One-on-One: Focus Policy on Health Rather Than Healthcare

Cancer, diabetes, heart disease rates hinder economic development, says Foundation for a Healthy Kentucky CEO Ben Chandler

By Mark Green

Editor’s note: This is a longer version than what appears in the September magazine.

Ben Chandler was named president and CEO of the Foundation for a Healthy Kentucky in September 2016.
Ben Chandler was named president and CEO of the Foundation for a Healthy Kentucky in September 2016.

Mark Green: What is the current mission statement of the Foundation for a Healthy Kentucky?

Ben Chandler: Our mission is to try to improve the health of the people of Kentucky. Kentuckians are not very healthy. We lag behind in health indicators like cancer, heart disease, diabetes, drug problems, all of those things. We’re down in the very bottom of the country. It’s unfortunate and very harmful not only to the lives of the individuals who have those health problems but also to the economy of the state generally.

MG: Do we know why Kentucky is trending toward the wrong end of these health metrics?

BC: Really, it’s poverty, a lack of education. There are correlations there that you always see. When you have poverty and you have a lack of education – and those two things go together – poor health follows. It’s sort of a chicken-and-egg kind of a thing, because it’s very hard to be successful economically when you have poor health, poor health is a big factor in causing poverty and a lack of economic success.

There is a chronic cycle, and how that cycle began in the first place I can’t answer, but there is no question that we’ve got one. For the economy to thrive here in Kentucky we need a healthy workforce, and we don’t have one.

MG: What are the key mechanisms to addressing Kentuckians’ high rates of obesity, diabetes, cancer and heart disease?

BC: It’s complicated because there are no easy answers for a question like this. If there had been, it would’ve been solved a long time ago. We need to work on what we call the social determinants of health, and that is poverty, education, access to decent healthcare, access to opportunities to exercise, and access to good, wholesome fresh food. All of these things play a role, and many more. Answering all those questions is not an easy thing.

But there are particular things we do that are harmful, that stick out. One of those is smoking. Our smoking rate in Kentucky is 27 percent; the national average is 17 percent. We’re well above the national average, and as a result we have the highest cancer rate in the nation. We could easily be called the cancer capital of the country, which is not somewhere you want to be. We also have a high obesity rate.

There are certain solutions for these smoking and obesity rates that are a little easier than working on some of these social determinants, but you have to have the political will to put them in place. One of those is a higher tax on cigarettes. We have seen in other states – New York is a good example – very high tax rates on cigarettes, and you’ve seen a decline in the rate of smoking. It correlates very closely; the cost of cigarettes and the rate of smoking go together. And we could do smoke-free laws. Lexington had the courage to enact a smoke-free law, and it has had an effect; the smoking rate has gone down, and it’s a healthier place than a lot of the rural areas of the state, which have not enacted laws like that. You could raise the age for smoking from 18 to 21. That’s another easy way. All three of those things – tax increase on cigarettes, raising the age for smoking, and smoke-free laws – none of them cost the taxpayer anything. That’s the beauty of those particular solutions.

Smoking and obesity contribute to almost every health problem our people have. Obesity causes so many problems – diabetes, for example, is one it contributes to. But we can impact the obesity problem, for instance, by enacting a sugary-beverage tax. Now, the chances of that happening in Kentucky right now, I think, are quite slim. But it’s something cities in this country have undertaken, and they believe that those measures have a positive effect on the obesity rate.

MG: Medical experts now identify overuse of sugar in commercially prepared foods, especially since the low-fat diet trend began in the 1980s, as a key trigger for the diabesity epidemic. What is the foundation position toward sugar taxes?

BC: We think sugar taxes are a good way to go. You’ve got to figure out a way to get the public to not consume as much sugar. There isn’t any question but that it causes you to gain weight. There isn’t any question that we have a significant obesity problem. And there isn’t any question that it affects the overall health of not only the individuals but the state. And one of the obvious ways to attack that problem is to raise taxes on sugary beverages in particular.

Now, why single out the beverages and not other forms of sugar? Because, really, these sugary beverages have no other nutritional value. What we’re looking to do is deal with the high-caloric and low-nutritional things. You don’t want things that have high calories and low nutritional value. You would prefer, obviously, high-nutrition and low-calorie.

MG: Has the foundation searched out in dollar terms what are some of the costs of Kentuckians’ above-average rates of obesity, diabetes, cancer and heart disease?

BC: You can’t get an exact figure on it, but I can tell you that the costs are dramatic. For instance, the Campaign for Tobacco-Free Kids estimates that the cost of smoking in the Commonwealth of Kentucky is $1.92 billion. And $590 million of that is to the Medicaid program alone. The cost of cancer, according to the Kentucky Cancer Consortium, is $3.8 billion by 2020. The cost of diabetes in Kentucky is $3.85 billion, according to the Kentucky Department of Public Health. The cost of heart disease is $351 billion. Now, that’s a huge number. And that comes from the Kentucky Cabinet for Health and Family Services. And obesity costs us an estimated $6 billion in healthcare costs, according to the United Health Foundation, the American Public Health Association and Partnership for Prevention.

MG: Those are big dollars.

BC: Oh my, they are! And of course, you hear the argument, for instance, on smoking that tobacco is an economic force in Kentucky and is a positive economically. The costs from smoking far outweigh any kind of economic gain we get from tobacco.

MG: What are some of the indirect costs of these health conditions?

BC: Just as a result of the smoking habit, every household in Kentucky has to pay $1,100 a year more than they otherwise would for health insurance. That’s whether you smoke or not. So that’s an indirect cost. The indirect costs start with loss of productivity and the cost of health insurance.

Economically, the Kentucky Chamber of Commerce will tell you very quickly one of the first things companies looking to locate in different places want to see is a healthy workforce. Why is that? In terms of productivity, they want employees who don’t lose days, and they don’t want to pay high premiums for health insurance. We’re losing a lot of economic development opportunities as a result of the poor health of the people of the state, which is a tremendous loss to our economy, to our business and economy climate here in Kentucky.

MG: What health improvement steps can Kentucky take that might quickly pay for themselves and begin producing dividends?

BC: Addressing the smoking rate is the obvious one because we are 27 percent compared to the national average of 17 percent. That’s dramatic. It’s nearly 60 percent above the national average. If we were just to get to the national average on smoking, it would mean over 300,000 fewer smokers. It would save taxpayers in the neighborhood of $600 million a year. And that’s just getting down to the national average, not having everybody quit.

There are a handful of things we can do that would impact this in a favorable way, the principal one being a significant hike of a dollar or more in the cigarette tax. It would cause a significant number of people to either quit smoking or not begin the habit. And not only does it not cost the taxpayers anything, it brings in revenue to the state.

MG: What community or state or country is doing a good job addressing health concerns and bringing about improvements? What tools are they using?

BC: Almost every country does better than we do. The ultimate measure in terms of your health outcomes is your longevity. Our life expectancy is below every other industrialized country in the world. The European countries’ life expectancies are in the low ’80s. Ours is about 78. All those countries are doing it better than we are.

And there are states in this country that do it better than we do – the Northeastern states in particular, because they don’t have some of the same habits we have in Kentucky. Their smoking is dramatically lower. Their obesity rates are lower. We’re 47th or 48th in obesity. For population, keep in mind, this state is about 26th in the country, yet we’re 47th or 48th or 49th in a lot of these health indicators. And in the case of cancer, we’re last.

A report from the American Medical Association recently showed cancer mortality in this country since 1980 is down 20 percent, except in Kentucky, where it’s up. Now, if that isn’t a call to action, I don’t know what is.

MG: What steps are they taking? What are they doing differently in terms of public policy?

BC: Behavior is what you want to impact. You want public policies that encourage people to exercise more, that encourage and make it easier for people to have access to nutritious food. Good farmers’ markets that are available, and the ability for low-income people to be able to afford the food at those farmers’ markets, are important policies. A lot of states have those policies. Kentucky, to some degree, has made an effort in that regard, but we need to make a greater effort.

The Foundation for a Healthy Kentucky itself has undertaken programs in seven different counties, to bring coalitions together in those counties, schools, governments, hospitals, concerned citizens – anybody who might be interested in joining a coalition – to work to enact healthy policies in that locality. Clinton County, Ky., in Appalachia down on the Tennessee line is a good example. It has enacted policies that allow the school gymnasium to be used by the community after school. Another good policy is complete streets policies: when you’re developing a street, you have to have sidewalks, you have to have bike paths. In other words, being healthy is an easier option that way. Being able to exercise is an easy choice rather than a difficult choice.

MG: The foundation website references the initiatives in those seven counties. Is the thought to experiment in individual counties to see what mechanisms will work that you can share as best practices elsewhere?

BC: That’s exactly right. We hope these will be pilot projects, that other Kentucky communities and counties will look at these projects to find some answers to the health issues. We focus on the young people. It’s trite to say, but they are our future, and we want to get them into good habits. Consequently, the focus is often on the schools and school districts and what kind of policies they have. They can be a big factor in changing how we view health. One of the unfortunate things has been a movement to have less or no physical education in schools. We almost discourage young people from moving around as much as they ought to. We’ve got to get people moving. It’s important. A sedentary lifestyle is a very unhealthy lifestyle.

MG: Why is cardiovascular disease mortality increasing in some areas of Kentucky while it is decreasing significantly in the United States as a whole?

BC: Heart disease in Kentucky is very, very high. It’s a hugely expensive and deadly problem, and it is directly related to the two big behavioral indicators: smoking and obesity. Again, we are off the charts on both of those. We’ve got to address those behavioral factors, and until we do we’re not going to make any progress in heart disease, or cancer, or diabetes or any of the other problems that bedevil us.

MG: Many employers have wellness programs that encourage or even include hard financial incentives for employees to adopt positive health practices. What impact is this having?

BC: Companies that enact those policies end up making money as a result of their investments that encourage the health of their workers. It ends up helping the bottom line, even though the company is giving incentives and paying workers to engage in more healthy behaviors. It not only causes their health insurance rates to go down, it also helps productivity. So they see an increase in the bottom line for the company.

MG: Should there be tax incentives of some sort for wellness programs?

BC: It would certainly suit me. We ought to do everything we can to try to affect this issue.

In this country we spend almost all of our money on a rescue system. We wait until people get sick, and then we rescue them. We talk about healthcare all the time, but I have yet to meet a person who wants healthcare if they can have health. It’s important to have a system that helps people when they’re sick, but it is also the least efficient way to spend your healthcare money. That’s why we spend twice as much per capita in this country as any other country in the world, and our outcomes are, according to the World Health Organization, 37th in the world.

Now, this is a business magazine. Tell me this: If you spent twice as much in your business as everybody else and only had the 37th-best result, how long would you stay in business? That’s what we’re doing in healthcare in this country.

What we ought to do is redirect some of that spending to prevention programs. We can do that through the public health departments, for instance. We have 61 public health departments in Kentucky. They need to be the chief health strategists for their communities. Public health departments are underutilized and underfunded, and it’s tremendously important that we utilize them, not just to provide additional clinical services but to actually be the health strategists for their communities.

We’ve got to spend more money on encouraging health. Acute conditions caused by poor health cost more to treat than money spent keeping people healthy in the first place. That’s what other countries do a whole lot better than we do.

MG: Providers and experts talk about the need for better “access to health care.” What are the impacts of improved access to health care?

BC: The thought is that it’s about a 10 percent factor in whether we’re healthy or not. That’s a big chunk, and access, particularly to prevention services and to early detection services, is very, very important. For instance, if we can ascertain somebody’s got a condition at an early stage, it costs a whole lot less to treat than if we only discover it at a late, acute stage. Not only is it cheaper, but you’re more likely to be successful. So early detection and prevention are extremely important to having a healthy populace. Access to healthcare is crucial so people can have the opportunity to get the care they need at the appropriate point, when it can be successful.

MG: Why and how was the Foundation for a Healthy Kentucky founded?

BC: In the late 1990s, I was elected attorney general, and there were a lot of health conversions going on across the country. Different Blue Cross/Blue Shield plans in different states around the country were converting to for-profit companies. And in the case of Kentucky in particular, the Anthem insurance company merged with the Blue Cross/Blue Shield entity. That’s a valuable marketing thing, to be the Blue Cross/Blue Shield entity, and those assets that that Blue Cross/Blue Shield entity had were charitable in nature – they received tax benefits from the public over several decades that were not accounted for in the merger. As attorney general I filed a lawsuit to recover those charitable assets. We entered into an agreement for a $45 million settlement, and that money was used to set up this foundation, the idea being that the money would be used to try to improve the health of the people of Kentucky. And it opened its doors in 2001.

After the settlement, of course, I went on and did my thing, I ran for governor and I served in the Congress and I was director of the Humanities Council here in Kentucky. Then they approached me in 2016 about heading it up after my predecessor retired, and it sounded like an interesting opportunity for me to come full circle and to try to make a real impact in the health of our people. I just couldn’t pass it up. I’ve come full circle from ultimately being a big part of founding the organization to now guiding it.

MG: And what is the foundation’s annual budget and number of employees today?

BC: The foundation was begun with $45 million. It gave million-dollar grants to both UofL and UK to establish endowed health chairs at those universities. We’ve given away over $27 million, and we now have $54 million in the endowment. We’ve given a significant amount of money to worthy causes here in Kentucky. Now we want to move into being active on public policy because we believe the health needle in Kentucky needs to be moved, and we’re not going to do it unless we have strong public policies like the ones I’ve talked about that encourage healthy behaviors.

One reason we need to go in that direction is that our budget is about $2 million a year, and it’s just not enough to make the kind of impact we want simply by giving out grants. We’ve got to have a strategy to affect public policy in the state, and that’s what we’re going to try to do.

As for employees, we have seven.

MG: The Foundation has polling conducted regularly and reports the results. What is the strategy behind this?

BC: The strategy is to affect public policy. We want leaders of the public whether on the local or state level to know where their citizens stand, what behaviors their citizens are engaging in, how they feel about particular issues. We believe those results have the potential of having a positive impact on public policy.

One of our questions over the years has been, are you in favor of a smoke-free policy in public places, workplaces and buildings in Kentucky? And that number has steadily risen from about half of respondents to now 71 percent in favor in Kentucky in our most recent poll. That’s information policymakers need. If 71 percent of the people are for something, they’re much more likely to support it than if 50 percent or fewer are.

MG: Opioid abuse has become a major health issue in the past several years. Should the makers or marketers of opioids be sued?

BC: We’re particularly concerned about the opioid problem. That’s the focus of our annual conference this year in Lexington at the Griffin Gate Marriott on September 25. The author Sam Quinones, who wrote the book “Dreamland,” is going to be our keynote speaker. He gives a pretty interesting history of how this opioid problem came about. And there isn’t any question but that it was encouraged and fueled by the drug companies, starting in the late 1990s. I remember because I was attorney general and helped create the KASPER program to try to combat it here in Kentucky.

We did combat it, to some extent successfully, by limiting the number of prescriptions people had. But the unintended consequence of that was that heroin came in, mostly from Mexico, and it filled the gap because we already had an addicted population.

What the drug companies have done is encourage doctors to give out opioids for pain. It used to be, here in Kentucky and in the country, opioids were considered to be tremendously addictive and quite dangerous and were typically not given for pain unless you were a terminal patient. That changed in the 1990s as a result of lobbying on the part of the drug companies, and it became standard medical procedure to give opioids for regular pain. If you had a knee operation, or a shoulder operation, or any other sort of normal pain in the course of living, you had an opportunity to get a prescription for opioids. That new policy that developed in the 1990s was largely at the behest of the drug companies who were selling opioids.

So in our view, they absolutely have culpability. They have been sued before. In fact, Kentucky has sued Purdue Pharma for this very thing. So we’ve already had these lawsuits, and these lawsuits have been successful. At least they’ve been settled for large amounts of money already, in both Kentucky and in other states in the country.

MG: Does the foundation have a position regarding filing a lawsuit?

BC: That’s the province of the state’s attorney general, but we think there has been a culpability on the part of some drug makers. And there’s been a change of attitude in the country, and we need to revisit that because of the damage it’s causing. We had 1,400 deaths last year in Kentucky of overdose alone, and everybody who knows anything about this thinks we have an opioid crisis in Kentucky and it’s damaging our health tremendously. As bad as that is, the 1,400 deaths pale in comparison to the 9,000 or so deaths we have from tobacco every year. And we don’t treat that as a crisis. But 9,000 deaths a year compared to 1,400. This 1,400 deaths is our high-water mark on the opioid problem. The 9,000 is a recurring number for tobacco, year in and year out.

MG: Recent community health needs studies in Kentucky have identified behavioral health as a top need. Are we in the early stages of awareness regarding the need to provide better behavioral healthcare?

BC: We’ve been talking about this for years. Behavioral health is really another term for mental health services. Mental health problems have been stigmatized in the past. That’s wrong. We need to take the stigma away. Mental health problems are really just like physical problems. They’re often chemically related, and they can be dealt with by a lot of measures that allow us to have a positive impact on behavioral health problems.

But they’re also very closely associated with drug use, with our addiction problems. Consequently, we need to be funding behavioral health treatment options as best we can because it’s extremely important. It’s becoming more important all the time, particularly with all the stresses we deal with in modern society. I’m happy to see us trending toward being more interested in treating behavioral health issues.

MG: Do you have a closing statement?

BC: The key to this whole thing is that we’ve got to start focusing on health as opposed to healthcare. Not to diminish the importance of healthcare, but if we can have a healthier population on the front end, and if we can invest in policies that cause our population to be healthier, then not only are people going to have more fulfilling lives, but we’re going to help our economy, we’re going to create jobs, and we’re going to help the business climate. We’ve got everything to gain and nothing to lose by taking that position. We just haven’t done a good job of it in this country.


Mark Green is executive editor of The Lane Report. He can be reached at [email protected]

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