the real price to Texas' patients and economy is $21 per pack of cigarettes.
• Obesity threatens Texas' physical and fiscal health. More than 5 million Texans are obese. And this number is expected to double over the next 20 years. By 2040, three out of every four Texans will be overweight.
• Obesity is responsible for 27 percent of the growth in health care spending.
• The state must focus on preventing obesity rather than treating the diseases that result from it.  

Jeffrey Levin, MD, MSPH, chair of TMA's Council on Science and Public Health, praises TMA's budget-conscious approach to public health issues in the legislature.

"It's a winning combination: no up-front cost, with the potential for long-term gains. That's an investment equation most legislators can sink their teeth into," he said.

Smoke-Free Laws Save Money, Improve Health

Public health experienced a devastating blow last session when the legislature failed once again to pass a bill outlawing smoking in public facilities and indoor workplaces. SB 544 by Senator Ellis emerged from the Senate Health and Human Services Committee intact as a comprehensive bill for the first time ever, and its companion, HB 5 by Representative Crownover, received votes from more than half of the House members. In addition, 68 percent of Texans polled in 2009 indicated they favored a smoke-free state.

Despite the support, the bill died because it didn't generate a two-thirds majority of the 31 senators needed to allow it to come up for a vote.

Although a statewide prohibition on public smoking has been elusive in legislative sessions past, Dr. Huang says physicians can help strengthen the bill's traction by voicing their support.

"Doctors are leaders in their communities. They should talk to their legislators, write letters to the editor of their local newspapers, and make it clear physicians realize the smoke-free legislation is an investment in prevention," he said. 

Joel Dunnington, MD, a Houston radiologist and consultant to the TMA Council on Science and Public Health, says he's unsure whether smoke-free legislation will survive this session and be signed into law.

"Making the state of Texas smoke free in public places is the cheapest, easiest, quickest public health intervention that will result in making our patients healthier. In the long run, it saves money for patients and the state," he said.

According to the 2006 report, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, secondhand smoke is a major cause of disease, including lung cancer and coronary heart disease, in healthy nonsmokers. The report's research indicates smoke-free policies are the most economic and effective approach to protect nonsmokers from exposure to secondhand smoke.

The state of New York is a case study in immediate positive health outcomes from a statewide ban on smoking. Researchers in a November 2007 article in the American Journal of Public Health report that admissions for acute myocardial infarction (AMI) at New York hospitals declined after the state passed a comprehensive smoking ban in 2003.

AMI admissions decreased 8 percent, with 3,813 fewer hospital admissions in 2004. Direct cost savings totaled $56 million the same year.

Should the legislature fail once again to enact a statewide smoking ban, Dr. Dunnington says, the health and economic costs to Texans will be great.

"Essentially, we've been flatlining in the number of smokers in Texas for years. It has come down a little. If we can keep kids from smoking and knock down the tobacco use rate in adults, we're going to see significant cost savings, especially in Medicaid dollars," he said.

Comprehensive smoke-free workplace ordinances cover 34 Texas cities. Twenty-nine states are now smoke-free, and seven, including Texas, are considering smoke-free laws. In a January Baselice & Associates Inc. survey, 70 percent of Texans supported banning indoor smoking, including in restaurants and bars.

A DSHS analysis of smoking ordinances in El Paso County and Travis County – areas with populations of at least 50,000 that had the most restrictive smoking ordinances passed since 2005 – reveals reductions in potentially preventable hospitalizations (PPHs) from 2005 to 2009. 

According to Mike Gilliam, MSW, MPH, DSHS assessment and benchmarking specialist in the Center for Program Coordination, during the five-year period, El Paso County adult residents experienced a reduction in the chronic obstructive pulmonary disease PPH rate that was 50 percent less than the state rate. Residents' congestive heart failure PPH rate fell to 22 percent less than the state rate, while the bacterial pneumonia PPH rate was 16 percent less than the state rate.

From 2005 to 2009, Travis County adult residents' asthma PPH rate was 22 percent less than the state rate.  The chronic obstructive pulmonary disease PPH rate was 56 percent less than the state rate, while the congestive heart failure PPH rate was 43 percent less than the state rate. Residents' bacterial pneumonia PPH rate was 47 percent less than the state rate.

No Harm to Business

"Texas can no longer afford to indulge the smoking habits of a few at the cost of Texas taxpayers," Dr. Levin said.

Even with large public support, passage of smoke-free legislation won't be easy, he warns.

"Some might argue the smoke-free bills, for example, have some sort of an indirect cost. A classic argument is that a prohibition on public smoking will result in reduced revenues for certain business sectors, such as bars and restaurants. But we have ample evidence to suggest the indirect impact is actually favorable for those business segments."

A DSHS 2000 analysis of sales tax data in four smoke-free Texas cities, titled "Impact of Clean Indoor Air Ordinances on Restaurant Revenues in Four Texas Cities: Arlington, Austin, Plano and Wichita Falls 1987–1999," [PDF] found smoke-free policies don't affect restaurant revenue or the sale of alcoholic beverages in bars.

Also, a one-year assessment of the impact of a smoking ban on restaurant and bar revenues in El Paso indicates gross restaurant and bar, restaurant-only, and bar-only revenues continued to increase after that city's 2002 smoking ban.

The same is true in smoke-free states.

A 2010 study on the effects of the statewide comprehensive smoke-free law in Washington showed bar and restaurant revenues from 2005 to 2007 were actually higher than what they had projected, had the law not taken effect. Bar revenue experienced an estimated net gain of $105.5 million for the two-year period immediately following implementation of the smoke-free law.

On top of that, a 2009 Baselice & Associates survey of adults indicated a net increase of 16 percent of Texans would go to bars and restaurants more often with a statewide smoke-free law in place. The survey revealed only 8 percent of Texans would go to bars and restaurants less often than they do now.

Obesity Costs Texas

State officials estimate that obesity costs Texas businesses $9.5 billion annually. If the obesity rate and the cost of health care continue to increase as projected, the cost to businesses could reach $32.5 billion per year by 2030, according to a recent report released by Comptroller Combs. The price tag for obesity is nearly three times the estimate Ms. Combs released in 2007.

In February, the comptroller released a new report, Gaining Costs, Losing Time: The Obesity Crisis in Texas. It uses updated data and new research by leading health economists to recalculate the cost of obesity-related health care, absenteeism, decreased productivity, and disability to Texas employers.

The report estimates Texas employers paid $4 billion in direct health insurance costs related to obesity in 2009. Indirectly, obesity cost employers an estimated $5.4 billion in 2009, including $1.6 billion for obesity-related absenteeism, $3.5 billion for reduced work productivity, and $320 million for obesity-linked disability.

Two-thirds of adult Texans – 66.7 percent – were overweight or obese in 2009, higher than the national rate of 63.2 percent. Among Texas children aged 10 to 17 years, 20.4 percent are obese, compared with 16.4 percent of U.S. children.

Gaining Costs, Losing Time identifies successful efforts to combat obesity through:  

• Workplace wellness programs;
• Higher nutritional standards for school meals;
• Increased emphasis on PE and nutrition awareness in public schools; and
• Community-based initiatives to help children and adults lose weight and achieve healthier lifestyles.   

TMA supports similar obesity prevention strategies this legislative session. (See "TMA Supports Obesity Prevention Strategies.")

The report includes recommendations to encourage and invest in obesity prevention and intervention programs.

"My goal is to expand proven successful programs through targeted interventions in areas that are at high risk of obesity,” Ms. Combs said.

She recommends the legislature increase PE requirements in middle schools and high schools.

"Among our high school seniors, only 8 percent of girls and 9 percent of boys are considered physically fit," Ms. Combs said.

To read the report, visit the comptroller's website, www.window.state.tx.us/specialrpt/obesitycost.

Smaller Bottoms, Bigger Bottom Lines

Dr. Huang encourages legislators to invest in effective obesity interventions to reduce chronic disease in Texas because obesity contributes to heart disease, stroke, diabetes, and cancer.

"Community-based public health programs play an important role in the state's overall strategy to prevent obesity. We must continue to invest in these interventions so that we are addressing the new epidemics of the 21st century," he said.

Kim Avila Edwards, MD, medical director of the Healthy Living Happy Living obesity prevention program at Dell Children's Medical Center of Central Texas, says the budget-conscious legislation TMA supports highlights behavior changes that promote health and wellness and results in significant savings to the state in the long run.

SB 185 and SB 186, she says, would increase the number of days children participate in physical activity per week and would provide outstanding learning environments to improve children's health through physical education. 

"The available evidence shows that children who are physically active and fit tend to perform better in the classroom and that daily physical education does not adversely affect academic performance. In addition, the reinstatement of health education for Texas high school students would strengthen their foundation of health knowledge, which we know is important for disease awareness and prevention," Dr. Avila Edwards said.

A 2009 study by the Texas Education Agency indicates students who are more physically fit are more likely to perform well on tests and have fewer disciplinary problems at school.

In the study, researchers compared the scores of 2.4 million public school students in grades 3 through 12 on the Texas Assessment of Knowledge and Skills with performance on the FITNESSGRAM, a physical fitness test developed by the Cooper Institute of Dallas. The FITNESSGRAM evaluates child fitness levels based on measures of body composition, aerobic capacity, muscular strength, endurance, and flexibility.

Children who were more physically fit achieved higher standardized test scores than students who were not. In addition, schools with a higher percentage of fit students earned better state performance ratings than those with a lower percentage of fit students.

Last session, lawmakers passed several of Senator Nelson's obesity prevention bills.   

• SB 282 allowed the Texas Department of Agriculture to award grants to public schools and early childhood education facilities for children aged 3 and 4 years to implement best practices in nutrition.
• SB 870 directed Medicaid and the Children's Health Insurance Program to implement pilot programs to help reduce childhood obesity among enrollees. The Medicaid Child Obesity Prevention Pilot began Nov. 1, 2010, and ends Oct. 31, 2012. Its goals are to decrease the rate of obesity, improve nutritional choices, increase physical activity levels, and achieve long-term reductions in Medicaid costs incurred as a result of obesity.
• SB 891 established a standard definition of PE curriculum across the state and required 50 percent of each week's PE classes to involve moderate or vigorous physical activity.  

"Our previous work to boost physical education is paying off. The third round of FITNESSGRAM assessments last year measured gains in fitness for students in grades 3 through 8. Fitness levels start to decline in middle school, and that is why we should require daily physical activity during all six semesters of middle school. High school students were the least fit of all age groups, which demonstrates the need to restore PE to the curriculum," Senator Nelson said.

Reducing the impact of obesity and curtailing tobacco use require comprehensive, multipronged approaches, Dr. Levin says.

"We're at a breaking point. We can't continue to sink resources solely into treatment of advanced disease. We need to focus on preventing disease. Lacking these legislative measures, we have to think about how to dedicate our resources on the front end," Dr. Levin said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail.

SIDEBAR

Tobacco's Toll on Texas

Economic Cost Due to Smoking: $13 billion a year
Adult Smoking Rate: 17.9 percent
High School Smoking Rate: 21.2 percent
Middle School Smoking Rate: 9.5 percent
Smoking Attributable Deaths: 24,570 a year
Smoking Attributable Lung Cancer Deaths: 7,770 a year
Smoking Attributable Respiratory Disease Deaths: 6,324 a year

Source: American Lung Association

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SIDEBAR

Tobacco Prevention Funding

Source: Texas Department of State Health Services

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SIDEBAR

  TMA Supports Obesity Prevention Strategies

 TMA supports these school-based strategies to combat obesity:  

• Senate Bill 224 by Sen. Jane Nelson (R-Lewisville) would establish a program to recognize schools that implement successful coordinated school health programs, improve fitness assessment results, and demonstrate active school health advisory councils (SHACs).
• Senate Bill 225 by Senator Nelson would require school districts' campus improvement plans to include strategies to comply with the Texas school nutrition policy and would require SHACs' reports to add a summary of the districts' compliance with the physical education requirements.
• Senate Bill 226 by Senator Nelson would allow for student fitness data to be tracked with academic test results and reported to the Texas Education Agency.
• House Bill 127 by Rep. Carol Alvarado (D-Houston) would allow only these types of beverages to be sold on campus during school hours: water, fruit juice, vegetable juice, and milk.   

Kim Avila Edwards, MD, medical director of the Healthy Living Happy Living obesity prevention program at Dell Children's Medical Center of Central Texas, says the strategies are part of an effective obesity prevention program.

"Such a program in Texas would be supporting the implementation of evidence-based strategies that facilitate obesity prevention. Obesity is a multifaceted problem that requires as complex a solution. This program would promote the recognition of schools that are creating healthy environments for their students through the engagement of all the various participants needed to implement the necessary behavioral changes to support Texas students' health," she said.

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