''Thinking outside the doctor's office to build a strong, healthy nation''

"Healthcare costs are spiraling upward, and the country is not getting healthier for the money spent. Nearly half of all Americans have at least one chronic illness today, signaling more complications and higher costs tomorrow. We cannot spend our way out of this — we need a new approach.

The most urgent health problems facing our nation — such as obesity, asthma, diabetes, heart disease and injuries — are shaped more by where we live and work than by what happens in the doctor's office or hospital.

As a physician, I have seen this firsthand. I can treat a heart attack if someone gets to the hospital in time, but I cannot prevent it if air pollution was the trigger. I have had patients who wish to follow my exercise recommendations, but live in neighborhoods where walking is dangerous due to traffic or crime. I have cared for diabetics who struggle to find fresh produce because there are no grocery stores in their neighborhoods, yet fast food is available on every corner.

To address skyrocketing medical costs and improve the well-being of our citizens, we need to take health into account when making decisions that shape the world outside the doctor's office. A recent National Research Council committee (on which I served) found health impact assessment (HIA) a promising tool. An HIA is a type of study that helps policymakers find and address the likely health effects of decisions in other fields, such as building a major roadway, planning a city's growth or developing agricultural policy.

HIAs consider benefits, not just risks. They can help make the case for a project, policy or plan. An HIA of a Farm to School bill in Oregon showed that providing incentives to deliver fresh local food to schools could not only improve childrens' diets but also create jobs, especially in the hard-hit farm industry. The report looked at employment because it is a health issue as much as an economic concern: Jobs help people afford safe places to live, adequate amounts of food and healthcare. The assessment made recommendations to maximize the benefits the bill offered. The HIA was instrumental in generating broad, bipartisan support for a pilot project.

The goal of an HIA is to bring health into a deliberation about a policy so it can be weighed alongside other considerations. An HIA of the Low Income Home Energy Assistance Program in Massachusetts showed that families faced with high heating bills must often choose between heating their homes and buying food. Moreover, these families turn to space heaters and ovens for warmth, increasing the risk of fires, burns and carbon monoxide poisoning. The state controller recognized that these health risks could lead to unrecognized costs: Burns and fires are not only dangerous, but the emergency room and hospital care they require is expensive, and the costs are often shifted to the taxpayer. After seeing the analysis from the HIA, decisionmakers chose to support the energy program.

States across the nation are leading the way: Alaska, California, Massachusetts and Oregon are all finding ways to make health a more routine factor in decisionmaking through the use of HIAs, each using a model that suits its needs and capacity. At the local level, Atlanta; Baltimore; Nashville, Tenn.; and Minneapolis are also using HIAs to address pressing health concerns. More needs to be done, but these states and cities are on the cutting edge.

There are many factors contributing to the rising costs of healthcare, but there are just as many solutions. Whether in health, transportation, energy or agriculture sectors, public or private, we all have a role to play in solving our nation's health challenges, and health impact assessments are a smart way to help us do it. With national healthcare expenditures at $2.5 trillion in 2009 and climbing, we cannot afford to wait."

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