In a Nutshell:
- Heart disease is the leading cause of death in Michigan and the United States.
- State level policies can help prevent and treat heart disease by addressing the underlying risk factors that contribute to the disease.
- While Michigan has made some efforts, there are a number of policies recommended by the CDC that would improve and expand upon Michigan’s existing services and programs that many other states have implemented.
Heart disease, while rarely discussed as a health policy priority, is one of the most common health issues that people experience. Because it impacts such a wide range of people, and because the health effects of the disease are so dire, we should consider how policy solutions can be integrated into the larger public health approach addressing the disease.
Heart disease continues to be the leading cause of death in the United States and affects people of all ages and ethnic backgrounds. In 2020, heart disease accounted for 20 percent of all female deaths and 25 percent of all male deaths in the U.S. The primary risk factors for heart disease (diabetes, obesity, unhealthy diet, physical inactivity, and excessive alcohol use) are determined by individual health behavior, which is influenced largely by sociodemographic and structural circumstances. Therefore, public health approaches and policies that address these factors can be particularly effective in reducing the prevalence of heart disease.
The Michigan Department of Health and Human Services (MDHHS) houses the Heart Disease and Stroke Prevention Unit, which develops various programs and initiatives aimed at reducing the prevalence of heart disease. MDHHS has received two significant grants from the Centers for Disease Control and Prevention (CDC): $2 million to design, test, and evaluate new ways to address diabetes, heart disease, and stroke in the U.S., and close to $2 million for efforts focused on prevention of diabetes and heart disease. However, there are additional concrete strategies Michigan can implement to promote heart health in the state.
The CDC highlights different state policy strategies to combat heart disease. The strategies include both preventative measures that can address some of the risk factors of heart disease and crisis-control measures that can save lives when someone is in immediate need. Michigan has enacted some, but not all, of these recommendations. For a health issue as widespread and serious as heart disease, Michigan should pursue an agenda that adopts as many of these measures as possible.
Public Access Defibrillation Programs (PADs)
Public Access Defibrillation programs (PADs) ensure that automatic external defibrillators (AEDs) are immediately available when they are needed. The CDC recommends seven types of PAD interventions that can be implemented in state law. These include 1) targeted AED site placement, 2) training anticipated responders, 3) EMS coordination, 4) emergency response plans, 5) routine maintenance and testing of AEDs, 6) continuous quality improvement, and 7) limited civil liability or qualified immunity.
Michigan has implemented most of the recommended PAD interventions but has not enacted laws related to EMS coordination. For example, Michigan could require a registry of AED devices, require entities that sell, supply, or acquire an AED to notify an EMS system, and require a person who uses an AED during a medical emergency to call 911 and activate an EMS system. Twenty-two states have enacted policies requiring all three of these interventions, with several others implementing at least one of the policies. Michigan’s Division of EMS Trauma within the Bureau of Emergency Preparedness, EMS, and Systems of Care is already tasked with EMS coordination throughout the state. Registration and/or notification requirements are relatively low-cost strategies that could be integrated into the existing system.
Pharmacist Collaborative Practice Agreements (CPAs)
Research has shown that drug therapy monitoring, counseling, and educational services provided by community pharmacists contribute to improved health outcomes related to various conditions that lead to heart disease, including hypertension (high blood pressure). The CDC found strong evidence of effectiveness in blood pressure control when a pharmacist was included in team-based care. Some states have enacted laws that explicitly authorize pharmacist collaborative practice agreements (CPAs) to allow pharmacists to provide certain services.
Michigan does not currently have a law directly authorizing these types of agreements. While Michigan’s physician delegation statute generally allows physicians and pharmacists to enter into these types of agreement, the Board of Medicine is authorized to promulgate rules to further restrict or limit the agreements. Currently, the Board only limits the delegation of prescribing controlled substances to an advanced practice registered nurse. However, the board is free to place additional restrictions that could impact physician-pharmacist agreements in the future. Authorizing CPAs in statute – as the vast majority of states already do – would ensure that these agreements remain available and may encourage broader utilization of these practices.
Community Health Workers
Community Health Workers (CHWs) are considered frontline public health workers who improve the quality and cultural competency of health care service delivery by connecting people in their communities to the health care system. Evidence shows effectiveness for team-based care interventions that engage CHWs in controlling hypertension and high cholesterol among people at risk for heart disease.
Some states have enacted laws related to CHWs, including laws addressing scope of practice, reimbursement, and certification. According to a 2016 CDC report, about half of the states have laws addressing the CHW workforce, including laws that require an entity to research and make recommendations to study training, credentialing, reimbursement, and payment. In addition, 15 states either define a CHW scope of practice or specify CHW responsibilities and functions, and a handful of states explicitly specify a role for CHWs in chronic disease prevention. Some states also authorize Medicaid reimbursement for CHW services or incorporate services through Medicaid waivers and state plan amendments.
Michigan has not addressed CHWs legislatively or through other regulatory action. However, the Michigan Department of Health and Human Services recently formed a CHW subcommittee to support CHW efforts statewide. The subcommittee’s goals include creating recommendations to support standardized basic training and exploring sustainable funding models and opportunities. While this is a productive start, Michigan should catch up to other states and cement CHWs in statute to ensure this work remains a permanent part of Michigan’s health care approach and is regulated in a similar manner as other health professions.
Workplace Health Promotion Programs
Evidence shows that certain types of Workplace Health Promotion programs (WHPs) can lead to better health outcomes. WHPs often address behavioral health factors that are commonly associated with heart disease, including smoking, obesity, and stress. The CDC has recognized at least 21 components WHP laws that can be enacted by the state. About half of states have implemented six or more of these components.
Michigan has enacted laws that address three of these components, including authorizing state grants for WHP programs, authorizing WHP programs to provide incentives for employee participation, and authorizing workplaces to make WHP program benefits available to family members, but the state does not appear to be actively funding grants for these programs. Michigan could expand this legislation by specifying required components of WHP programs, including AED training and health promotion activities (e.g. obesity prevention, interventions for high blood pressure and diabetes, and providing education on the signs of a heart attack). Other potential legislation could include authorizing state tax credits for WHP programs, creating a certification for WHP programs, and requiring state evaluation of WHP programs.
Hypertension is a risk factor for heart disease, and reducing sodium consumption can lower blood pressure. The CDC has recognized a few state policy interventions that have been shown to be effective at reducing sodium intake, including sodium limits for certain meals and items, item and menu labelling based on sodium content, and economic incentives for low sodium items. The CDC has recommended placing sodium limits on daily meal providers and items served in workplaces, stores, or vending machines. The federal Food and Drug Administration (FDA) requires certain restaurants and similar retail food establishments to provide calorie and nutrition information, including sodium content, for standard menu items, and issues voluntary guidance for sodium limits for prepared foods. More restrictive regulations are generally not well-received in the U.S. because they are viewed as infringing on individual health and economic decisions, but some states have been able to enact a few of the CDC recommended policies.
Michigan has not enacted any laws that aim to reduce sodium content, nor has Michigan enacted any other dietary restrictions that target health behaviors. It is not clear the political appetite exists to do so, as many conservatives are generally opposed to food restrictions for public health efforts and point to undue burdens on the food/restaurant industry. Further, progressives have not prioritized nutritional food restrictions and labelling requirements as part of their public health agenda despite the significant health and economic costs of high blood pressure.
Considering the significant number of people who will suffer from heart disease and the seriousness of health outcomes that come from it, Michigan should be doing everything possible to address this issue. There are a number of strategies recommended by the CDC that Michigan has not adopted that many other states have implemented successfully, even if certain recommendations, such as policies targeting sodium consumption, would be politically difficult to implement in Michigan. The state should focus on both specific interventions for heart disease along with broader public health efforts that can impact a wider range of chronic illness.