On the road to wellness: lawmakers want Americans to eat better, stop smoking, exercise and relax.

Dave Barry was kidding, but he was way ahead of the curve in 1985, when he advised everyone to "stay fit and healthy until you're dead." U.S. Secretary of Health and Human Services Mike Leavitt, however, was dead serious when he said, in October 2006, that he wants to make Americans healthier.

"Emphasis on the four pillars of the HealthierUS initiative--physical activity, good diet, healthy choices and preventive screening--is crucial for the nation's health," says Leavitt. "Changing the culture from one of treating sickness to staying healthy calls for small steps and good choices to be made each and every day. [The department's] physical activity guidelines will encourage the creation of a culture of wellness across America."

The California governor's plan for health care reform, announced last month, also gives a nod to wellness, leading off with a proposed Healthy Action Rewards/Incentives program for both publicly and privately insured Californians. It would provide incentives such as gym memberships, weight management programs and reductions in health insurance premiums to promote prevention, wellness and healthy lifestyles.

It's no wonder that Leavitt and other policymakers want to encourage Americans to adopt healthy habits and stay well. Treatment for chronic diseases accounts for 75 percent of what the country spends on health care each year. Rates continue to rise for one of the leading precursors to chronic disease, obesity. An estimated 66 million Americans are overweight or obese. More than 60 percent of American adults do not get enough physical activity, and 25 percent are not active at all.

Another 44.5 million U.S. adults continue to smoke cigarettes, even though this will result in death or disability for half of them.

Treatment for the consequences of these unhealthy behaviors is improving. But it costs--a lot. Preventing diseases and promoting good health for everyone can help control these costs. Making healthy food choices more available, designing environments to encourage physical activity, offering incentives for healthy behaviors and encouraging preventive screenings are strategies that work at lowering costs.

"We have a finite amount of resources to spend on health care," says Hawaii Representative Josh Green, an ER doctor who chairs the House Health Committee. "The only way to afford the things we must have is to focus on preventive health measures and screening. We'll always need trauma centers like the one where I work, but that means we need to be smart about other health costs."

STARTING YOUNG

During the past 30 years, obesity rates have more than quadrupled for children ages 6 to 11 and more than tripled for young people 12 to 19. Many lawmakers are enacting wellness policies for schools, where 98 percent of 5- to 17-year-olds can be found on any given school day in the United States.

Beginning this fall, federal law requires school districts participating in federally funded school meals programs--nearly every school district in the country--to establish a local wellness policy that includes goals for physical activity. School meals must meet nutrition standards set by the U.S. Department of Agriculture. And there must be a plan for measuring success.

Colorado, Florida, Illinois, Indiana, Kentucky, Mississippi, Ohio, Pennsylvania, Rhode Island, Tennessee and Washington have all enacted legislation in the past few years to support school and state wellness policies.

Legislators have worked to improve the nutritional quality of school foods, provide more opportunities for physical activity, and ensure that nutrition is part of the school curriculum. At the local level, 92 of the nation's 100 largest school districts--which educate 23 percent of American students--have developed a wellness policy.

Lawmakers are also looking at ways to encourage kids to get more exercise on the way to school. The federal Safe Routes to School program includes $612 million for grants over five years for communities to build bike lanes, sidewalks and trails that will make it safer and easier for children to bike and walk to school.

GETTING WORKERS HEALTHY

Investing in employee health also pays off. Healthy workers are more productive. An analysis of 32 studies of workplace wellness initiatives found 28 with an average return on investment of $3.48 per $1 in program costs, as reported in 2001 in the American Journal of Public Health. Citibank saved $8.9 million over two years after investing $1.9 million for wellness initiatives, translating into a return of $4.70 for each dollar spent on the wellness program. Motorola saw a return of $3.93 for every dollar spent on its wellness program, and saved nearly $10.5 million annually in disability expenses for program participants compared to non-participants.

State governments and other public employers are initiating workplace wellness programs as well. The U.S. Department of Health and Human Services awarded Hawaii an innovation in prevention award last November for promoting physical activity and nutrition at work. The state health department has outlined these ideas in an online Worksite Wellness Toolkit, so that other employers can start similar programs.

Delaware, Kentucky, Oklahoma, Rhode Island and South Dakota have launched health promotion initiatives for state employees. And Arkansas, North Dakota, Ohio and Vermont have statewide wellness programs for the whole population. In 2005, Nevada's legislature established a State Program for Fitness and Wellness and a state advisory council to raise awareness and create programs for physical fitness, nutrition and the prevention of obesity and chronic diseases. In Arizona, an executive order created a State Employee Wellness Advisory Council in 2005 that organizes wellness fairs and health screenings for state employees, including blood pressure screenings, cholesterol checks, smoking cessation, weight management and diabetes screenings.

States have also had success by starting on a small scale, building on pilot programs. North Carolina's HealthSmart program started with nine local programs that identified employees with specific health conditions and provided them with intensive health advice on lifestyle changes. It was expanded to all state employees in 2005. Delaware launched the Health Rewards pilot study program for state employees in 2003, offering comprehensive health assessments, guidance, and fitness advice to state employees through their group health insurance programs.

State efforts to improve workplace wellness have also included smoking bans that cover all workplaces, including bars and restaurants. Hawaii's ban, effective in November 2006, is "essentially the end of the issue of secondhand smoke in public places," says Representative Green.

BUILDING HEALTHY COMMUNITIES

The way we design our communities can influence our health. Decisions about zoning, community design and land use affect the daily choices people make, whether it is to drive or walk to the store, exercise, or the buy healthy foods. Creating incentives can encourage cities and developers to take health and livability into account when retrofitting old developments or building new ones. The design of neighborhoods, transportation systems and biking or walking paths can encourage physical activity.

Healthy foods, such as fresh fruits and vegetables, which are accessible and affordable, are part of the equation. Encouraging schools and government agencies to buy local produce, providing fiscal incentives for locating grocery stores in all communities--especially underserved urban or rural communities-and setting school nutrition standards and school wellness policies can have a big impact on people's health.

INCENTIVES FOR WELLNESS

Indiana Senator Beverly Gard wants to give employers incentives to create wellness programs. She sponsored legislation last year that will allow Indiana employers to offer financial incentives to reduce employee tobacco use.

"This seemed like something we could do that would give employers an opportunity to provide employees with incentives for healthy behavior," Gard says. Rather than penalize smokers, Indiana amended its smokers' bill of rights to allow employers to implement financial incentives related to employer-provided health benefits that are intended to reduce employee tobacco use. "We wanted to take a more positive approach," Gard says.

States have looked at a number of different ways to provide incentives for wellness and healthy behavior for individuals and for businesses, large and small. Some of the most popular are:

* Insurance incentives such as premium discounts or rebates. Michigan enacted legislation in 2006 that requires insurers, HMOs and nonprofits that offer group health insurance coverage to give premium rebates when a majority of employees or health plan members enroll and maintain participation in group wellness programs. The rebate applies for individuals and families with their own policies who participate in approved wellness programs too.

* Insurance rating incentives. New Hampshire lawmakers in 2004 permitted small group and individual insurers to use a rating factor to discount premium rates for plans, giving monetary incentives for participants in wellness or disease management programs.

* Tax credits. Over the past few years, wellness tax credits have been proposed in at least seven states including Hawaii, Iowa, Mississippi, New Jersey, New York, Rhode Island and Wisconsin. The idea is to provide employers--especially smaller businesses--with income, franchise or corporate tax credits for wellness programs such as nutrition, weight management, smoking cessation or substance abuse counseling, or purchasing or maintaining fitness equipment.

* Insurance benefits for screenings and early treatment. According to Blue Cross-Blue Shield's "Survey of Health Plans" for 2005, specific preventive or screening benefits currently required by states include alcoholism treatment (44 states), blood lead screening (7 states), bone density screening (15 states), cervical cancer screening (29 states), colorectal cancer screening (24 states), diabetic supplies or education (47 states), mammography screening (50 states), morbid obesity care (4 states), prostate cancer screening (28 states) and well child care (32 states).

* Task forces, advisory committees or studies. States have considered creating task forces or advisory committees, or conducting studies exploring the benefits and feasibility of wellness programs or health promotion activities.

* Raising awareness. Legislators are sponsoring or participating in wellness events. For example, the Legislature declared May 2006 as Fitness Month in California and encouraged all Californians to enrich their lives through proper diet and exercise. Kentucky established the Governor's Council on Wellness and Physical Activity specifically to raise public awareness and promote citizen engagement.

SOMETHING MUST BE DONE

What if Americans don't get healthier? The costs could be shocking. Future cost of health care and other benefits could reach between $600 billion and $1.3 trillion for the nation's estimated 24.5 million active and retired state and local public employees.

Moving U.S. health policy toward a more preventive approach is key to containing health care costs. "The burden of chronic disease is increasingly making the U.S. health system unaffordable and causing much unnecessary pain and suffering," says former U.S. Surgeon General David Satcher. The solution? According to health experts at the Robert Wood Johnson Foundation it is "Leadership that informs and motivates, economic incentives that encourage change, and science that moves the frontiers."

NCSL's health care expert Amy Winterfeld tracks wellness and obesity.

Paying for Prevention for the Publicly Insured

States have recently begun to structure public insurance programs to cover more preventive care to help ward off chronic conditions, which account for 96 percent of Medicare spending and about 83 percent of Medicaid spending. Examples include the following:

* Coverage for obesity prevention services. In Connecticut, the state's Medicaid managed care plans pay for obesity related services if they are medically necessary. Nutritional counseling, exercise programs and behavioral health services are covered under Medicaid and SCHIP if they meet the necessity criteria. The state also covers gastric bypass surgery through Medicaid, if medically necessary.

* Coverage for smoking cessation treatments. In 2005, 38 states covered some tobacco-dependence counseling or medication for all Medicaid recipients. Four more states offered coverage only for pregnant women. Oregon is the single state offering all smoking cessation medication and counseling treatments recommended by the U.S. Public Health Service.

* Wellness incentives. West Virginia has some of the nation's highest rates of obesity, diabetes, heart disease and smoking. In three pilot counties, Medicaid patients will be asked to sign contracts agreeing to do their best to stay healthy by attending health improvement programs as directed, having routine checkups and health screenings, taking prescribed medicine, keeping appointments and limiting emergency room use. As an incentive, they will receive antismoking and weight loss classes, home health visits as needed, mental health counseling, diabetes management assistance, cardiac rehabilitation and additional prescription medications. Over future years, Medicaid beneficiaries who stick to the plan will qualify for extra benefits, possibly orthodontic or other dental care. Medicaid recipients who do not sign or adhere to the contract will be limited to the standard benefits determined by the state. Critics say the plan may limit access to the enhanced benefits by those most likely to need them, for example, people with existing mental health or substance abuse problems that create difficulties in keeping scheduled appointments. It may also put doctors in an awkward position as administrative enforcers of factors that may be beyond patient control and may interfere with effective doctor-patient relationships.

* Preventive services for those on Medicare. In January, Medicare increased payments to doctors for face-to-face doctor-patient consultations about a patient's health and what needs to be done to maintain or improve health. The hope is to encourage more discussions about preventive services like controlling diabetes and get doctors to refer more patients to diabetes self-management training and medical nutrition therapy. Medicare will also now cover these services at federally qualified health centers, increasing access in rural and underserved areas.