Final Meeting: RWJF Commission to Build a Healthier America
October 9, 2009

Washington, D.C.

Building a healthier nation will require substantial collaboration among leaders across all sectors, includingsome—for example, leaders in child care, education, housing, urban planning and transportation—who may
not fully comprehend the importance of their roles in improving health. This Commission challenges individuals,communities, employers and unions, the business community, media, faith leaders and congregants,
philanthropy and government officials at all levels to work together on promising strategies and solutions.

Meeting Background, Goals and Key Take-Aways
Since the release of its final report, Beyond Health Care: New Directions to a Healthier America, the Commission’s
recommendations have generated considerable interest and support across a spectrum of organizations and decisionmakers: health insurers, public health groups, civil rights organizations, state and local government, biomedical andhealth services researchers, and leaders in early childhood, housing, and community development.
As the official work of the RWJF Commission to Build a Healthier America draws to a close, the Commissioners and theFoundation are mindful that there is a great deal more work to be done to fulfill the goal of a healthier America. To thatend, the Commission hosted a final meeting on October 9 of organizations and policy leaders in the areas of earlychildhood, nutrition and physical activity, housing and the built environment, and population health. The invitation-only
meeting included a series of policy roundtable discussions with public officials, philanthropies, and stakeholder groups
about progress on and implementation prospects for the Commission’s recommendations.
The following is a summary of the meeting proceedings, overall goals and key take-aways from the discussions.
Goals:
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Report on progress in realizing the recommendations and assess the environment and prospects for furtherchange.
Hear from representatives of the Administration regarding the state of inter-agency collaborations focused on
improving health, proposed investments in prevention and wellness in health reform, and an update on thedirection of federal and state policies and programs related to the Commission recommendations.
Give Commissioners, policymakers and stakeholder organizations an opportunity to talk together about possiblecollaborations and how to continue the work begun by the Commission, including featuring key stakeholder
groups’ activities related to the recommendations.
Energize stakeholders and motivate further action by those who will continue to pursue these objectives after
the term of the Commission ends.

Key Take-Aways:
Cross-sector and inter-agency collaborations are essential to continue to advance shared goals of achieving
better and more equitable health outcomes for all Americans.
Foundations play a critical role – as ―knowledge sharers‖, innovators and conveners – to solve multi-facetedproblems.
The Commission recommendations can be used to support a more holistic approach to policy development.
Community and program level measurement and accountability is critical to the dissemination of successful
work across a variety of environments.
Making a strong business case for investments in health is important to get greater uptake and to ensure
farther-reaching benefits.

Perspectives from the Commission and the Robert Wood Johnson Foundation

There has been a noticeable shift in the national conversation on health – the very definitions of what affects
Americans’ health have expanded.
It has become increasingly clear to different sectors – transportation, housing, education – how their work
affects health.
The Commission’s work has provided the Foundation with a roadmap of how to address social factors of healthwell into the future.
The Foundation hoped that convening this final meeting of the Commission would energize participants andmotivate further action to continue the work to improve America’s health.

Prevention, Wellness, and Health Reform
Martha Coven, Special Assistant to the President, Domestic Policy Council, provided an overview of the Administration’scommitment to and focus on the issues addressed in the Commission recommendations to improve the health of all
Americans:The Administration recognizes the strong connection between obesity and increased health care costs; it iscommitted to reducing rates of childhood obesity and raising awareness of the importance of healthy foodchoices.
There is notable symmetry between the Commission recommendations and progress on several federal
initiatives, including the Early Learning Challenge Fund, WIC and SNAP reforms, and addressing food deserts
through an increase in grocery stores.
The Administration understands the importance of supporting prevention and wellness with strong evidence andevaluation of impact – to determine what programs and policies are most effective at the local level – and that
community interventions and will require concerted efforts across sectors.
One can expect to see language in the health reform bill focused on prevention, specifically, what Medicaid andMedicare can do in terms of prevention; a menu labeling provision; and support for employer sponsoredwellness programs.

Roundtable Discussion on Early Life
Ensure that all children have high quality early developmental support—child care, education, and other services—bycommitting additional resources to meet the needs of children in low income families.
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Even with the current economic situation, early childhood is a cost-effective area where there needs to be agreater investment.
The Recovery Act included additional funding in Early Head Start, Head Start, and the Child Care andDevelopment Block grant, earmarking some of these investments for quality improvement.
In September, the House of Representatives approved the Early Learning Challenge fund as part of the StudentAid and Fiscal Responsibility Act, at a level that would provide multi-year grants to states totaling $8 billion over
8 years to implement comprehensive standards-based reforms to their early child care and development
programs.
Beyond the roles of government, there’s promising evidence that public-private collaborations can make a big
difference in early childhood development programs.

Linda Smith, Executive Director, National Association of Child Care Resource and Referral Agencies, provided a brief
overview of the state of child care today and NACCRA’s policy platforms to improve child care quality.
Child care should be considered as serving multiple purposes: work support, opportunity for early education,and as an economic driver in the community.
There needs to be more parent involvement and education – most parents think that the care their childreceives is high quality, but in reality only ten percent of children receive what would be deemed high quality
child care.

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Joan Lombardi, Deputy Assistant Secretary, Administration on Children and Families, HHS, provided a brief overview of
the Administration’s investments and initiatives for young children as well as some of the challenges that theAdministration faces.
Child care should be regarded as an opportunity to improve the lives of children.
The Administration has made a $2 billion investment in the Child Care and Development Block Grants and theestablishment of the Early Learning Challenge Fund which encourages states to develop child care standards
and build integrated data systems so that families can be better served.
There need to be policies that support health promotion education to parents, infrastructure, and interagency
cooperation.
Debbie Chang, Vice President, Nemours, described how an initiative focused on promoting child health by improving
pediatric health care quickly moved beyond clinical services to address the social determinants.
To support a comprehensive approach in early care and education, there has to be policy change as well aschanges in practice.
All relevant stakeholders should be engaged in the process of developing changes to policies and practices.
Federal opportunities include the Child Nutrition Act, Department of Agriculture appropriations, and the creationof interagency workgroups at all levels of government.
All types of foundations have a role – they can act as both funders and conveners.
The subsequent discussion on early life interventions included the following:
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The first step is to affirm the importance of providing comprehensive services to vulnerable families and children
as a part of early care.
States and local communities have moved ahead of federal policy; they are aware of the science on early life
experience that supports the need for action; they have connected the dots and developed a model that takes
the entire life course into consideration.
There needs to be a way of measuring schools and communities on how they are doing on physical health andother indicators of well-being, and the data then should support systems change.
The major source of child care funding is federal; we need to find additional sources of support.
Mental health is critical; studies have found high rates of depression among Head Start and Early Head Start
families and child care workers – so children are at risk of involvement with depressed caregivers both at homeand in other care settings.
Rural children have different needs and face different issues; leadership capacity at the local level is necessaryfor effective programming.

Roundtable Discussion on Nutrition and Physical Activity
Fund and design WIC and SNAP to meet the needs of hungry families for nutritious food
Feed children only healthy foods in schools
Require all schools to include time for all children to be active every day
Create public-private partnerships to open and sustain full-service grocery stores in underserved communities

One in three young people are overweight or obese – and nearly as many have a risk of being diagnosed withdiabetes in their lifetime.
When kids are sick, they can’t do as well at school.
Community-based interventions—such as ensuring that fresh foods are accessible in all communities – havebeen raised in the context of chronic disease and obesity prevention and health reform.

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Julie Paradis, Administrator, Food and Nutrition Service, USDA, provided an overview of the President’s commitment toreduce obesity and end child hunger by 2015.
Key funding in the Agriculture appropriation included:
$85 million for a series of summer demonstration programs to test methods of reaching kids
$22 million on how to improve direct certification so that kids can get into the school meals programs withminimal difficulty,$5 million to WIC for performance bonus payments to states that improve breastfeeding,$25 million for school equipment, and improve the child and adult care food program,$8 million for administrating a competitive grant program for child care settings,
Authority to develop a SNAP electronic benefits transfer-type benefit for schools that are dismissed for morethan 5 days (for cases such as public health emergencies),
The Child Nutrition Reauthorization offers the opportunity to:Break down barriers and insure low income children have access to healthy food,Identify alternate models in school districts and move to a different way of determining qualifications,
Make school breakfast program more accessible,Improve school meal quality,Increase school wellness programs and training for school food service directors,
Increase the reimbursement rate of school meals,
Put authorities in place to make sure competitive foods are consistent with dietary guidelines
Ginny Ehrlich, Executive Director, Alliance for a Healthier Generation, described some of the issues facing nutrition andincreased physical activity in the schools.
Strategies to address competitive foods will require a cross-sectoral approach and working with the foodindustries to provide healthier food options in schools.
Food service directors have various levels of expertise, so technical assistance is important.
Having strong champions within the school system and getting student buy-in are essential.
Food costs and product availability continue to be barriers to providing healthier foods in both school meals andcompetitive foods, particularly in rural areas.
To move the needle further, there should be:
A Health in All Policies approach in the Child Nutrition Reauthorization,
Good transportation policy that includes bike- and walk-to-school programs,

Safe school facilities for physical activity and more cafeterias,
A means to support infrastructure and diffuse innovations.
Lori Glass, Director, Government Relations, described The Reinvestment Fund’s efforts to increase the number ofgrocery stores to reduce food deserts and the factors essential for success:Presence of a financial intermediaryData-driven approachFlexible programs that partner with local groups at the community level
Diverse groups of stakeholders – city officials, labor, philanthropies, chain supermarkets, and independent
operators
The following discussion on nutrition and physical activity included these observations:Food Stamps (now SNAP) educational interventions have been associated with a reduction on obesity, butthere needs to be additional research.
Programs that frame access to healthy foods as fostering economic development, along with public healthimpacts, have been sucessful.
Healthy food should be made available in all of the institutions and venues that serve children: child care, afterschool, and summer feeding programs.
Restricting SNAP food selections assumes that SNAP participants have many choices available to them, but infact greater resources may be needed to increase the actual choices participants face.
There needs to be additional research to determine what works on the community level.
4Roundtable Discussion on Healthy Homes, Communities, and Workplaces
Become a smoke-free nation
Create healthy community demonstrations to evaluate the effects of multiple health-promoting policies and programs
Develop a health impact rating for housing and infrastructure projects that reflects expected effects on health, and create
incentives for projects with positive health impacts
Integrate safety and wellness into every aspect of community life, in schools, workplaces and neighborhoodsSeeking solutions to improved life choices and daily practices such as whether we smoke, what we eat, andhow active we are within communities is a public health strategy that has come of age.
The Department of Health and Human Services (HHS) released $120 million in ARRA funds for prevention andwellness programs within three areas: statewide policy and environmental change, tobacco cessation, andspecial initiatives to create health-promoting policies and environments.
Ambitious collaborations to create healthier homes, workplaces and health-promoting community designs havebeen launched by several private organizations and public agencies over the past 6 months.

Rebecca Morley, Executive Director, National Center for Healthy Housing, and a founder of the National Safe andHealthy Housing Coalition, provided an overview of the national housing picture and opportunities to improve health andsafety.
Look widely at rural, rental, and owner-occupied housing to make a difference, and to invest upstream toprevent asthma, house fires, and serious injury from falls in the home.
Increase the scope of federal homes inspections, for example through FHA loans (currently no health inspection
is needed).

Establish a Federal Interagency Council to coordinate healthy housing interventions and to provide flexible
funding to make ―every touch count‖ when a federal program enters a home for some kind of remediation.
Enforce local and state housing codes, to ensure safe and healthy housing is also affordable.
Matt Ammon, Deputy Director, HUD Office of Healthy Homes and Lead Hazard Control, described the importancecollective expertise and cross-sectoral collaborations to achieve healthy housing.
Foundations have a critical role as knowledge sharers, innovators and conveners to solve multi-facetedproblems.
Healthy homes lead to healthier families and communities, and innovation opportunities lead to early andcombined intervention on all fronts: lead, pests, safety, etc.
HUD’s strategic plan includes a Healthy Homes Initiative that engages other Federal agencies such as Energy,EPA, CDC, Commerce, and USDA in an effort to address issues of housing quality in an integrated fashion.
Cindy Phillips, Senior Advisor for Community Health, NACCHO, described her organization’s work at thecommunity/local level to address underlying causes of inequalities.
Equip health providers with the skills/approaches to reduce health inequities.

Educate and engage communities in thinking about health more broadly.
Incorporate health officials’ input into community design decisions through the use of health impactassessments.
Support greater collaboration in the use of American Recovery and Reinvestment Act (ARRA) funds to createand support healthy communities.
The subsequent discussion on healthy homes, communities and workplaces included the following comments:


The Administration has worked to integrate ―healthy‖ and ―green‖ into one message.
Business communities are currently less engaged in these discussions. We need to characterize health as aninvestment for employers, rather than just a cost.
Consider homes as part of and existing within communities to address housing mobility, desegregation, and theconcentration of poverty. Schools in high-crime or high-poverty areas are especially run-down and falling apart– major funding is needed to refit these schools, while keeping them sited in the community and without
releasing toxins like lead and asbestos into the environment and neighborhood.
5Market investments to educate private citizens and to create an ―energy star‖ type rating or seal for quality
healthy homes and products could be effective strategies.

Reflections and Closing Comments
While this Commission was not the first to tackle social factors affecting health, it created a focus for the issue andencouraged and supported others to address social determinants head-on to close enormous gaps in health.
The Commission’s work helped crystallize the priorities of the Robert Wood Johnson Foundation, which is:Recommitting to social determinants using the Commission’s language to make the issues more
understandable to wider audiences. This includes the Foundation’s priority topics like tobacco and childhoodobesity.
Prioritizing the Fresh Food Financing Initiative work and challenging the Grocery Manufacturers’ Associationand grocers to make fresh foods available and affordable in underserved areas.
Investigating how WIC interventions decrease childhood obesity.
Establishing a four-year project with Pew Charitable Trusts to develop and expand the practice of health impactassessments.
Developing an online community to connect groups across sectors, states and countries to implement
recommendations, share best practices and successes
It is vital to engage the philanthropic community; we need a common framework for better leveraging philanthropic
support for addressing the social determinants of health.

More Resources
Visit commissiononhealth.org for more information, including Beyond Health Care: New Directions to a Healthier America– the Commission’s full report, model programs, key organizations, charts and figures, websites, issue briefs and reports.
The Robert Wood Johnson Foundation Commission to Build a Healthier America – a national, independent, nonpartisan group of leaders – investigated why Americans aren’t as healthy as they could be. Recognizing that there’s more
to health than health care, the Commission looked outside the medical care system for ways to improve health. TheCommission’s 10 recommendations are rooted in the twin philosophy that good health requires individuals to makeresponsible personal choices and society to remove the obstacles blocking too many Americans from making healthy
choices. Learn more at commissiononhealth.org.

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