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REMARKS BY: DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES PLACE: University of Minnesota, The School of Public Health, Minneapolis, Minnesota DATE: April 27, 1995
My congratulations to this remarkable institution for 50 years of outstanding service and leadership.
I came here today to talk about the future of our country.
I'd like to step into a time warp -- to transport you to the year 2020 -- and offer you a vision of the kind of public health services we need every community to have in 25 years.
I want you to imagine a family living in the Twin Cities in the year 2020: Let's call the parents Clare and Tom Baker -- and imagine what we want for them.
The Bakers' three year-old daughter is in a health-conscious day care program modelled after the Early Head Start program created in 1995.
Their eight year-old son is receiving great health and science education at school.
Both children were fully vaccinated by age two -- because their health plan sent out vaccination notices and because brilliant biomedical research in the 1990's made it possible to administer more vaccines with a single shot -- and even to vaccinate children by feeding them genetically-engineered fruit.
The Bakers live in a clean and healthful neighborhood -- because every government agency thinks about the health implications of what they do.
The water is monitored by computers.
Engineers have designed an environment-friendly sewage system.
There isn't a drop of lead in the water, gasoline, or housepaint.
No one is exposed to secondhand smoke.
And, in 2020, it's safe again for children to play outside.
Tom and Clare both have private health insurance at their jobs. They chose managed care programs because they liked the quality, the price, and the focus on keeping people well.
And because all health insurance in the year 2020 is portable, Tom kept his coverage when he changed jobs -- even though he has what used to be called a "pre-existing condition."
You see, because of the National Institute of Health's Human Genome Project -- and our ability to apply its findings to disease prevention -- Tom knows that he's carrying a gene that makes him susceptible to colon cancer -- which killed his father fifteen years before.
As a result, his health plan devised a strategy to enable him to eat right, exercise, and come in for timely check-ups.
Tom Baker's mother lives across the state in Lincoln County.
Telemedicine has brought specialty care into her primary care clinic -- adding to the team of caregivers who set up shop in Lincoln County because America put prestige back into community health care.
Because she needs a little help unloading the groceries and preparing meals, a publicly-funded home care worker comes in three times a week -- which keeps her from having to enter an expensive nursing home.
Maybe the most important thing about this family of the future is that they are all health- and science-literate.
They understand the links between behaviors and health.
They take responsibility for their health.
And, they make informed decisions about the hot button health issues that come up in their communities -- and can't be manipulated -- the way Harry and Louise were manipulated by the insurance lobby in 1994.
Sound too good to be true?
Well, it doesn't have to be, and let me tell you what the Clinton administration is doing to bring 2020 into focus.
We believe that reducing preventable disease and increasing the lifespan for all Americans depends on access to a personal health care system supported by a powerful public health system.
We were terribly disappointed that the 103rd Congress could not pass health reform -- and we remain committed to working in a bipartisan way with the Congress this year to expand insurance coverage, make insurance portable, and banish "pre-existing conditions" to the annals of history.
The race to improve American health care is a marathon -- not a sprint -- and one of the things we are doing for the long run is to overhaul this country's approach to public health.
One of our visionaries is Dr. Phil Lee, our superb Assistant Secretary for Health -- who is on a crusade to reinvent public health.
To do this, we have listened to public health experts and advocates around the country and implemented three profound and interrelated changes of philosophy.
Three cylinders that will drive this country to better public health in the year 2020.
First, we are working to move away from the old clinic-based approach to public health to provide far greater support for population-based strategies.
You taught us that improving the quality of life and health in this country can't begin in clinics and hospitals.
It has to begin in homes, schools, workplaces, churches and all places where people make everyday decisions that dramatically affect the only lives they ever have.
Like the decision to quit smoking, to get off the couch, to use the new FDA food labels, or to go get a mammogram.
The population-based approach requires empowering people and communities to become health-literate -- and we have done that.
It requires having the discipline to put out clear, consistent messages on everything from AIDS prevention to drug abuse -- and we have done that.
It requires involving the private sector in public health education campaigns -- and we have done that -- drawing in business and advertizing leaders all across this country to help market abstinence, immunizations, and non-violence with the same intensity that fast food and cars are advertised in this country.
That's what I call working across the population, and it goes hand in hand with our second fundamental change -- which is moving from the medical model of care to the health model -- and putting prevention into practice.
Past administrations have talked the talk of prevention.
We've walked the walk -- and you can read this in our record:
During an era of zero growth in the federal budget, almost all of our funding increases have gone to prevention:
Head Start. Pre-school immunizations. AIDS and TB prevention. Drug treatment for pregnant women. Family Preservation and Support.
Some of our biggest victories have been quiet ones -- like continuing the upward trajectory of support for biomedical research at the NIH ....
But we have also been ready and willing to draw lines in the sand when necessary and fight major political battles for prevention -- whether it was to gain $8 billion for crime prevention programs under the Crime Act, to prevent major cuts to rural health under the GOP's 1995 rescissions bill, or to make sure that the President's Surgeon General nominee, Dr. Henry Foster, gets a fair hearing to discuss his success preventing unplanned teenage pregnancies and giving young people bright futures.
The third change we have made is really about federalism -- about re-defining the proper role of the federal government in relation to states, cities, communities, businesses, and citizens.
During the past year, we asked state and local health leaders what they thought about our programs in the Public Health Service, and this is what we found:
You told us you could do a better job with public health in your communities if we gave you more breathing room -- less federal micromanagement, and less paperwork.
To that end, the Public Health Service has proposed consolidating 108 different programs into 6 Performance Partnerships and 10 consolidated grant programs.
This bold plan will allow states and communities to work with the federal government to define priorities and performance measurement standards.
It will give states and communities far greater flexibility in using federal resources to achieve those standards.
And it will give all of us tangible outcome measurements to determine how we're progressing and where we have to improve.
One initiative that reflects the core changes we have made is the President's Childhood Immunization Initiative.
This is a wise investment in prevention, saving dollars and hardship and precious lives.
It is an example of the population-based approach, because we are addressing the many different reasons children don't get their shots -- whether it is poor public awareness, or insufficient clinic hours, or the high cost of vaccines for families who have a private doctor but don't have insurance that covers immunizations.
And it is truly an example of great partnerships -- as we have teamed up with state and local health officials, with businesses, with doctors, with community groups, and of course with parents.
This week is National Infant Immunization Week -- and there's a lot of good work going on in Minnesota.
The St. Paul Immunization Team is giving parents pictures of their children and reminding them to "Get Those Shots." And the Minnesota State Health Department is fanning out to community centers, parks, hospitals, homeless shelters, and health clinics -- anywhere parents go with children -- and asking "11 Shots by Two, How Sure are You?"
Partnerships. Prevention. Population-based thinking: These core principles are like three strands of a great chord -- interweaving and pulling us towards 2020, where the Baker family is counting on us.
But as we work toward that day, we also have to think about what could happen to the future of our country if we don't succeed.
Maybe the Bakers won't have access to child care or immunizations or the breakthrough discoveries of the Human Genome Project.
Maybe Tom's mother out in Lincoln County won't benefit from telemedicine or home care under Medicaid.
These are very real possibilities -- not only because it will take many years of sustained commitment to get where we want to go, but also because there are some reckless ideas being thrown about in Washington that could roll back the progress of the last thirty years.
One is the so-called "welfare reform" bill recently passed by the House Republicans, which is weak on work and tough on children.
In the name of reform, the bill cuts about $68 billion from children over five years -- including $20 billion from Food Stamps, $13 billion from disabled children, $6.6 billion from child nutrition, and $3.5 billion from abused, neglected, and abandoned children.
These proposals will undermine basic health standards -- and even throw disabled children off Medicaid.
If enacted, they would result in a massive cost-shift to states -- including more than $900 million for Minnesota alone -- which could mean fewer services or higher taxes.
Another bad idea is the knee-jerk call to gut or even eliminate the Food and Drug Administration -- which reflects a complete failure to understand the critical public health functions of the FDA.
Sure, we need to continue streamlining the regulation process and accelerating the approval time for drugs -- and we are making big gains there ....
But going "back to the future" of an America without safe food and drugs will ultimately lead to preventable tragedies -- and anybody who doubts it should read up on the shocking history of that "wonder drug" thalidomide.
And then there's the almost mind-numbing suggestion made by some Republicans that we can cut Medicare and Medicaid with a meat ax -- and shift Medicaid to the states in the form of a block grant without doing serious harm to the poor and older Americans and their hardworking, middle class families.
That's like saying up is down. That's like saying cruel is kind. That's like saying ketchup is a vegetable.
Let's be very clear: Between 1996 and 2002, these proposals would take about half-a-trillion dollars out of our health system.
They could mean a steady decline in services.
They could mean the evisceration of state public health budgets.
They could mean higher Medicare co-payments -- literally forcing some older Americans to choose between going to the doctor and buying their groceries.
And they could mean fewer home-care and long-term care options available for seniors under Medicaid.
There's a common misunderstanding that Medicaid only helps low-income women and children, when in fact, about two-thirds of its funds are spent on older Americans and people with disabilities.
Many of these people -- like the hypothetical Baker family -- are solid members of the middle class who have exhausted all their savings and assets and now depend on Medicaid -- and we shouldn't reverse our historic commitment to helping them and their families.
Make no mistake, these are very serious threats not just to public health as we want it to become in 2020 -- but to public health as we know it right now.
The most striking difference between President Clinton's commonsense approach and the Republicans' is that this administration has a vision of where we want to go.
We know it will take a lot of work to get there -- government can't do it alone -- and you're going to have to lead.
And so, in honor of the return of baseball -- we're going to need lots of home runs from our public health professionals -- and let me tell you the four bases you have to touch.
First, we need you to develop even stronger working partnerships with the doctors, nurses, and other health professionals.
Everybody knows that an artificial distinction still exists between the clinical practitioners and the public health professionals -- and with that comes a failure to communicate well and to understand each other's perspectives.
We don't have two health systems -- we have one -- and the system will function best when you work in tandem.
Second, we need stronger relationships between public health leaders and government leaders -- and in particular, we in government need to hear your criticism.
Don't let public officials in Washington and in State Houses across the country do our jobs without considering what you need to do yours.
We need an activist public health community that is not content to write polite policy recommendations and then sit back and let the politicians decide.
I challenge you to hold our feet to the fire, to point out the flaws in proposed legislation and service delivery, to tell us what's working and what's not in your communities, and above all, to bring the health perspective to bear on every single issue taken up by government.
And that leads to the third base: We need you hit the streets and go back to the grass-roots and build a big-tent constituency for public health.
Too many citizens take health promotion activities for granted until they go away. That's true of trash collection, that's true of Medicaid's long-term care, and that's true of food safety inspection.
It's clear that for the next few years, at every level of government, every budget battle will be tougher than the one that came before.
And it's clear that the know-nothings who want to slash budgets even at the expense of the common good will always have receptive audiences if we don't have a health-literate population.
And so we need you to help organize communities, to write letters to the editor, to sit on school boards, and to become spokespersons and salespersons for public health.
And that brings me to the fourth challenge -- the final base you have to touch in hitting a grand slam for our citizens of today and tomorrow.
The best way to build the constituency we need is to give back to the public what they are demanding from all of us -- demonstrable results -- clear evidence that our work and their tax dollars are making a difference.
When we go back to the public and say, "we have immunized 90 percent of our children with the most important vaccines by the year 2000 as we said we would," we will get their attention.
When we go back to the public and say, "We have reduced teen pregnancy rates by 33 percent -- but we won't stop there," we will earn their respect.
And when we go back to the public and say, "We have dropped illicit drug use to its lowest levels in fifty years," we will gain their confidence and their sustained support.
And with that support -- with the public on our side -- we'll make sure the Bakers and every family in America have the chance to live healthy and productive lives. Thank you.