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Contact: Scott Turner 602-513-0028 04/12/2017

ACHIEVING A Healthy future

for our CHILDREN, our schools & our STATE





Future Arizona


, health, public-private, statewide


to dramatically improve health in


Scott Turner, CEO & Co-founder, PhD, MA, MBA. Business exec, 30 years; giving back pro bono last 7 years; Board, Social Venture Partners Arizona; Board, Arizona Business & Education Coalition (ABEC); ADHS AzHIP Obesity & School WorkgroupsArizona Health & Physical Education AZHPE, established 1931, is Arizona affiliate of SHAPE America (the national Society of Health And Physical Educators) Close to 1000 members, representing ~2600 certified physical & health educators of AZ Hans van der Mars, PhD. Professor & Program Director, PE Teacher Ed & MPE Programs, ASU; AZHPE Director of Advocacy; >60 papers/book chapters/textbooks; Boards, SHAPE America & President’s Council on Fitness, Sport & Nutrition ScienceEmpower Youth Health Program (EYHP) Highly effective, nationally recognized program that substantially improves PE, PA, fitness, nutrition ed @$10/student/yearEYH State Leadership team: Jason Gillette, Chief, Office of Tobacco Prevention, Cessation & Secondhand Smoke, ADHS; former School Health Director, ADE (3 years); Board of Directors, Arizona Public Health Association. Jen Reeves, MEd. Associate Research Scientist, UofA (18 years): >$200M in grants; Principal Investigator, EYH; former PE teacher, Avondale, Tucson (20 years); Spanish-speaking; national SHAPE America Award Keri Schoeff, Physical Education/Physical Activity Coordinator, ADE (5 years); former PE Teacher, Dysart USD; Glendale Union HSD (14 years) Scott TurnerArizonans for RecessAdvocating for more recess time and better recess policies & practices in Arizona schools, including prohibition of withholding recess as punishment. 430+ members, Christine Davis, Founder. Parent of 2 Madison ESD students. Deputy County Attorney, Maricopa County.

Note: PA=physical activity Slide @02/20/2017


Introductions (cont’d)

3Stanfield ESD LeadershipVery low-income rural school district with no M&O override, yet national leader in increasing physical activity & healthy nutrition & integrating health in standards-based curriculum; first AZ school: USDA Healthier US Schools Challenge Gold w/Distinction Award

Melissa Sadorf, Superintendent, EdD. All Arizona Superintendent of the Year for Small Size Districts; AZ Middle Level Principal

of Year





Lineberry, Principal, EdD. Co-author, Recess Was My Favorite Subject: Where Did It Go?; Co-Founder, Core Purpose Consulting; PreventionPublic health consulting, training, and technical assistance with emphasis in healthy eating and active living Adrienne Udarbe, Executive Director, MS, RDN. Former Community Programs Manager, ADHS; Nutritionist, Amer.ican Red CrossNAU Dept. of Health Sciences (Fit Kids of Arizona /Northern Arizona Healthcare(NAH))NAH-funded physical activity & healthy habits education programs for over 10,000 students in more than 20 schools in northern AZ. Dirk DeHeer, Assoc. Professor, Dept. of Health Sciences, NAU. Research & evaluation focused on community-based physical activity & health promotion programs for high-risk populations & integrating these programs into health care systemsAmerican Academy of Pediatrics, Arizona ChapterCommitted to improving the health of Arizona children and supporting the pediatric professionals who care for them. Anne Stafford, Executive Director. Formerly ED of Community Health Charities, Arizona Market. Note: PA=physical activity Slide @04/12/2017



AZ Stakeholder Input from:Superintendents/Arizona School Administrators (ASA)Debbi Burdick, Calvin Baker*, Deb Duvall, Roger Freeman, Chad

Gestson, Betsy Hargrove*, Mark Joraanstad, Melissa Sadorf, Jeff Smith, Paul Stanton*, Paul Tighe*AZ School Boards Association (ASBA), AEA, AZ Health & Physical Education (AZHPE),

SHAPE America


Carly Braxton, Steve Jeffries, Chris


*, Paul


*, Matt Mixer, Andrew Morrill*, Tim Ogle*, Janice Palmer, Trish Robinson, Keri

Schoeff, Hans van der MarsArizona State Board of Education (SBE) (& SBE’s A-F School Accountability Ad Hoc Advisory Committee)Calvin Baker*, Reg Ballantyne, Tim Carter, Roger Jacks, Janice Mak*, J.D. Rottweiler*, Chuck Schmidt*, Karol Schmidt*, Jared Taylor*, Tom Tyree; (April Coleman*, Whitney Chapa*, Michael Henderson*, Mitra Khazai*, Foster Leaf*, Paul Tighe*)Nonprofits/NGOs/Misc. (AforAZ, ABEC, AHA, AZ Chamber, CAA, CFA, EMA, Fit Kids, GS, GPL, Goldwater, MA, Playworks, SALC, SVPAZ, TriAdvocates)Amanda Burke, Ernie Calderon, Terri Wogan Calderon, Ellis Carter, Patrick Contrades, Christine Davis, Pearl Chang Esau, Katie Fischer, Dick Foreman, Sybil Francis, Mike Gardner, Neil Giuliano, Stuart Goodman, Becky Hill*, Michael Hunter, Lisa Graham Keegan, Bert McKinnon, Jaime Molera, Dana Wolfe Naimark, Nicole Olmstead, John Pedicone*, Brandy Petrone, Jon Ragan, Paul Shoemaker, Anne Stafford, Marissa Theisen, Adrienne Udarbe*, Chuck Warshaver, Jim ZaharisHealth Care Providers & Plans (AHIP, AzAHP (AHCCCS), AzHAA, Banner, BCBSAZ, HSAA (Alliance), Mercy Care/MMIC/Aetna, Tenet/Abrazo, United HC)Tony Astorga, Reg Ballantyne, Chuck Bassett, Jason Besozo*, Jennifer Carusetta, David Childers, Mark Fisher, Tad Gary, Joe Gaudio, Deb Gullett, Debbie Hillman, Christi Lundeen, Andy Kramer Petersen*, Karrie Steving, Trisha Stuart, Deborah Fernadez-Turner, Greg VigdorGovernor’s Office (including GOYFF)Kirk Adams*, Christina Corieri, Governor Ducey*, Debbie Moak, Danny Seiden*, Kristine FireThunder, Dawn WallaceState Agencies (ACA, ADE, ADHS, AHCCCS)AZ Commerce Authority*, ADE (AZ Department of Education): School Health/PE, ADHS (AZ Dept. of Health Services): AzHIP Obesity & Cross-Cutting Strategies/School Health Workgroups & BNPA, AHCCCS*Legislators & Legislative StaffSylvia Allen, Catcher Baden, Nancy Barto, Carlyle Begay, David Bradley, Kate Brophy-McGee, Paul Boyer, Heather Carter, Regina Cobb, Jeff Dial, Adam Driggs, Randall Friese, Gail Griffin, Katie Hobbs, Jay Lawrence, Debbie Lesko, Emily Mercado, Eric Meyer, Lynne Pancrazi, Frank Pratt*, Jesus Rubalcava*, Matt Simon, Steve Smith, Reed Spangler, Melissa Taylor, Kelly Townsend*, Bob Worsley, Kimberly Yee*Foundations/Grantmakers (Arizona Community Foundation/ACF, AGF, AZSTA, BHHS Legacy, Helios, Piper, Rodel, United Way)Jacky Alling, Don Budinger, Shelley Cohn, Robbin Coulon, Kim Covington, Charles Hokanson, Kimberly Kur, Robin Lea-Amos, Laurie Liles, Jackie Norton, Janice Palmer, Sue Pepin, Marilee Dal Pra, Suzanne Pfister, Roy Pringle, Steve Seleznow, Brian Spicker, Mary Thomson, Merl

Waschler, Glenn Wike, Jerry Wissink, Vince YanezHigher Education/ResearchTacy Ashby(GCU), Chuck Corbin(ASU), Dirk DeHeer(NAU), Kimberly LaPrade

(GCU), Melanie Logue(GCU), Teri Pipe*(ASU), Jennifer Reeves(UofA), Hans v.d. Mars (ASU)

National Leaders, Experts & OthersCDC, CMS, David Katz, Lloyd Kolbe, Michael O’Donnell, US House & Senate Legislators & StaffNotes: *=spoke briefly with; []=[scheduled]. Not a comprehensive list.

Green: particular thanks for key early encouragement and/or involvement by organization leaders—note: these organizations are not yet formally affiliated with HFA. Key

input goals: Do homework, understand perspectives, build consensus, figure out win-wins, etc. Lessons learned include: avoid unfunded mandates; no new taxes; must be accountable; non-punitive; need credible ROI; etc. Slide @04/12/2017










economic crisesFirst stage solution K-12 physical & health “education vaccination”It’s good for student achievement & engagementAnd a rapid payback & great ROI for health organizations How get there? Foundation-laying: Empower Youth Health (EYH) Program, Healthy Future AZ coalition, >RecessAccountability: A-F School Grading, School Report Cards, Recess, School Wellness Policy/SHI, FitnessGram assessments, YRBS surveys, TBDCo-invest & scale-up: Private-public pay-for-performance investment: health orgs, govt via HFALong-term goals$300-500M/year in new $$ from health sector into K-12 in AZReverse child obesity, diabetes, chronic epidemic trends in AZ, USAImprove other aspects of healthNote: ROI=return on investment; A-F=A-F School Accountability formula; SHI=School Health Index (wellness policy plan); YRBS=Youth Risk Behavioral Survey; EYH=Empower Youth Health; HFA=Healthy Future Arizona. Slide @04/12/2017


Health Organizations



Investing in

evidence-based, behavior-changing

physical & health education

Health Organizations




Better child health; Lower child health costs; Payback <1 yearLonger-term: Better adult health; Lower adult health costs; ROI >100xOr -- If Continue on Current Path: With > half of children headed for life of early diabetes & other chronic conditions + related adult health costs of >$10K-15K/person/year = Mounting cost pressures & financial viability risks6Notes: early diabetes = the early onset of Type 2 diabetes, due to unhealthy behavior starting in childhood. Google images clipartfest. Slide @04/12/2017Health Sector Win-Win (or else)


PE not

Pills: Payback <1 Yearrapid ROI from health sector investment in EYH @$10/child/year





Evidence-based Empower Youth Health (EYH) “


-vaccination”, primarily in the form of high levels of moderate-to-vigorous physical activity (MVPA) in this research analysis,

reduces health costs by

preliminary est. $30-50/child/year @scale cost of $10/student/year = <1year payback. EYH costs per student are higher at smaller scales: ~$15-30/student/year. It often only takes ~1-2 children per class becoming healthier to pay back EYH investment within 1 year. Payback/ROI formula: Condition Cost x Condition Prevalence x Reduced Incidence of Condition = Treatment Cost Reduction per Average Student (across all students). K-12: Kindergarten through12th grade. ADHD: attention deficit/hyperactivity disorder. BH: behavioral/mental health. MS: middle school. HS: high school. MVPA is key to improving many of these conditions: MVPA=e.g., after several minutes of MVPA, children are panting, starting to sweat, & having trouble conversing while moving. Target total of 60 minutes/day of MVPA from before, during and after school activities. Utilized peer-reviewed journal articles, when available, and also population data from government statistics/reports. ADHD & depression can improve particularly quickly, though BMI has been improving within 1-2 years in both EYH and Fit Kids. Reduced incidence of obesity estimated based on reduced obesity compared to what would have been expected in that sociodemographic population at those ages. Longer-term ROI = >100x, as health condition on-set is delayed or averted & the severity in middle age & later is postponed and reduced. Rapid payback at all grade levels by particularly reducing: Elementary: ADHD, asthma; MS: ADHD, misc.; HS: obesity, depression/BH. ADHD & depression costs vary dramatically based on type of treatment, and can be much higher. Also, EYH payback/ROI is estimated based on changes in the 78% of students now in the Healthy Fitness Zone (HFZ); however, the 22% non-HFZ obesity rates did not likely improve as much. There is some possible double-counting of teen obesity/depression/BH savings, since obesity costs can include some depression/BH costs. Class size assumption: 30-35 students. References include: Domino et al, 2009; Fullerton et al, 2012; Hampl et al, 2007; Katz et al, 2010; Kuhle et al, 2011; MACPAC, 2015; Pelham et al, 2007; Schuch et al, 2016; Skinner et al, 2016; Thapar et al, 2012; Wang et al, 2005. More Notes & References: see Payback Details slide. Slide @11/15/2016.Health ConditionTreatment Cost (per treated student/year)Prevalence (% students with condition)Reduced Incidence(% drop in students with condition)Grade Levels with Most Reduced CostsAverage Reduced Health Cost per Student/Year(all students)Asthma, ADHD, Obesity, Depression/Other Behavioral Health$400-15005-24%14-33%Roughly spread across K-12$30-50


8Notes: Empower Youth Health (EYH) results 2012-2015 from lower-income AZ schools with 79-98% FRL (Free & Reduced Lunch) student population; 90% Hispanic, 5% Native-American, 3% White, 2% African-American. By Year 3: 20 schools in EYH, 16,000 students, Sunnyside USD, Tucson;

increased % students with cardio-vascular aerobic fitness 4x from 17% to 78%; >6x increase in % of students with good nutrition: 11%  73% consuming recommended fruit & vegetable servings;

% of students at normal weight increased by 12.5% from 48% to 54% among students in the Healthy Fitness Zone (HFZ), even though students would typically be increasing BMI and becoming more obese as they age; 35-40% of students receiving 60+ mins. PA/day. Healthy Fitness Zone is the national FitnessGram/PYFP standard for fitness, as measured by objective aerobic capacity (PACER), BMI, & muscular strength & endurance metrics. EYH costs $10/student/year at scale (produce costs may be additional). References: Reeves, 2016: US Department of Education Grant Performance Report (ED 524B): Jennifer Reeves, UofA, Principal Investigator; fall 2012 - spring 2015. Other notes/references: EYH costs kept low by: school-wide wellness policy planning; training existing PE & classroom teachers & MS/HS student fitness volunteers (& not adding more staff); and regular assessment with


. Moderate-to-vigorous physical activity (MVPA) & healthy nutrition increase brain capacity & academic achievement, per extensive research evidence. Teen aerobic fitness is correlated with 35% less heart attacks in middle-age (


, Nordstrom, 2014); reducing % of Medicaid enrollees with CVD by 35% would save $50B/year nationally (Kaiser Family Foundation, 2012). Teen fitness correlated with




- 2/3 less risk of type 2 diabetes in middle-age (Crump et al, 2016). Potential to reduce chronic health conditions & costs by 20+% with 100x or more ROI (Edunuity estimate). Rapid payback for health sector within first year of EYH implementation in schools, due to reduced health costs for ADHD, asthma, obesity, depression, and related preventable child health issues (see Payback slides/references). Rationale: as fitness increases & nutrition improves, chronic health conditions decrease, Medicaid/AHCCCS/health insurance & out-of-pocket health costs decrease, & productivity & GDP increase from less absenteeism/presenteeism (Milken, 2007); also, as a result, state (& local & federal) tax revenues go up & govt. costs go down. Slide@04/12/2017. Contact: Scott Turner 602-513-0028 scott.turner@edunuity.orgEvidence-based Programdramatic outcomes @$10/student/year


How EYH So Effective & Low Cost

? P-T-A: Plan + Train + Assess  Continuous Improvement


1) Self-Assessment

of all School-based Health-related Elements

School Health Index (SHI) to identify & reduce health risk behaviors, including addressing gaps &


2) Policy/Plan Development for School-based Health PromotionMutually agreed plan by staff to improve health: incl. administration, food services, nurse, classroom & PE teachers 3) Standards-based Instruction K-12 w/training: Physical/Nutrition/Health Educationprofessional development of PE teachers, other staff + on-going field support 4) Youth Development & Student LeadershipStudent volunteer peer-led physical & wellness activities before, during, after school incl. lunch & recess 5) Collaborations with Community Partnerships including before, during, and after school, as well as on weekends, holidays, and vacations (e.g., parents, school food service vendor, neighborhood associations, youth physical activity promoting CBO’s, park and recreation, YMCA’s, after-school programs, Walking School Bus Programs, local businesses, and more) 6) School Health Advisory CouncilsImprove instructional programs, policies, & support services for the 8 components of a coordinated school health/WSCC model; meet min. every other month, ensure wellness implementation for students, staff, & community 7) Regular Assessment of Student Health BehaviorFitnessGram (Presidential Youth Fitness Program), YRBSS, portfolio/“resume”, & other validated assessments for reliable, balanced, comprehensive review & continuous improvementNotes/References: *Schools which now have inadequate numbers of certified PE teachers &/or PE & recess minutes can usually fund PE staffing, by re-allocating their existing instructional time & funds back to PE, without harming academic performance (Kwak et al., 2009; Lees & Hopkins, 2013; Rasmussen &

Laumann, 2013; RWJF, 2009; Shephard, 1996; Singh et al., 2012; Trost & van der Mars, 2010; Trudeau & Shephard, 2010; et al); in fact, schools can increase academic success with rigorous PE/moderate-to-vigorous PA (MVPA) (Ahamed et al, 2007: Action School! BC; Castelli

et al, 2007-12; Donnelly et al, 2009: PAAC; Hollar et al, 2010;

Kamijo et al, 2011, 2012). Slide @04/12/2017


existing school staff & students & community partnerships, with current PE & recess time*, without added


keeps down costs =

$10/student/year @scale


Fit Kids Example

Northern AZ Healthcare investing $1M/year in schools10

Founded 2012, Flagstaff:



from Northern AZ Healthcare



invested; $60-70/student/


PA program cost (if NAH’s peers invested comparable amount = $100M+/year new money into AZ schools)20 elementary/middle schools, 5 districts, >9000 students/yearMandatory 1 class/week moderate-to-vigorous physical activity (MVPA) & nutrition ed, led by trained Health AidesOptional before/after/lunch activity sessionsSupplements existing PE, health educationEvaluation: 2350 children, 4x BMI measurements over first 2 yearsOutcomes: ~50% reduction in likelihood* of being overweightNote: *50% reduction in the incidence of being overweight from what would be expected based upon school district data. Fit Kids physical activity programs in K-8 schools costs approx. $60-70/student/year, primarily cost of trained health aide to lead physical activity (PA). References: Fit Kids evaluation reports (DeHeer, 2014)/NAU emails; Fit Kids website:; Fit Kids staff ; Google images:, Signal Sciences Labs Slide@04/12/2017



Diabetes Onset Dramatically Reduces Costs

>100x lifetime payback/ROI for Empower Youth Health Program “ed-vaccination”


Notes: Lifetime cost varies enormously by age of diabetes onset. Data includes both men and women. References



et al, 2014,

The Lifetime Cost of Diabetes and Its Implications for Diabetes Prevention

: Table

2—Life-years lost to diabetes and lifetime incremental medical spending attributed to diabetes. Sources: Linked data from the 2005–2008 National Health Interview Survey and the 2006–2009 Medical Expenditure Panel Survey and from published national vital statistics. Earlier and interval costs estimated by Edunuity: “(est)”. Slide @04/12/2017. Undiscounted lifetime incremental spendingOnset AgeChild inactivity/ obesityActive children K-12+ Follow-on Policies with Adults


Why Educators Support?

M-V physical activity (MVPA) improves


Reallocating time



does not improve


Wilkins et al, 2003; Trudeau & Shephard, 2008

Keeping/increasing* time allocated

to PE/PA does not harm achievementKwak et al., 2009; Lees & Hopkins, 2013; Rasmussen & Laumann, 2013; RWJF, 2009; Shephard, 1996; Singh et al., 2012; Trost & van der Mars, 2010; Trudeau, 2010; Trudeau & Shephard, 2010; USDHHS, 2010Regular Physical Activity (PA) throughout day helps academic outcomesAhamed et al, 2007: Action School! BC; Donnelly et al, 2009: PAAC; Sallis et al, 1999 Moderate-to-vigorous PA (MVPA) improves cognitive functioning & academic performanceFedewa et al., 2011; Hillman, Castelli et al, 2007- ; Hollar et al, 2010; Kamijo et al, 2011, 2012; Shephard, 1996PE, PA, Sports increase engagement & reduce drop-outsDesy et al, 2013; Rumberger, 2011Notes: e.g., Trudeau & Shephard, 2008: “Given competent providers, [up to 60 minutes*] PA can be added to the school curriculum by taking time from other subjects without risk of hindering student academic achievement. On the other hand, adding time to ‘academic’ or ‘curricular’ subjects by taking time from physical education programs does not enhance grades in these subjects and may be detrimental to health.” Lees & Hopkins, 2013: systematic review of RCTs: “There was no documentation of APA [aerobic physical activity) having any negative impact on children’s cognition and psychosocial health, even in cases where school curriculum time was reassigned from classroom teaching to aerobic physical activity.” See other slides, for detailed references. Slide @04/02/2017


Win-Win Coalition







(with EYH)

PE/HE metrics in ESSA, School Report Card, A-F School Accountability

GradeGreater academic achievementHealthier childrenMore fundingAlso:Higher attendanceIncreased enrollmentGreater student engagementFewer drop-outs, higher graduation%PE/HE metrics provide data to inform policy, and focus attention & resources on improving PE/HEReasonable # minutes school/instructional time for PE, MVPA recess, classroom activity breaks, HE/health-related teaching, healthy nutritionShort-term: Adequate time across school day & before/after-school to reach 60 minutes/day moderate-to-vigorous physical activity (MVPA)Longer-term: 150 mins./week PE in Elementary/MS; 225mins./week PE in HSConsensus effective school wellness policy planQuality PE/HE training & staff at each schoolPrincipal, PE & classroom teachers, food services, school nurse, district: all aligned & prepared to improve school healthHealth orgs.Investing in healthier behavior by supporting improved & expanded PE/HEShort-term: Better child health; Lower child health costs; payback <1 yearLonger-term: Better adult health; Lower adult health costs; ROI >100xWith almost ¼ teens pre-diabetic & > half of adults with chronic conditions--& worsening quickly—related health costs of >$10K-15K/person/year = unsustainableLegislature/Govr/Business/Taxpayers/ArizonansState matches monies, as health organizations invest into an Arizona private-public preventive education health improvement fundHealthier population, More productive workforce, Lower health costs, Higher profits/salaries/GDP/tax revenue, Lower AHCCCS costsROI is even higher, when one considers other direct & indirect benefits of a healthier population to government budgets, business & family incomes, etc.CMS/MedicaidSustainable evidence-based “ed-vaccination” preventive K-12 education monies into programs with proven impact on health outcomes20% EYH+ reduction (to ultimately 50% HFA+ decrease) in Medicaid enrollee chronic conditions & costs.

Begin w/Medicaid waiver to help fund EYH scaling incl. monitor & evaluate to show program link to healthier outcomes & ROIHealthy Future AZ

Empower Youth Health (EYH) program & TBD. Training

, support, admin. Accountability: ensuring implementation, outcomes & ROI.Fulfills mission of dramatically improving Arizonans’ health, starting in K-12 schools.

(Notes: EYH: Empower Youth Health. Slide @12/02/2016)Focuses first on PE & nutrition

in K-12 schools, then adds other health/life-ready programs & policies K-12 & beyond.


14HFA Intermediary Role Ensures Outcomes, ROI

funders invest via HFA, not directly in schools; HFA implements & assumes responsibility for health outcomes; pay-for-performance/success: without results, the monies


Health & Education Associations & Nonprofits

School Districts:

School Boards, Superintendents,




PE & Classroom teachers, Food services directors, School nurses, Other school personnel, Parents

Health Care Providers & PlansADE, ADHS, AHCCCS, Gov. officeFoundations, OthersState & Regional Community GroupsLocal Nonprofits, OthersDiscussion draft slide version @12/02/2016LegislatureMedicaid/CMSFUNDERSBusiness/Leadership Orgs., Foundations, OthersIMPLEMENTERSINVESTMENT$HEALTHOUTCOMESCOLLABORATORS


15Healthy Future Arizona Initiative

Working title Healthy Future Arizona (HFA) (affiliated with: Healthy Future US)Org. Status Fiscal sponsorship under Arizona Community Foundation [501(c)(3)]

First Priority Scaling Empower Youth Health in AZ (& nationally) to trajectory of >20% reduction in chronic diseases & costsFollow-on Co-develop path to ~

50% reduction in chronic diseases & costs; including



Priorities school settings TBD; dramatically improve other aspects of health; (

see below


Vision Arizona as the Healthiest State (& USA as healthiest country)

Mission Empower individuals to substantially improve their health, in the broadest sense, by developing, funding, & implementing systemic, sustainable, long-term, evidence-based, highly-effective, high-ROI, accountable, school-based & other/mutually reinforcing approaches, in social context“Health” Whole-person: physical, cognitive, social-emotional, mental, financial, civic, creative, etc.Guidelines SEAS approaches: Scalable, Effective, Affordable, Self-fundingROI-based Highly results-oriented, evidence-based, quantified, objective, accountable, “speed of biz”; measuring financial, public + private, socioeconomic & quality-of-life returnsGovernance Independent on-going statewide citizens/community oversight board/“commission” : shared governance; social, economic, political cross-section, incl. key fundersFunding Year 1-2 seed funding by leader Co-Founder-Partners  evolving longer-term to sustainably self-funding via HFA health outcome value-adddiscussion draft slide version @04/12/2017


Next Steps


Short-term Policy Advocacy:


dd PE/HE


A-F School Grading Formula & School Report Card

Expand recess K-5

: HB 2082

Health Sector Funding:

Early champions with $$Capacity Building: $$ for Healthy Future AZ launch incl. staffScaling: Empower Youth Health Program to 90+ low-income schoolsACF/Others: Help expand coalition, capacity$$, scaling$$Measurable Pay-for-Performance Long-term Goals:$300M+/year new money into K-12; $200M+/year new state tax revenues (First steps: $1M/yr EYH scaling to $11M/yr all-AZ EYH ASAP) AZ first state to clearly reverse child obesity & diabetes trends(First steps: quantify & continually improve EYH outcomes & ROI as scale up)Slide @04/12/2017




Notes: (clockwise from upper left): PE; classroom activity break; peer-led physical activity; PE teacher & student; parent involvement.

References: top photos

from & from Google images

; bottom from

EYH AZ/Sunnyside USD



Policy Failure Diagnosis: “Silo Syndrome”


Google images: Signal Sciences Labs Slide @02/10/2017


Sector Focus:



in Clinical


(ignoring K-12

prevention)Education Sector Focus: Reading/Math,Cognitionin Classroom(marginalizingbody & behavior)


Prescription? A

Different Vaccination at School“Old School” model:

injected Vaccines vs. Viruses “Ed-Vaccines” (


PE/Health Ed)


Unhealthy Behavior


Google images

: Above/left: First and second graders at St. Vibiana's school are among the first to be inoculated for polio with the new Salk vaccine in Los Angeles, April 18, 1955. Right: recent Empower Youth Health peer-led physical activity. AZ/Sunnyside USD Slide @12/22/2016


Serious Warning Signs

an undeclared 20+ year public health emergency


Notes/References: Google images; NHE


2015: US health costs; US



median HH

income: $57,600 @2.6 people; OECD

Health Indicators, 2015; JAMA, 2014; CDC, 2015: “treating people with chronic diseases accounts for 86% of our nation’s health care costs…Half of all American adults have at least one chronic condition, and almost one of three have multiple chronic conditions.”; Mensah G., May 23, 2006: Global and Domestic Health Priorities: Spotlight on Chronic Disease, National Business Group on Health webinar: 80% of heart disease & stroke & type-2 diabetes and 40% of cancer is preventable; NHIS, 2014: diagnosed levels—true levels higher+; also see ADA & AHA, 2011-15; Pediatrics, 2012 in US News, 5/21/2012 (youth prediabetes); Skinner et al, 2016: Prevalence of obesity and severe obesity in US children, 1999-2014; Milken, 2007; ADHS AZ CVD State Plan, 2005?; ADHS State Health Assessment, 2014; ~83%: EYH FitnessGram baseline data, 2012—J. Reeves, UofA, Principal Investigator; Diabetes% (adults): Boyle et al, 2010; Schneiderman et al, 2014; No chronic conditions=$4,342/year; Diabetes=$13,313/year: Kaiser Family Fdn., 2012 (Medicaid); Edunuity ests. Slide @04/12/2017 $3.2 trillion/year USA health costs  $10,000/personUnaffordable/unsustainable: median household income = $22,200/personUS costs 2x other major developed countries, yet worse health50+% of US adults = chronic conditionsChronic conditions = 86% US health costs, mainly preventableUS adults: 36+% obese, 11+% heart disease/25+% hypertension, 14+% diabetic/35+% pre-diab.4-5% teens severely obese (>100 lbs.); 23% teens pre-diabeticLatinos, Native-Americans, African-Americans, lower-income: much higher prevalence rates, mortalityAZ approaching USA levelsAZ: 20% ave. (20-30% lower-income) child obesity/25-30+% adult obesity; ~83% lower-income kids unfit1/3 of adults diabetic by 2050 (@3x healthy person cost)Health costs: serious social, economic & philanthropic risks


1/3 Students will become Diabetic !?!

23% Teens Pre-diabetic already from Inactivity & poor Nutrition


Notes: 35% of adults pre-diabetic: 86M/243M


Approaching 500,000 w/diabetes in AZ now. Much higher-than-average diabetes rates among Mexican-American, Native-American, & lower-income populations. Diagnosed + undiagnosed diabetes, prevalence% of US population calculated using same diag./


. ratio as in 2010. $245B = USA 2012, and growing fast.

Annual medical expenditures per nonelderly (ages 18-64) adult enrollee in Medicaid, 2009: No chronic conditions=$4,342/year;


(cardiovascular disease) =$9,414/yr; Diabetes=$13,313/year; after out-of-pocket costs; per Kaiser FF. References: Pediatrics, 2012 in USNews, 5/21/2012 (youth prediabetes); Diabetes. org (adults); Boyle et al, 2010 (“middle-ground projections); CDC, 2014: Long-term Trends in Diabetes; Schneiderman et al, 2014; other ests. & details Google images. Slide@04/12/2017 Diabetes cost nearing $15,000/adult/year [3x person with no chronic disease]Prevalence% (total US population)1/3 of adults = >1M diabetics in AHCCCS (AZ) =>$15 billion/year just for diabetes in AZ = an existential threat to future tax cuts & K-12 funding


“Reforming” Health Care as We Sinknot addressing root causes:

unhealthy behaviors22

Unhealthy Behavior







Reduce End-

of-Life CostsNo ExerciseCutMedicareFraudJunk FoodSmokingAHCCCS/Medicaid: Higher Co-pays, Lower Pay-outs, Etc.IT/E-recordsN-Ps/PAsreplaceMDsReferences: Google images; Turner, 2015-17 Slide@03/20/2017Cross-State CompetitionReform Tort/MalpracticeInsurance“Doc Fix”1.0 & 2.0Drug Re-Importation/Price ControlsMedicareVouchersRepeal/Replace ObamacareOpioid, Epi-pen Headline du JourMedicaidBlock Grants


Next Flavor

of the Year


Time Running Out from K to 12

 a life sentence for diseases & costs


Notes: It is very difficult & expensive to change adults’ health behavior, and even changed adult behavior often reverts. Initial measurements indicate that >80% of lower-income AZ students are unfit. National longitudinal data indicate that > 2/3 of lower-income students will not change their health behavior, and will remain unfit & increasingly unhealthy as adults, unless their habits change K-8. Low-income student fitness data based

on baseline

Empower Youth Health (EYH)


results from representative sample of approx. 16,000 students


20 lower-income schools in AZ, 2012-2015, indicating 83% with cardiovascular aerobic unfitness (i.e., not in aerobic “Healthy Fitness Zone”). Adult unfitness estimates based on statistical 80+% persistence of overweight/obesity from adolescence into adulthood. References: Google images:;;; AZ student fitness EYH baseline FitnessGram PACER data, 2012--Jennifer Reeves, UofA, Principal Investigator, EYH; Herman, Craig, et al, 2009: Tracking of obesity and physical activity from childhood to adulthood. Also, see Kaiser Family Foundation, 2012: The Role of Medicaid for Adults with Chronic Illnesses; Whitaker, Wright, Pepe, Seidel, & Dietz, 1997; Brownell & Horgan, 2004; CDC, 2015. Slide @02/14/2017.K-56-89-12Adultsthe vast majority of low-income K-12 students have unhealthy habits & are unfit + without effective physical & health education, they do not change their habits = vast majority of lower-income students remain unhealthy as adults


24Physical Education & Recess in AZ Schools?

Local Control  Local NeglectReferences

: Arizona Administrative Code, Title 7. Education, Chapter 2. State Board of Education. R7-2-301. Minimum Course of Study and Competency Goals for Students in the Common Schools. Recess and Physical Education Survey Results, ADE Survey of Arizona Public Schools, Fall 2010. Empower Youth Health baseline fitness measurements in 2012, southern Tucson schools (Reeves, 2016). Fit Kids BMI evaluation 2012-14, greater Flagstaff schools (DeHeer, 2014). Diabetes stats/projections: Pediatrics

, 2012 in


, 5/21/2012 (youth prediabetes); Diabetes. org (adults); Boyle et al, 2010 (“middle-ground projections); CDC, 2014:

Long-term Trends in Diabetes



et al, 2014; Edunuity ests. Slide @04/12/2017

2010: HB 2725  Section 15-108 of Title 15Required all school boards including charters to consider improving recess policyAdvocated providing >=30 minutes/day, in addition to existing lunch recess K-52010: ADE PE & Recess SurveyOrganized by Mark Anderson, Senator & Representative, 1994-2008, R-MesaAlmost ½ of schools <= 20 minutes Recess/day (typically only “lunch recess”)Majority of schools <= 2 days PE/week2010-2017: March 16, 2017 Senate Education Committee HearingNumerous testimonies from parents in many different districts, who have tried for years to change district & school policies, with little progress made- If anything, in many schools recess time has declined since 2010


25Progress on Recess (HB2082)– but Not There Yet

References: Arizona House of Representatives, 02/21/2017 vote on HB2082. Slide @02/21/2017


Chronic Conditions 

2-3x Higher Health Costs


Note: Annual medical expenditures per nonelderly (ages 18-64) adult enrollee in Medicaid, 2009: No chronic conditions=$4,342/year; CVD (cardiovascular disease)=$9,414/year; Diabetes=$13,313/year; after out-of-pocket costs. References: Kaiser Family Foundation, 2012:

The Role of Medicaid for Adults with Chronic Illnesses / Cardiovascular Diseases

: 56,274,369 nonelderly adult


enrollees, of which 28% with CVD=15.8M individuals; 9% with diabetes=5.1M. AZ AHCCCS Population Highlights, October 2015: 1,818,445 individuals


US Census, Arizona population, 2014 estimate, 6,731,484. Chronic conditions = vast majority

of Medicaid costs: Slide @12/04/2016Medicaid: Annual Medical Expenditures per Adult , 2009


Preventive Power of Physical Activity

rapid payback during childhood from MVPA




MVPA: moderate-to-vigorous physical activity. ADHD

: attention deficit/hyperactivity disorder. BH: behavioral/mental health.

[MS]: moderate cost reduction among middle


chool students. HS: high school. More

Notes & References: see other Payback Details slides. Slide@02/02/2017. References: Buescher, Whitmire, Plescia, 2008: Relationship Between Body Mass Index & Medical Care Expenditures for North Carolina Adolescents Enrolled in Medicaid in 2004. DeHeer, 2014: Fit Kids at School: Executive Report. Domino, Burns, Mario, et al, 2009: Service Use and Costs of Care for Depressed Adolescents: Who Uses and Who Pays?Fullerton, Epstein, Frank, Normand, Fu, McGuire, 2012: Medication Use and Spending Trends Among Children With ADHD in Florida’s Medicaid Program, 1996-2005Hampl, Carroll, Simon, Sharma, 2007: Resource Utilization and Expenditures for Overweight and Obese Children.Katz, Cushman, Reynolds, et al, 2010: Putting Physical Activity Where It Fits in the School Day: Preliminary Results of the ABC (Activity Bursts in the Classroom) for Fitness Program.Kuhle, Kirk, Ohinmaa, et al, 2011: Use and cost of health service among overweight and obese Canadian children.MACPAC, 2015: Behavioral Health in the Medicaid Program—People, Use, and Expenditures.Pelham, Foster, Robb, 2007: The Economic Impact of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.Reeves, 2016: US Department of Education Grant Performance Report (ED 524B) (report on early Empower Youth Health & related elements).Schuch, Vancampfort, Richards, et al, 2016: Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Skinner, Perrin, Skelton, 2016: Prevalence of Obesity and Severe Obesity in US Children, 1999-2014.Thapar, Collishaw, Pine, Thapar, 2012: Depression in Adolescence. Wang, Zhong, Wheeler, 2005: Direct & Indirect Costs of Asthma in School-age Children. Wolraich, et al, 2014 (CDC): Key Findings of The Prevalence of Attention-Deficit/Hyperactivity Disorder: Its Diagnosis and Treatment in a Community Based Epidemiologic Study.Edunuity summary costs/prevalence/reduced incidence estimates, based on above studies; $ & % range estimates based on conditions with biggest impact on cost at given ages. ConditionTreatment CostPrevalenceReduced IncidenceGrade Levels w/ Most Reduced CostsAsthma$400 (Wang et al, 2005)6% (Wang et al, 2005)14% (Katz, Cushman et al, 2010)Elementary, MSADHD$1,000-$1,500 (CDC, 2016; Fullerton et al, 2012; Pelham et al, 2007)7-9% (Wolraich et al (CDC), 2012/2014; MACPAC, 2015)33% (Katz, Cushman et al, 2010)Elementary, [MS]Obesity$600 (Buescher et al, 2008; Hampl et al, 2007; Kuhle et al, 2011)12-24% (DeHeer, 2014; Reeves, 2016; YRBS - AZ, 2013)10-20% (

DeHeer, 2014; Reeves, 2016; Skinner et al, 2016; Edunuity est.)

[MS], HS

Depression/BH$700 (Domino et al, 2009)

3-5% (MACPAC, 2015; Thapar et al, 2012)

26-33% (Shuch et al, 2016)[MS],



Teen Fitness

 1/2 -

2/3 less Diabetes as Adult>100x lifetime payback/ROI for

Empower Youth Health Program “




Notes: Type 2 diabetes. Hazard ratio (HR) (95% CI),


value <0.001: 1.00, 1.58, 3.07 respectively (controlled for SES, education level, BMI, family history of diabetes, etc.; national cohort study population of 1.53M 18-year-old males without prior diabetes). Aerobic capacity had biggest associated impact, but muscle strength was also important. “Overall, the combination of low aerobic capacity and muscle strength was associated with a 3-fold risk for type 2 DM…Overall, these findings suggest that physical fitness has important health benefits for all, even for persons who are not overweight or obese…These findings suggest that interventions to improve aerobic and muscle fitness levels early in life could help reduce risk for type 2 diabetes mellitus in adulthood.” Empower Youth Health (EYH) is an evidence-based program that helps K-12 schools improve physical & nutrition education, including both aerobic/cardiovascular fitness and muscular strength, as verified by

FitnessGram. Reference: Crump, Sundquist, et al, 2016: Physical fitness among Swedish military conscripts and long-term risk for type 2 diabetes mellitus. Reeves, 2016. Slide @12/02/2016Hazard ratio: increased risk for diabetes in adulthood helps achieve this lower-diabetes fitness level


Teen Fitness

 35% less Heart Attacks as Adult

>100x lifetime payback/ROI for Empower Youth Health Program “ed-vaccination”


Notes/References: CVD=cardiovascular disease. Results from long-term study of population of 743K 18-year-old men in Sweden followed into middle-age; controlled for BMI, diseases, education level, blood pressure, SES, etc. “Thus, our results indicate that regular cardiovascular training in late adolescence is independently associated with ~35% reduced risk of myocardial infarction in men.”:


, Nordstrom, Nordstrom, 2014:

High aerobic fitness in late adolescence is associated with a reduced risk of myocardial infarction later in life: a nationwide cohort study in men

. 2009 Medicaid annual medical expenditure data for nonelderly adults ages 18-64: in 2009, per Kaiser Family Foundation 2012 Fact Sheets: 28% of Medicaid nonelderly adult enrollees had CVD, costing Medicaid $9,414/year: Kaiser Family Foundation, 2012:

The Role of Medicaid for People with Cardiovascular Diseases

. $4,342/year per capita cost to Medicaid for “nonelderly Medicaid beneficiaries without chronic illness”: Kaiser Family Foundation, 2012: The Role of Medicaid for Adults with Chronic Illnesses. 56,274,369 adult Medicaid enrollees, of which 28%=approx. 15.8 million with CVD x $9,414/year = $148B * .35 = $52B in potential savings. Slide @12/04/2016potential $50 billion/year Medicaid savings? helps achieve this less-heart-attacks fitness level


>20% Lower Lifetime

Costsdue to 13 years

effective K-12 PE/health ed


Note: Relative health care cost in




for males in US commercial market.

Preliminary projections estimated based on actual data. If

costs are shifted down by 5 years (in effect, the onset & impact of chronic conditions are postponed due to prolonged, effective, early intervention K-12), total amount saved for ages 6-64 is 22%; if shifted down by 10 years, 36% is saved; if shifted down 6.5 years initially then tapering toward 0 years (i.e., returning toward current actual costs by age 64), 21% is saved. Significant savings start early in life: “Chronic conditions in the young (under age 30) take a higher relative toll on that population than they do for the older population. For commercial members under 30 identified with cancer or circulatory conditions…their costs were much higher on average.” Also see Payback slides: EYH can pay for itself within 1st year. References: 2010 commercial cost data held by Health Care Cost Institute (HCCI) w/analysis from: Yamamoto, 2013: Health Care Costs—From Birth to Death, sponsored by Society of Actuaries; reduced costs estimated by Edunuity based on research data including Crump et al, 2016; Hogstrom et al, 2014; Zhuo et al, 2014; Turner, 2016-17, also see Payback Details slide. Slide @02/05/2017Health cost aging curve indexAgePostponing on-setReducing severityDecreasing costsLowering cost at each age from childhood through middle-age+


EYH School Example: Stanfield ESD

Stanfield SD can do PE/PA/EYH; so can your school !


Rural (near Casa Grande), 1 school, 85% FRL, 510

students PK-8




20% Native-American, 20%


72 FTE, Total budget FY15 $4.2 millionLoss of an override, $650,000 reduction to M&O in FY13&14Yet 60-80+ minutes/day physical activity, 4-5 days/week PE, in grades K-8Notes/References: Melissa Sadorf, Superintendent: “K-5 has 45 minutes of PE 4 times a week in addition to the 30 minutes of PA/recess at teacher discretion on when it is taken during the day. The 15 minutes of PA (physical activity) at lunch is another opportunity daily. 6-8 has the 15 minutes of PA at lunch and 70 minutes of PE daily. Additionally brain breaks are taken throughout the day, up to hourly depending on need of the students.” Arts education: K-5: 45-60 minutes/week; 6-8 60 minutes/week. First AZ school: USDA Healthier US Schools Challenge Gold w/Distinction Award. Chris Lineberry, Stanfield Principal: ASBA-ASA presentation on EYH, 12/10/2015; image from Slide@02/10/2017


Whole-Population-Health Investment—

via Whole-Student-Population Ed-Vaccination

Bad news

Good news

for health organizations





—which child will be their customer/patient in future - So need to “ed-vaccinate” all childrenToo difficult & expensive to change adults’ behavior—so need to work with children - Need to improve habits in childhood to have a strong chance for healthy adulthood, which also lays a foundation for better following health recommendations in adulthoodChild health conditions & costs so high already—that payback is rapid - HMO, ACO, Capitated, Managed Care, many PPO, et al: benefit immediately from child health savingsAdult chronic health costs so high—that early investments provide very high ROI - A single major health organization can cost-justify whole-population ed-vaccination; if several large health organizations co-invest, the payback & ROI are even more compellingGiven the lack of adequate prevention alternatives—what choice do you have? - Unrelenting, unsustainably increasing cost pressure from growing chronic condition epidemics32Note: TBD=to be decided. Slide @01/09/2017


Some other whole-population-health perspectives:

Preventive K-12




uilds “

Reinsurance Pool

to protect balance sheets

Invest 0.TBD% of chronic health condition costs (e.g., invest 0.1% of chronic costs in preventive K-12

ed-vaccination)Health plans reimburse TBD% of health care providers’ investments (depending on type of plan)Health care providers/plans invest in K-12 from surplus/reserves and/or add to chronic condition bills/plan premiums“Whole-Population PR” is extremely compelling public communications Nothing as powerful as investing in “game-changers” for everyone in the community-- not just your own customers & some incremental-change foundation grants“Pay-for-Performance” HFA model gives health orgs. control, without day-to-day responsibilityStart in targeted populations, ensure results, choose to keep scalingInvest via Healthy Future Arizona (HFA), not directly in schoolsShare HFA Costs to accelerate payback/increase ROI from reduced child health costs Share investment via Healthy Future Arizona with other health care providers and plans33Note: TBD=to be decided. Slide @04/12/2017Whole-Population-Health Investment—via Whole-Student-Population Ed-Vaccination (cont’d)


34HFA Stakeholder Governance (draft)

broad-based, nonpartisan, funder/public/community accountability; no existing agency/nonprofit spans sectors & can guarantee outcomes

Intent Public governance with broad statewide and funder representationStructure Large Oversight Board with small implementation-oriented Executive CommitteeGovernor/Exec. Appt. 1x Ed & 1x Health experts; ex officio observers (AHCCCS, ADHS,


. Ed & Health advisors)

ADE PE/health



; ex officio observers (Dep. Supt. Health & Nutrition, TBD)

Legislature 1x House, 1x Senate: jointly by Health & Ed Committees incl. min. 3 Minority votes; ex officio TBDK-12 1x: ASA; ASBA; AEA; ACSA; AZHPEHealth sector 1x: AzAHP; AzHHA; HSAA; AzAAP; Commercial insurance rep(s); Health NGO rep (AHA, etc.)Business/Leadership 1x: AZ Chamber; Hispanic Chamber; ex officio (GPL; SALC; NALC)Funders Any funder of >=$100,000/year (but not multiple voting reps. from same org./dept.)Community Incl. >=3x Latino, >=2x Native-American (selection process TBD; can overlap/“two hats”)Executive Committee 7 members; elected by super-majority of HFA Board (Scott Turner as interim Chair)(Program experts) (Core programs; non-voting) Initially: Empower Youth Health expert = Jen ReevesNotes Board role: includes approving HFA executive committee & senior executives; approving annual budgets & long-term strategic plans; regularly monitoring progress Targeting max. 20-25? voting members by “double-counting/two hats”? & mutual representation agreements Other details tbdNote: NGO=nongovernmental organization (e.g., nonprofit org.); discussion draft slide @04/12/2017


35How Work with Health Care/Funders, Schools funding & implementing EYH & related future programs (draft):

foundations, health care organizations do not work directly with schools but via HFA;“speed-of-business” pay-for-performance model for a

serious public health long-emergency

Funds Flow


Health Orgs/Foundations


 Work

with Schools

(directly or via contractors)Legislature/CMS/Other Govt.  ADE/AHCCCS/ADHS? (pass-through with oversight)  HFA  Work with SchoolsNotes: This is a cross-sector public-private partnership with multiple private for-profit & non-profit health and other organizations, and state & federal funding sources. In many cases, funding may also come from school district, municipal, and county government sources, too, given the broad responsibility & impact in education, health & related social services & economic development. Yet existing public agencies are typically sector-specific, and there is separate gubernatorial & ADE leadership; public ed monies also tend to get spread equally=thinly, rather than going where most needed; the existing state political & fiscal structure is not well-suited to administer this initiative directly. In addition, many foundations & other funders do not wish to interface directly with schools on funding & implementation issues. The worsening public health crisis is Exhibit A that the current structure and approach is not working. In addition, unless health outcomes are met under the HFA initiative, the health sector (both private & public/government) will stop funding HFA. Only a focused HFA organization can and will guarantee the performance of these investments on penalty of termination. The public-private cross-sector stakeholder-citizen HFA Coalition Oversight Board, with strong funder clout/veto, will ensure effective investment, & be measured on publicly released & objectively assessed fitness, nutrition, health, and other confidential & privacy-protected aggregated outcomes. [Possible evolution: After 3 years of implementation and 3 years meeting agreed outcome goals in a given school district/charter school organization, an individual SD/charter org. may receive funds & manage implementation itself, though also on a pay-for-performance basis—as long as outcomes continue to be met. If not, monies & administration revert to HFA for that LEA. In any event, HFA will continue to monitor results for all public schools.]Implementation by Schools with local control, assisted by HFA/contractors (Outcomes-measured): 1) Plan  2) Train  3) Assess  4) Report  5) ImproveNotes: HFA can hire staff or contract service providers to assist schools with planning, training & support/technical assistance, assessment, reporting, and continuous improvement. (It is much faster, lower cost & more effective for HFA to manage funds, instead of a govt. agency, & for HFA to proactively & directly provide equipment, training & support as needed, rather than to provide funds to SD, which then orders from TBD. The Oversight Board with pay-for-performance requirements and funder & state government board members provides more than enough oversight; indeed, the HFA model could even become an option to improve certain other public services in the future.) discussion draft version @12/10/2016


36Next Steps: HFA Initiative (cont’d)

key investments in capacity & programsManagement

General Management, Strategic Partner Dev. & Relations: Health Care/Plan, Education, Foundations, Business, School Districts, Government (State/County/Local: Education, Public Health,



Gov.’s Office


Legislature; Federal: Exec.: CMS etc., Congress)

EYH Operations Training, Field Support, Technical Assistance, Ops. Mgmt./Admin./Logistics, FitnessGram Tech SupportEYH R&D Training/Materials/Curric. Dev., Program Improvement & ExpansionEYH M&E FitnessGram, YRBS, Other Assessment & Evaluation, QC Audits, Health OutcomesCommunications With PE/Classroom Teachers, Student Fitness & Nutrition Clubs, School Staff, Strategic Partners, Funders, Employees, Public; Reports, Articles; Website, Email, Traditional & Social/Digital Media, etc.Funding Cost-benefit/ROI/Pay-for-performance & Other Research, Grant-writing, Fund-raisingG&A Accounting, HR, IT, Compliance, Internal Audit, Admin. & Office Support Notes: underlined indicates immediate focuses; bold indicates other current priorities for expanding EYH to more schools; discussion draft slide version @01/05/2017


Healthy Behavior

through Lifelong LearningK-12 lays foundation; ages 0-5 & follow-up policies with adults TBD

Financial Incentives with AdultsUse Most Effective Approaches throughout Life

Strategy: financial (dis)incentives

for adults reinforce

training of parents & education



Criteria: measured, evidence-based, behavior-changing,

low cost, high effect size, practical, developmentally appropriate, demanding, systematic, well-implemented, and politically achievable, with

a net tax reduction from ROI savings. -0.75(Preg-nancy)3 6 9 12 15 18 Working Parent/Family Senior 0(Birth)AgeOB/GYN: with Mother-to-bePrimary Care (Pediatric+WIC+): with Mother & ChildPreschool: with Child & Parent(s)Elementary School: Behavior-changing Health Ed & rigorous PE with Child & Parent(s)Middle School: Healthy Behavior Ed & rigorous PE w/Child, Peers, Parent(s)High School: Health Ed & PE/aerobic alternatives w/Teen & PeersCollege w/Student: TBD & Prevention Financial IncentivesMedicare Tax: Prevention Financial IncentivesHealth Insurance: Prevention Financial IncentivesMedicare: Prev. Incents.Medical + w/Parents Schools w/ChildrenMedicaid/ACA: Prevention Financial IncentivesNote: Rigorous PE includes high # MVPA (moderate-to-vigorous physical activity) minutes. Reference: Turner, 2013-17. Slide @10/16/2016Employee Wellness: Programs & Prev. Incentives37Sales Tax: Stop Subsidizing Unhealthy Foods/Bevs.


38Strategies that Worked vs. Smoking

…Yet We Aren’t Doing Now to Promote Physical Activity & Healthy Nutrition

[Report Card graded (A-F) on if & how well we are re-using strategies that helped reduce smoking]


health-related education programs in schools




Broad & profound awareness of seriousness of problem

(D)Hard-hitting, pervasive public information campaigns (F) Large insurance premium discounts for healthy behavior (D+) Cost-effective behavior cessation/adoption products/programs (D)Very strong government health warnings (D)Government restrictions on unhealthy prod. marketing/promotion (F)Dramatically increased unhealthy product sales taxes (F)38Notes: Effective steps we can realistically start taking NOW are bold and/or underlined. Anti-smoking track record: 42% US adults smoked in 1965  17% US adults now. List of key strategies that helped to dramatically reduce smoking among Americans; followed by an (A-F) grade, indicating Edunuity’s rating of how well AZ & the USA are using the particular strategy to prevent other unhealthy behaviors--particularly lack of physical activity and unhealthy nutrition--and thereby prevent or reduce chronic health conditions. Ranked by Edunuity in rough order of what is realistically implementable & politically achievable starting in 2016. Population-wide K-12 preventive education (“ed-vaccination”) builds a foundation of support for other policies, including by “raising consciousness” of students & their parents about the impact of health-related behavior. References: at Google images; CDC, 2015 (NHIS, 1965; YRBSS 2013 data, AZ: HS student cigarette use); Ending the Tobacco Problem, Institute of Medicine, 2007; Turner, 2014-16 Slide @12/20/2016


BHAGs: Some Big but Achievable Goals

for AZ as Healthiest State + USA

AZ success

 Nationwide model

First state to

reverse child obesity


in a major, sustainable way

First proven,

low-cost, scalable

model substantially reducing chronic health conditions through higher physical activity & healthier nutrition, incl. in lower income, Latino-/African-/Native-American populationsSustainably much lower per capita costs for health care than any other state (AZ low already, but demographics are ominous)First state to significantly, intentionally improve student achievement by boosting: fitness & nutrition and physiologically-based cognitive capacity & executive function Sustainably much lower Medicaid/AHCCCS costs than any other state (AZ low already, but demographics are ominous)Providing large sustainable long-term funding source for schools (AZ>$300M/yr.), AND over which schools have significant control (sustain with success: effective PE & nutrition ed.  healthy children  healthy adults  Medicaid/ACA/Medicare/health insurance & productivity savings  govt. & family $$$ for schools)Large sustainable tax cuts & permanently lower federal & state taxes from lower health costs, higher productivity/GDP, higher tax revenues without higher tax ratesHuge long-term economic development boost from highly sought employee base (due to healthy, productive, low cost, educated workforce)Sustainably structurally balanced state budgets & reduced federal deficits/debt39discussion draft slide @12/02/2016



Us? Why Now?our personal & collective opportunity & responsibility

It’s Too Late to Wait Addressing 25+ years of widespread neglect/negligence of PE/health


/child health

Children’s lifetime


determined during K-8 years

- Each year delayed increases risk—a permanently lost opportunity - 1/3 of current K-12 students will become diabetic, unless we improve PE, HE, etc. Future ed, other funding at risk from skyrocketing health costsEssential for Arizonans’ Health No alternatives exist to affordably improve health on large scale (per AzHIP, 2016) - There is no other plan—no one else is coming to “save” us…it’s on usFirst in USA Potential Short-term: first state to put physical & health education into school A-F accountability formula Short-term: first state to bring major sustainable health sector $$ into schools Long-term: first state to reverse child obesity & diabetes epidemicsSchool Funding We have a realistic, sustainably “self-funding”, politically feasible plan to bring new $$ into schools - Health sector new pay-for-performance $$$ into K-12 schools [e.g., Northern Arizona Healthcare (Fit Kids/Flagstaff $1M/yr)  AZ-wide: $100M/yr, because leads to better health & lower health costs/high health sector ROI]Note: AzHIP: draft Arizona Health Improvement Plan—school health including much more moderate-to-vigorous activity (MVPA) critical part of draft statewide plan to improve health in AZ. Slide @04/12/2017


Healthier AZ+USA Timeline

(draft/in progress/partial)ramp-up ASAP--with quality; 

$300M+/year in new AZ school funding,with net positive impact on state & federal budgets Finalize HFA founding coalition Fund EYH (initial scale-up = some philanthropic, then mainly health industry $$)

Build HFA/EYH organizational capacity (initial)

Submit EYH-AZ funding waiver app to CMS

Request appropriation to expand EYH to some AZ low-income schools—ASAP, to all

Agree additional high-ROI investments in physical & health education

Begin expanding EYH to other states Add more evidence-based high-ROI health-related programming Permanent CMS outcomes-based co-funding for EYH nationwide Continued improvement & expansion nationwide of high-ROI, effective, evidence-based, accountable, systemic programs412017 2018 2019 2020 2021 2022 2023 2024 2025 2026 Notes: discussion draft slide version @04/02/2017


EYH School Waiting List

partial list, 2016-17: initial scaling from 20 to 90 schools42

Notes: Voluntary, not mandatory. Applications open to all public district & charter schools that meet EYH requirements including support by principal. Schools wanting to participate apply individually, so in some cases not all schools in each district are participating. Initial

focus is lower-income schools, which

statistically have unhealthier, less

fit students.

This is a partial list of school districts with schools, which have applied to participate in EYH & been accepted @Nov. 2015, subject to change. References: ADE/EYH, 2015. Slide 12/22/2016


School District Name


Rough Rock Community SchoolCochiseDouglas Unified School DistrictCoconino Heritage Elementary SchoolGilaPayson Unified School DistrictGraham[To be decided]Greenlee[To be decided]La Paz[To be decided]MaricopaAcademy of ExcellenceMaricopaArizona Academy of Science and TechnologyMaricopaBalsz School DistrictMaricopaFowler Elementary School DistrictMaricopaKyrene School DistrictMohave[To be decided]NavajoHolbrook Unified School DistrictNavajoKayenta Unified School DistrictNavajoPinon Unified School DistrictPima

Flowing WellsPimaMarana Unified School District


Sunnyside Unified School District (SUSD)Pima

Tucson Unified School District

PinalEloy Elementary School District


Florence Unified School District


Stanfield Elementary School District

Santa Cruz

Santa Cruz Unified School District


Acorn Montessori Charter


Carpe Diem High



Whole School, Whole Community, Whole Child Model

WSCC=Coordinated School Health 2.0: a collaborative preventive approach to health via schools

Empower Youth Health Program addresses many of these


References: ASCD, CDC, 2014-16:


44AZ State Spending: 2002 vs 2012

need to reverse trend of less educating, more medicating—by increasing healthy behavior


Notes/References: % of state budget. Also, USA total national education public + private spending as % of GDP, per OECD: education, 7%;


ealth: 17%.

AZ Joint Legislative Budget Committee

2013: General fund operating budget spending. Fiscal years 1979-2014. JBLC, 2014: Other appropriated fund operating budget spending: Fiscal years 1989-2014. (Health: AHCCCS + ADHS + Veterans Services) Slide @12/07/2016


Conditions & Costs Worsen

with Ageearlier condition on-set

continues to worsen this trajectory significantly


Note: Relative health care cost in 2010


age for males in commercial market. High chronic costs start in childhood: “Chronic conditions in the young (under age 30) take a higher relative toll on that population than they do for the older population. For commercial members under 30 identified with cancer or circulatory conditions…their costs were much higher on average.” References


2010 commercial cost data held by Health Care Cost Institute (HCCI) with analysis from: Yamamoto

, 2013:

Health Care Costs—From Birth to Death, sponsored by Society of Actuaries. Slide @01/09/2017Health cost aging curve indexAge


US Health Care Costs >100% Higher

Notes: U.S.

R&D only 5% of USA health care costs). Latest US per capita expenditure: OECD, 2015 = $8,713., based on Purchasing Power Parity (PPP).Reference:  Organisation for Economic Co-operation and Development (2010), “OECD Health Data”, OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011

). Downloaded

11/20/2014 from



: Australia & Japan: 2007.  Figures for Belgium, Canada, Neth., Norway and

Switz., are OECD estimates.  US$ = PPP adjustedPer Capita Health Expenditure, 200846Ouch!


Americans’ Health: Not Better yet >2x More Costly

US--better: smoking, cancer; worse: diabetes, obesity, heart disease, life expectancy, costs

Notes: *Approximate value based on OECD charts. Based on OECD definitions for comparison, may not match other data in slide deck. OECD includes virtually all major Western developed countries + some others. References:  OECD Health Indicators, 2015: downloaded 1/28/2016 from http://www.oecd-







Diabetes prevalence: OECD, 2015:

Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care, 2011 data, page 47, downloaded 1/29/2016 from: (source: IDF, 2013, IDF Diabetes Atlas, 6th Edition)47Health IndicatorUSAOECDNotesLife Expectancy78.880.5at birth, in yearsMortality from Heart Disease128117ischemic, deaths per 100K populationCancer Mortality198*202*Breast Cancer Survival93%*87%*5-year relative survivalDaily Smoking14%20%% for whole populationAlcohol Consumption8.4%*8.5%liters per capita (15 years +)Fruit & Vegetable Consumption47%/78%*60%/65%*% of population aged 15+ eating fruit/vegetables dailyDiabetes Prevalence13%*9%*ages 40-59, 2011 dataObesity (adults)35%19%UK 25%, Mexico 32%Obesity & Overweight (children)34%*23%*% of children at various agesHealth Expenditure per Capita$8,713$3,453US$ at purchasing power parity (PPP)Health Expenditure % GDP16.4%

8.9%as share of GDP, 2013


Lost GDP/Tax Revenue from Chronic Conditions

bad health is very bad for the economy



: Annual cost in $ billions in 2003.

$1+ trillion in lost productivity/GDP for USA

. Productivity loss from: ill




caregivers, if any) forced either to miss work days (absenteeism) or to show up but not perform well (presenteeism). Reference: DeVol, Ross, and Armen Bedroussian, An Unhealthy America: The Economic Burden of Chronic Disease, Milken Institute, October 2007 Tax estimates based on 2013 AZ GDP and tax data from Slide@10/22/2016Potential to increase AZ GDP $2B+ from 10+% less absenteeism & presenteeismAlso, $1B in new GDP generates state tax revenue of approx. $100M; so $200M/yearUS$ billions in lost productivity, 2003


Preventing Middle-Income Family Financial Crisis

2020’s shock: more & more families will cut non-medical spending to pay for health costs; from 50M+ struggling to pay medical bills now

 a “Great Health Care Recession” ?49Notes: Assumes continued real inflation-adjusted wage stagnation of middle quintile [40%-60%] household income

over long-term

, based on last 15+ years’ trends; 3% real annual average health care inflation until 2025 per CMS federal projections, then 2% real annual health care inflation until 2035; long-term average non-health costs rise at same rate as middle-income

wages (


assumptions based on past trends). References:

NerdWallet, 2014: including up to 650K households/year bankrupt from medical bills; BLS Consumer Expenditure Survey, 2013; National Health Expenditures Table 1, CMS, 2015;

Health Cost Trend: Behind the Numbers 2016, PWC HRI, June 2015; The Precarious State of Family Balance Sheet, Pew Trusts, Jan. 2015; Turner, 2015-17. Slide@02/05/2017% After-tax Income, Middle Household Income Quintile& what happens to education funding support, charitable donations & other non-health spending then…!?


Policy Agenda

(partial / long-term; preliminary draft)


NOW: Optimize policies:

ESSA + School Report Card + A-F Accountability Formula + Recess Time + TBD:


Physical & health education info into AZ


standards, & into detailed individual School

Report Card” e.g., average # minutes PE/day, # minutes recess/day, # minutes health ed/day, valid PE outcomes assessment? (FitnessGram: Y/N?), nutrition behavior (YRBS data?), policies (Healthier School Challenge level?), SHI, TBD 2) “Extra Credit”/Voluntary school participation for effective PE/HE in A-F School Grading Accountability Formula as long as not in Report Card and Formula = implies (literally) = physical & health education have zero value - Note: extra credit is voluntary--doesn’t count against schools, only helps their grade Why?: Parents want to know if children getting physical activity, good nutrition; MVPA increases academic achievement; & without effective PE/HE, most students will have lifelong bad health at unaffordable costsSOON: Expand foundational program: Empower Youth Health Program (EYHP) Highly effective & accountable AZ PE & nutrition ed. & wellness program @$10/student/year at-scale cost 2012-15: 17% fit to 78% fit, 48% to 54% normal weight, 11% to 73% fruit & vegetable consumption Accountability & metrics: regular FitnessGram (Presidential Youth Fitness) assessments; YRBS data; TBD Next: Grow EYH from 20 schools, 16K lower-inc. students  90 schools volunteering, 50K+ stdts @$1M/year Then: Keep increasing to all lower-income AZ schools: ~1000 schools?...then to all AZ public schools Co-funding/matching: AZ health sector (e.g., Fit Kids: Northern AZ Healthcare: ~$1M/yr now), CMS/legislatureLONGER-TERM: Build Support for All-schools EYHP, Funded Mandates; Grow to $300M+/year new money  K-12 Currently: Standards with unenforced mandates & little funding & no A-F value imply lip service, minimal respect for: PE/HE, PA/Recess, Children’s health, + hurt our academic outcomes, public funding & economic development Fund: minimum required PE, recess time w/accountable PE/HE outcomes assessments; EYH statewide; other TBD

incl. Add PE-certified teachers to bring minutes/week to 150’/elementary, 225’ MS/HS Pay-for-performance based on health outcomes

 Co-funding/matching: AZ health care orgs, plans, legislature, CMS 

Earn Medicaid/CMS co-funding with outcomes evidence, beginning with AHCCCS waivers



K-12 Accountability Metrics

(partial / long-term; preliminary draft)



Schools implementing AZ PE & HE standards

PE & HE as important parts of whole-child life-readiness education, preparing kids for success in life

State long-term goal to

reach nationally recommended 150 mins. PE (Elem), 225 mins. PE (MS, HS) per week

Moderate-to-vigorous physical activity (MVPA) as important for improving academics & health Healthy nutrition at school including breakfast in the classroom are important in improving student brains & success PE & HE as essential subjects, requiring adequate funding, staffing, training, equipment, facilities, etc. Valid PE & HE assessment as important in determining success & continually improving teaching, other approaches SCHOOL Average # minutes PE/week REPORT CARD: Average # minutes recess/day Recess managed by quality trained individual to increase MVPA & develop social-emotionally Average # minutes non-PE health education/day Quality of wellness policy plan being actively implemented (meeting ADE rubric including SHI TBD, with examples) Using FitnessGram/other valid PE assessments? if Yes: % students in Healthy Fitness Zone, or the equivalent Healthier US School Challenge HUSSC level (Gold/Silver/Bronze/NA), YRBS, or similar multistate nutrition & PA quality metric YRBS summary results: nutrition behavior, smoking, etc. TBD TBD: Quality of school meal nutrition (how measure?) Breakfast in classroom? Yes/NoA-F GRADE*: Quality wellness policy plan being actively implemented (including SHI, meeting ADE rubric TBD; with examples; details TBD)** (extra-credit/ % students at the level of fitness for good health per criterion-referenced standards [e.g., % students in or being reclassified into voluntary) the FitnessGram Healthy Fitness Zone (HFZ%), or other valid assessment w/equivalent %** Aggregate of selected YRBS nutrition behavior data (e.g., ave. student fruit & vegetable consumption) & yr-to-yr improvement % % students not smoking Valid alt. assessments e.g. portfolio allowed, once recommended by AZHPE, reviewed by ADE & approved by SBE Longer-term: AZ-standards-based PE/HE assessment, with broad statewide input including AZHPE reviewed & approved by SBE Formula to reflect growth/improvement% + encourage maintenance of improved outcomes + reflect FRL/poverty challenges Note: *A-F grade is extra credit and voluntary: schools are not required to request extra credit, and the extra credit formula will not reduce A-F score. Longer-term goals are listed. **Use of alternative assessment instruments: must

meet ADE quality rubric as approved by SBE. PE: physical education. HE: health education. MS: middle school. HS: high school. PA: physical activity; MVPA: moderate-to-vigorous PA. SHI: School Health Index. ADE: AZ Dept. of Education. SBE: AZ State Board of Education. HFZ: Healthy Fitness Zone (i.e., % students at the level of fitness for good health: Preliminary draft slide @02/17/2017


Exercise Improved Reading by full Grade Level

52Notes: Reading comprehension increased one full grade level following treadmill exercise. In related study, above graphic shows composite scan of 20 student brains taking the same test.

References: Graphic from Hillman & Castelli, 2009, Univ. of Illinois; Hillman quotes referring to study published in Neuroscience: Slide @12/22/2016

Dr. Hillman:


“had a

higher rate of accuracy,

especially when the task was more difficult



More Brain, More GainNeuroscience evidence:

prevent brain bottlenecks with MVPA & nutrition  more & better-wired hippocampus, basal ganglia, etc.

 sit still & focus attention, more self-discipline, greater cognitive capacity, more learning including better math/other scores53Notes: MVPA=moderate-to-vigorous physical activity. References: Best, 2010; Chaddock et al, 2010, 2011; Davis et al, 2011; Edwards et al, 2011;

Frisvold, 2015:

Nutrition and cognitive achievement: An evaluation of the School Breakfast Program

, Journal of Public Economics, December 2014; Geier

et al, 2007; Hillman, 2010; Hollar et al, 2010; Howie & Pate, 2012; Kamijo et al, 2011-2012;


, A., Finn, A., et al, Neuroanatomical Correlates of the Income-Achievement Gap, Psychological Science

, April, 2015; Pontifex et al, 2010, 2013; Singh et al, 2012. Image source: Slide @11/07/2016MVPAMore LearningSameTeachingNutrition


60 Minutes/Day Physical ActivityEYH can reach 60 mins. PA even with limited PE minutes

54Notes:. Physical activity (PA) should be moderate to vigorous physical activity (MVPA) for full academic and health benefits: moderate to vigorous physical activity = e.g., after several minutes of MVPA, children are panting, starting to sweat, & having trouble conversing while moving.

References: Adapted from LMAS PAL training, 2015 Slide @11/15/2016 Classroom exercise break sample, GoNoodle example:


Activity (PA)





Mins./dayactivityClassroom breaks during school (3/day x 7 mins. ea.)2116Physical Education class (60 minutes/ week PE)128Recess #1 (one 15 minute/day)1512Recess #2 (or PE #2: add’l 60 mins./week PE, totaling 120 mins/week PE)12-1512Before/after-school program/morning/afternoon activity1512Total Physical Activity75-7860



FitnessGram: Balanced Fitness Assessment(replaced Presidential Physical Fitness Test)

Notes: Healthy Fitness Zone standards “represent the minimal levels of fitness needed for good health based on the student’s age and gender”, per Presidential Youth Fitness Program (PYFP). BMI = Body Mass Index: comparing height vs. weight. [BMI]: Not recommending including BMI at present. References: PACER photo: from Google images;; PACER test overview: Slide @02/14/2017



- 15-20


sprints (PACER

/“beep test

”), 1

mile run/walk Muscular strength & endurance, flexibility - curl-ups (crunches), arm hang/pull-ups, push-ups, trunk lift[Body composition] - [BMI]Key criterion-referenced metric: % students in Healthy Fitness Zone (HFZ) = evaluates if student at level of fitness for good health


56PE assessments

mandated in 21+ states: AL, AR, CA

(grades 5,7,9), CT, DC, DL, GA, LA (focused on high-poverty districts), MO, MN (local assessments), MS (grade 5), NC, NY

(local assessments),




(grades 2,5, 8-12),


(grades 3-12), VA (grades 4-12), VT (grades 5-12), WV

(grades 4-8 & HSx1), WIMandated public reporting of results in 10+ states: AL, CA, CT (in Strategic School Profile), DC, DL (results to parents), MO (% meeting min.), SC (to parents + school effectiveness score), TX (summarized results to TEA) VA, WVNote: State assessments appear to be FitnessGram or equivalent in vast majority of cases. References: in Google images. Preliminary state analysis by Edunuity: NASBE., 2011:; Shape of the Nation 2016: Status of Physical Education in the USA, 2016; E CS personal communications, 2015-16. PYFP, 2014. Plowman et al, 2013. Slide @11/28/2016.Fitness Assessments esp. FitnessGrammulti-state precedents--yet FitnessGram rare in AZ & only part of solution


School Wellness Policy Plans & SHI

Local School Wellness Policy

Each LEA in NSLP required by Congress to establish plan for all schools in LEA,

& review at least every 3 years

Schools required to meet federal school nutrition standards

School Health Index (SHI)

Form & process for self-assessment, prioritization & planning by schools

4/8 modules: 1) School Health/Safety; 2) Health Ed; 3) PE & PA; 4) Nutrition Services

Schools identify strengths & weaknesses of their health & safety policies

Input from administrators, teachers, food services, parents, students & communityDevelop action plan based on school priorities to improve student healthAdd permanent School Health Advisory Committee (SHAC) including parents, community57Notes: LEA = Local Education Authority, i.e., school district. NSLP = National School Lunch Program. PE = physical education. PA = physical activity. Reference: USDA: CDC: Slide @12/20/2016.



All Levels

: Participates in SBP, NSLP, Team Nutrition; reimb. meals & snacks sold meet USDA nutrition standards (Smart Snacks); “Smarter Lunchroom” in all six areas: Fruits, Veg., Entrees, Milk, Sales of


. Meals, School Synergies


: SBP, NSLP: no min. ADP%; 45


./week PE + PA opportunities;


action itemsSilver: SBP: 20%+ ADP; NSLP: 60%+ NSLP; 45 mins./week elem. PE; MS/HS: PE offered + PA opps.; 50-69 action itemsGold: 90 mins./week elem. PE, MS/HS: PE offered; 70+ action items (Balsz SD, Stanfield SD—high FRL schools)Notes: SBP: School Breakfast Prog.; NSLP: Nat’l School Lunch Prog.; ADP: ave. daily participationHealthier US School Challenge HUSSC/ USDA: all schools should do Gold+


What is HFA Initiative?


Growing statewide coalition of education, health & other leaders



Arizona the healthiest state



- Develop, fund

& implement

- systemic, sustainable, long-term - evidence-based, highly-effective, high-ROI, - school-based & other mutually-reinforcing approaches - to empower individuals - to substantially improve their health - in the broadest sense & in social context“Health”: Whole-person: physical, cognitive, social-emotional, mental, financial, civic, creative, etc.Slide @11/11/2016


EYH Cost & Pay-for-Performance: high ROI

Initial Investment  Continued EYH Results  More $$ Invested in EYH

 More Fit Students  Better health & lower health costs @high ROI








80040-60K125K+425KDEVELOP LOCAL TEAMS & PLANS: School wellness policy team trainingSchool-wide staff--from administration, food services, nurse to classroom & PE--learn to develop & implement plan to increase students’ PA minutes & improve nutrition & health$60K$175K$475KPROVIDE UPFRONT & ON-GOING TRAINING & SUPPORTAfter initial trainings, continuously improve skills of PE & classroom teachers & staff & student-EYH-leaders at schools; major field assistance ensures fidelity & outcomes$210K$475K$1.2MTRAIN, IMPLEMENT FITNESSGRAM ASSESSMENTS incl. equipment, licensesRegular fitness assessment by school to monitor progress & improve PE/PA process, MVPA & fitness levels$200K$650K$1.9M*[Additional PE teachers, equipment, etc.]NA*TBD*TBDMANAGE SCALING & OUTCOMES: Capacity-building for successful results/ROIOversight of EYH training & support, continuously improve process, monitor & evaluate results, add new schools, optimize cost-benefits/ROI, accountability for monies$470K$790K$1.5MTOTAL$940K$2.1M$5.1M Ensuring high health impact & high ROI/paybackSchools must make commitment to fully participate. EYH ensures that schools do so effectively, including on-going training, support, evaluation & oversight. State invests increasing resources step-by-step, contingent on EYH’s continued success, as assessed by FitnessGram, YRBS, etc. When implement all of above, will typically increase Fit% at participating lower-income schools by 2-4x over 3-5 years, leading to >40x ROI for State of AZ, >100x overallNotes: EYH starting at cost of approx. $25/student/year due to upfront costs & capacity building, in order to scale, decreasing to approx. cost $10/student/year at scale, with >100x ROI for Arizona. The above $$ amounts pay for fitness-related physical education assessment equipment & software, training & support, including related nutrition education but not produce costs. All investments are needed; cannot maintain fidelity & accountability & achieve ambitious goals without all. EYH continues to support schools in future years. EYH participation is voluntary & will be available statewide. *[Schools which now have inadequate numbers of certified PE teachers can usually fund PE staffing by re-allocating their existing funds back to PE, without harming academic performance

(Lees & Hopkins, 2013; Rasmussen & Laumann, 2013; RWJF, 2009; Trudeau, 2010; Trudeau & Shephard, 2008; Wilkens et al, 2003); in fact, schools can increase academic success with rigorous PE/moderate-to-vigorous PA (MVPA) (Ahamed et al, 2007: Action School! BC; Castelli

et al, 2007-12; Donnelly et al, 2009: PAAC; Hollar et al, 2010;

Kamijo et al, 2011, 2012). Preliminary slide @11/07/2016.


Why Educators Support Improving PE/PA/HE?


Academic Improvement & Student Engagement

Evidence-based cognitive improvement via effective PE/PA & nutrition

Neuroscience: building physical brain “infrastructure”

capacity for learning

PE/PA/Sports motivate many student to stay in school

Children’s Health

Widespread recognition of health issues & value of school role by

ed leadersFinancial Resources for SchoolsPlaying Offense: New $$ from Health sector into K-12Example: Northern Arizona Healthcare ~$1M/year since 2012 in increased PE & nutrition edLong-term potential: $300M+/year in new money from health sector/budgets into K-12& Defense: Protecting current & future Ed. $$ from Health Cost Tidal WavePhysical & mental health-related absenteeism, dropping out--hurts ADA & enrollment-based fundingRapidly rising school district health insurance costsFuture threat of health-related government & family budget squeezes: health cost pressures on federal & state government spending & on family ability to pay higher taxes for education: our health overrides all other spending prioritiesSlide @11/23/16


Exercise & Nutrition

Improved Math Scores >5%62

Notes: Increase/decrease over 2 years in FCAT (Florida Comprehensive Achievement Test) raw scores among 1197 FRL low-income elementary school children in 4 intervention & 1 control school in an

Osceola, FL school


2003-04 through 2005-06

; non-Hispanic white

students; *reading results were not statistically

significant: HOPS

(Healthier Options for Public Schoolchildren)

intervention: quasi-experimental, nonrandomized study, using healthier schools meals, OrganWise Guys nutrition education; & in Year 2 WISERCISE/TAKE10! desk-side PA intervention (with lessons reinforcing reading & math instruction) as well as structured PA during recess & walking clubs. References: Hollar, D., Messiah, S, & Lopez-Mitnik, G. Effect of a Two-Year Obesity Prevention Intervention on Percentile Changes in Body Mass Index and Academic Performance in Low-Income Elementary School Children. American Journal of Public Health, v. 100 #104 (April 2010), pp.646-53. See also Shephard, 1996: grades 1-6 students receiving 60 minutes more PA than control students during the same length of school day (therefore, 11-12% less academic instructional time) improved academic performance by approx. 0.2 on a grading scale of 1-6. Change over two years in low-income students’ FCAT raw scoreChange in State Test Scores


Why Schools

Essential for Health ?“ed-vaccination”

for healthy behavior: biggest health issues now from behavior, not


Captive long-term audience

: 180 days/year x 13 years


ideal stages for learning

: ages 5-17

Very low cost

per individual: main school/staff costs covered already by public K-12 fundingMany effective, evidence-based approaches: @PE, HE, recess, classroom, before/lunch/after-school, etc.Can influence parents (adults) through childrenLays foundation for personal “ownership” of health, & for adopting future clinical & public health adviceNothing else comes close in low cost total population impact[Alternatives ??: Clinical settings not turning the tide… & Improving adults’ behavior is very expensive & much less effective.]63Slide @11/15/2016


Where HFA Headed?


Our 2020s Goals





obesity, CVD

, etc. trends w/$300-500M/year new, health money to K-12Our Past “Choice”: Neglect  1/3 Diabetic in future Our New Choice: Excellent PE/Health Ed +  Healthy Arizonans (K-12 ed = foundation for lifelong health & for building school & AZ culture of health)1st-Step: Scale-up into all AZ public schools Then: Keep Improving K-12 PE, HE, recess, related programs Add: Other high-ROI approaches before & after K-12Notes: CVD: cardiovascular incl. heart disease. Google images: www. Slide @11/11/2016


Health Care Costs since 1970+“reforming” health care without

preventing the root causes

References:  Organisation

for Economic Co-operation and Development (2010), “OECD Health Data”, 

OECD Health Statistics 



: 10.1787/data-00350-en (Accessed on 14 February 2011


Downloaded 11/20/2014: Research America 2012: Truth and Consequences: Health R&D Spending in US. Notes:  Australia & Japan 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.  Break in series: CAN(1995);  SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in 2008. Slide @12/02/2016Per Capita Health Expenditure, 1970-200865HMO’s will save us!Medicaid capitation, more Medicare reforms will keep costs down!Yet more Medicaid/ Medicare reforms, HSAs, more private insurance co-pays & higher employee % of premiums, surely now…Uhhh…HELP!!!Obamacare will tame costs!..No wait! Repeal & replace !? Ever higher deductibles & premiums…




Federal Health Care Spending

chronic health conditions

increase US debt & grab $$$ from other areas,

including from future generations via national debt & interest payments

Reference: Updated Federal Budget Projections: Fiscal Years 2013 to 2023, CBO, 2013. slide version @10/12/2016


Income Tax Rates Will Get Much Higher

(Again) as wages remain low for most & disposable incomes decline due to rising health costs & national debt grows

 upper-income families will have to subsidize Americans’ future, ever-higher medical bills




: Historical

Marginal Tax Rate for Highest and Lowest Income

Earners.jpg Slide @12/02/2016


68More Slides FYI

References: Fit Kids web site; Stanfield ESD report







PE Teacher


Teacher(s) (Classroom)



School Nurse/

Health Aide

Behavioral Health Prof.

Teacher’s Aide


at School

Close Friends

School Food Services Mgr.

City/Town Council/


School District

County Governing


US Senate

School Board

State Dept. of Ed

County Health Dept.

Parks & Rec. Dept.

State Dept.

of Health

County/City Social Services Dept.

US Dept. of Education


Enrichment Adult

State Legislature: Ed. & Health


USHHS: Other

US House

of Rep.


First Lady



American Academy of Pediatrics

Food & Beverage


(Unhealthy & Healthy)

Food Retailers (mainstream)

State Social Services Depts.


Food Retailers (“food deserts”)

Agribusiness (Unhealthy &


Media & Advertising Cos.

Urban Planners

Local Non-Profit


Health/Social Non-Profits

National/Regional Non-Profits

Health Insurance Cos.




Notes: Illustrative not comprehensive. References: Turner, 2013-17 (


, 1979; Vygotsky, 1978) @09/06/2016

Parents’ Employers’

Insurance/Health/Wellness Plans

Fast Food


State Medicaid

Director & Plans


Influencers of Children’s Health

biggest missing impact:

schools with parents


State Board of Ed

Parents’ Health Care





Social Worker



Major Continual Influencer


Other Key Influencer;

Other Influencer



for Healthy Behavior



Lower government spending; No new taxes;


Not pay for others’ unhealthy behavior;

Choice/avoid mandatory federal system

Democrats Improve health of lower-income families & affordability of health care for allBusinesses Reduce costs, boost profits & productivityHealth Advocates Improve public’s healthEducators Healthier kids; Higher student achievement, engagement; Lower district health costsHC Providers/Plans Better patient health; Lower costs; Long-term financial viabilityNational Security Fit, eligible recruits; More $$ available for Defense Voters/Taxpayers/ Sustainably affordable health care & lower family, USA Deficit/Debt private, Medicaid, Medicare, ACA costsReferences: & & & & at Google images. Slide 09/24/2016


Obesity/Unfitness Severity Worseningthe earlier conditions start, the worse they get later;

10% of teens very obese already

Reference: Teen obesity BMI >=35 kg/m2 = 9.5%, BMI >=40 kg/m2 = 4.3% (“severe/morbidly obese”): Skinner et al, 2016:

Prevalence of obesity and severe obesity in US children, 1999


Sturm & Hattori, 2013. Notes: Obese >30 BMI (Class 1); Seriously Obese >35 BMI (Class 2); Severely/Morbidly Obese >40 BMI (Class 3)=typically >100 lbs. overweight as adult. Sturm & Hattori’s calculation

based on Behavioral Risk Factor Surveillance Survey,



calculated based on self-reported height and weight

. Adjusted line (squares) uses cutpoint of 37.3 for men and 37.0 for women to make it comparable to BMI>40 calculated from objective height and weight measurement. 200 indicates a 200% increase over baseline, i.e. a tripling of baseline rates. Slide @12/02/2016Obesity Prevalence Growth by Severity of Obesity% Increase (baseline 2000)71



Relative health care costs

by BMI/condition

Health Costs

Up with



4-5% of teens; 15.5M+



obese--& increasing fastNotes: Per capita health care expenditures, 2009. Chart: from Underweight on left to Morbidly Obese on right: BMI (kg/m2): <18.5; 18.5-24.9; 25-29.9; 30-34.9; 35-39.9; >=40 (typically >100 lbs. overweight as adult). 4.3% of teens severely/morbidly obese, 2013-14. 15.5M US adults severely/morbidly obese in 2010. References: Arterburn et al, 2005: Impact of morbid obesity on medical expenditures in adults; Skinner et al, 2016: Prevalence of obesity and severe obesity in US children, 1999-2014; Sturm & Hattori, 2013


Unhealthy Body Unhealthy Mind

empower them to be fit physically & fit social-emotionally73

Depression can lead to obesity & obesity can lead to depression

in adolescence & into adulthood

Teen body

dissatisfaction contributor to

anorexia &


Overweight/obesity contributes to

lower grades, dropping out

References: Google images, Mellin et al, 1991; Gustafson-Larson & Terry, 1992; Levine, 1987; Smolak, 2011; Stice, 2002. Depression linked to obesity & obesity linked to depression in adolescence & into adulthood: Marmorstein et al, 2014: Obesity and depression in adolescence and beyond: reciprocal risks


Neuroscience: Evidence on Exercisebuilding physical brain “infrastructure” capacity for learning

74References: Best, 2010;

Chaddock et al, 2010, 2011; Davis et al, 2011; Edwards et al, 2011; Geier et al, 2007; Hillman, 2010; Hollar et al, 2010; Howie & Pate, 2012; Kamijo et al, 2011-2012; Pontifex et al, 2010, 2013; Singh et al, 2012.


Hippocampus &

Basal Ganglia

Improves Executive Function: Interrelationships, Memory, Cognition + Attention/Focus, Behavior, Self-Confidence Better Achievement



Recent News –Brain Size Bottleneck to Learning


References: Mackey, A., Finn, A., et al,

Neuroanatomical Correlates of the Income-Achievement Gap

, Psychological Science, April 2015

Lower-income children have developed



ray matter

Lower achievement (unless we improve nutrition & exercise)


Breakfast in Classroomsall low-income schools should

do this NOW76

Big advantages:

To school early

Start day with healthy nutrition

More regular attendance

Better grades, test scores



, 2014-15)

Reference: Frisvold, D.E.: Nutrition and cognitive achievement: An evaluation of the School Breakfast Program, Journal of Public Economics, December 2014


77Long-term Planning: K-12 PE & Health Ed

need to be as intentional & outcomes-oriented about Physical-Nutrition-Health Ed as other subjects


Curriculum Design Theory






Integration & Articulation

Balance (instruction time + MVPA)Continuity (follow-up/reinforcement)References: Ornstein & Hunkins, 2009; Schiro, 2008; Schunk, 2012; Turner, 2013. Slide @12/06/2016


MS Students Know: “Exercise &

Nutrition Help Me Academically”78

I do WorseI do About Same

I do Better






I do Worse

I do About SameI do BetterPhysical Activity4%49%47%How you do in class when you eat healthy food?How you do in class when have been physically active?References: Turner, 2013 (research in 3 primarily lower-income schools, grades 6-8, in Maricopa County, AZ)


Increased Student Engagement from PE/PAPE/PA/Sports decrease drop-out risks

79MS: PE favorite subject

—1st among males, 2nd among girlsHS: Sports participation most effective extra-curricular activity among teen boys


prevent dropping out



et al, 2013;

Rumberger, 2011;

Google images:,, Also, see Neuroscience & Literature Review slides.


PE/PA/Sports & Student Engagement

Julie Johnston: Dobson HS, Mesa & US Women’s Soccer

“She found school difficult and spent as much time as possible on the soccer field, viewing it as a kind of sanctuary:

‘It was my place that

I felt in control.’

80Note: Julie speaking of transition from Dobson HS to Santa Clara U. Reference: “US Defender is Erasing Her Doubts”, NY Times, June 21, 2015


ROI: There are many worthy causes—but which ones can

impact all Arizonans & have a credible

>100x ROI on a large scale for AZ?81Notes: Total AZ potential benefits include: lower public & private health costs; higher employer productivity & profits; higher employee salary, lower family health insurance & health costs, higher family net disposable income; higher GDP & tax revenues, sustainable tax cuts, more funds for education. See notes on EYH detailed itemized cost slide. References: In order of bullet points: 1)C)





Mensah G., May 23,


2) Kaiser Family Foundation,

2012; 3) Milken Institute, 2007; 4)5)A) Lifetime cost curve: Yamamoto, 2013: Society of Actuaries & Edunuity interpretation; 4)B) Hogstrom & Nordstrom, 2014: based on heart attack incidence; Crump, Sundquist, et al, 2016: based on reduced diabetes incidence; Edunuity interpretations. Preliminary slide @11/11/2016.How?: 1) Prevent major part of the majority of health costs, which result from preventable chronic conditions, caused primarily by lack of physical activity, poor nutrition, smoking (per CDC) 2) Reduce adult Medicaid enrollees with chronic diseases, who cost $5K-$10K+ more/person/yr. 3) Delay or stop the on-set of chronic conditions, by developing healthy habits throughout childhood & laying foundation/realistic opportunity for lifetime of health 4) Cut chronic conditions costing AZ $17B+/yr in lost productivity (absenteeism, presenteeism, etc.) 5) Postpone high costs of late middle-age chronic conditions to Medicare years & reduce severity Details: A) 13 years of K-12 fitness should shift chronic disease on-set 5-10+ years into future B) Teen aerobic fitness correlates with 35% less adult heart disease, 1/2 - 2/3 less diabetes C) 10-20+% reduction in chronic conditions reduces annual health costs by $thousands/person, $billions/state vs. long-term $10M/year AZ EYH investment at-scale & increases productivity 10-20+% through reduced absenteeism & preseenteeismState Government benefits include: EYH-related AHCCCS/other state govt. savings: $200M+/yr. EYH-related GDP growth  new tax revenue: $200M+/yr.


82An “Ounce”/$ of

Prevention vs. “1 lb.”/$$$ “Cure”need low-cost healthy

behavior “ed-vaccinations” at school


Infectious Disease Example

Measles-Mumps-Rubella (MMR) Vaccine: 2x, $40/person

Preventable Chronic Conditions

Empower Youth Health:



./yr. at-scale=~$130/stdt./K-12Fit Kids + other Improved PE/Health Ed.: $100-400/student/year x 13 years“Cure” Costs

Prevention Cost-effectiveness vs. References: CDC, 2015; Reeves, 2016; Cooper Inst., 2014; Ehreth, 2003; Edunuity estimates Slide @12/02/2016

= 21+ times payback from prevention via vaccination

vs. Disease Cost if No MMR vaccine:

>$800 direct medical costs per person

+ poss.




irth defects, brain

damage, deafness, etc.

+ indirect

costs incl. employer/economic

productivity & govt. services

= 10-100+ times payback on prevention

via healthy behavior “



vs. “Cure”

(typically not even a cure,

just “control”=“

disease management


$1000s/year for 20-60 years

in medical & economic costs


Everyone is Paying

(More & More)for everyone else’s

preventable bad health



Medicaid/AHCCCS, Medicare, ACA/“Obamacare”,

Veterans, Federal/military/state/county/muni.


Higher health insurance premiums/co-pays/deduct-

Employees ibles/out-of-pocket, other non-covered health care $$, lower salaries, lost work daysEmployers/ Health insurance premiums, lost work days, Small Biz “presenteeism” & lower productivity, disabilityHospitals/HC ER/other uncompensated care, low reimbursements, Providers quality of care challenges, financial stressHealth Plans/Insurers Unsustainable premium increases, disappearing reserves/surpluses, increasing profit pressureSlide @11/11/2016


Preventable Chronic Health Conditions (PCHC)majority of US health care costs

can be prevented

Total PCHC-related U.S. HC, Social & Economic Costs:

$2+ Trillion/year

Heart Disease

High Blood Pressure

High Cholesterol


Obesity & Overweight

Back & Musculoskeletal

Lung CancerOther incl. AbsenteeismCausesPoor NutritionLow Physical ActivitySmokingExcess AlcoholGeneticsAgeEnvironment/Stress/Other Substance Abuse/Etc.


Notes: PCHC: preventable chronic health condition. References



, 2016:


: treating

people with chronic diseases accounts for 86% of our nation’s health care

cost; half

of all American adults have at least one chronic condition, and almost one of three have multiple chronic

conditions; Mensah


., May 23, 2006:

Global and Domestic Health Priorities: Spotlight on

Chronic Disease

, National

Business Group on Health

webinar: 80% of heart disease & stroke & type-2 diabetes and 40% of cancer is preventable; also see ADA & AHA, 2011-15; Milken, 2007;


estimates. Slide @12/22/2016



Ominous Long-term Wage Trendsin spite of short-term blips, middle class stagnation has lasted 15+ Years

85Reference: Graph of United States income distribution from 1947 through 2007 inclusive, normalized to 2007 dollars. The data source is "Table F-1. Income Limits for Each Fifth and Top 5 Percent of Families (All Races): 1947 to 2007", U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements, as found at


Health Benefits % Compensationhuge impact on school district/govt. budgets, biz profits;& drags down disposable income, even if salary increases

86References: BLS, Employer Costs for

Employee Compensation, March 2015


Health Care Costs Squeeze Schools/Employers & Employeesschool districts, other organizations harmed & employee disposable income drops

Reference: Council of Economic Advisers, 2009



Health Costs Consuming More & More Family Income

average household loses $$ hundreds of thousands over lifetime due to preventable health costs88

Notes: Chart based on employees of large employers. Definitions (KFF): “Deductibles: set dollar amounts that enrollees must pay before their plan starts to cover the service or a group of services (e.g. $200 drug deductible before drug coverage begins); Coinsurance: a percentage of the allowed cost for covered services (e.g. 20% of the allowed cost for a specialist visit); Copayments: set dollar amounts for covered services (e.g. $20 per general physician visit)”.References: From WSJ 06/30/2016: The Next Big Debate in Health Care by Drew Altman. Sources: Kaiser Family Foundation analysis of


Health Analytics


Claims and Encounters Database, 2004-2014; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 2004-2014 (April to April).

Average household

savings impact: Google images: Epi-pen: Slide @01/08/2017

recent example:



Unhealthy Behavior is Indebting Future Generationsfirst time in history we are not

paying down debt after crisis spending89Note: Different definition than IMF. IMF includes debt held by both public & government accounts, CBO includes only debt held by public. References: CBO,

2015 Long-Term Budget Outlook


Congressional Budget Office.

Details: Historical

Data on Federal Debt Held by the Public (July 2010),


The Greatest GenerationThe Greediest Generation?


Subsidizing our

Unhealthy Behavior

by Borrowing from the (Grand-)Kids via national debt90

Current Taxpayers




References: Google images:;;


, 2015


Ominous AZ Demographic Trends

greater poverty = higher health, welfare & prison spending later

91References: U.S. Census Bureau: Current Population Survey, "Historical Poverty Tables: State Poverty Rates, Three-Year Averages" (2012) and American Community Survey 2011, "Percent of Children Under 18 Years Below Poverty Level in the Past 12

Months"; ADE, State Summary by Grade of Pupil Enrollment, FY 2013-14 Race/Ethnicity; ADHS, 2011-12: Natality: Maternal characteristics and newborn’s health


Increasing Obesity/Unfitness

AZ nearing US levels & higher % starting in childhood--but also an opportunity to turnaround AZ before exceed US averages




AZ: National

Survey of Children’s Health (NSCH)(parent-reported), 2004,

2011. YRBS data self-reported by teens is lower. Physically measured 2012-2015 BMI data from southern Tucson K-12 schools imply that BMI among lower-income students in AZ is much higher than teen self-reported rates.


measures BMI physically & would provide objective data. USA: Adolescents: Ogden

et al, 2010 (1976-80=1980); National Center for Health Statistics. Health, United States, 2011: With Special Features on Socioeconomic Status and Health. Hyattsville, MD, USDHHS, 2012 (mean); FitnessGram & southern AZ child obesity results--actual measured not self-reported--from EYH study (Reeves, 2016); same with northern AZ child obesity data from Fit Kids (DeHeer, 2014) ; Adults: Ibid + CDC, 2015:; RWJF, 2013-15:; CDC, 2015: Slide@02/05/2017Lower-income teens20-30%obeseBTW: AZ relies on data self-reported by teenagers


Teen Unfitness: National Security Risk

ineligibility to enlist (+ USA health-related-deficit-spending risk to defense spending)


Notes: QMA=Qualified Military Available. References: WSJ, June 27, 2014:

Recruits’ Ineligibility Tests the Military

. Army Strong Obesity Update

, July 1, 2013 file:///C:/Users/Scott/Downloads/SAY%20Meeting%2031%20JUL%20Obesity%20Challenges.pdf


Health Costs: the New Middle Class Threat

income taxes are no longer inflicting the most pain94

Notes: Taxes & health expenditures as % of before-tax income. Middle household income quintile [40%-60%]. Taxes as categorized by BLS consist primarily of federal, state and local income taxes, and exclude social security tax, real estate property tax and sales tax. Health costs include all household health expenditures including insurance and out-of-pocket spending on health care. References: BLS Consumer Expenditure Survey, 1988 & 2013

% Before-tax Income,

Middle Household Income Quintile


95SB 1508: EYH, 2016 Session

(Begay; Dial, Driggs)—1st year attempted, but “we have not yet begun to fight”


2-Year Scaling Pilot, from 20 to 90 Schools Statewide

Voluntary; Lower-income Public District & Charter Schools

$470K Appropriation for FY 2017/2018

50%-50% State-Private Match

Fitness Assessed regularly & objectively w/


*, etc.

Cost $10/Student/Year at-scaleKey: Training PE & Classroom Teachers & MS & HS Student “Clubs” (peer-led activity): how-to lead Moderate-to-Vigorous Physical Activity (MVPA) before/during/after-school  60 minutes/dayCredible GoalsBased on EYH Track Record & Future Health Cost Savings & Economic/Productivity Impact from Better Health: Short-term: Increase % Fit Students 4x to >80% Long-term: Decrease AHCCCS by >$200M/year Increase GDP >$2B, Tax Rev. >$200M/yr.Min. 40x ROI for State Budget, 100x for AZRationaleFor 2/3 of lower-income students, lifelong unfitness & chronic health conditions unless effective K-12 PE/PA Building on proven EYH program now in 20 lower-income AZ schools, with 4x improvement in 3 years: <20% fit  ~80% fitRe-building PE at very low cost by re-training existing PE & classroom teachers, plus student-volunteers, without adding school staff & $$$$MVPA proven to improve brain, academic resultsKids improve parents’ health, too, as happened with anti-smoking ed. in schoolsCDC: majority of health costs due to preventable chronic health conditions (diabetes, heart disease, obesity, etc.); main root causes are lack of physical activity, poor nutrition, smokingIt’s doable—but we aren’t doing: smokers down from 42% to 17% of Americans, but we haven’t seriously tried to increase children’s exercise & improve their nutrition habitsMiddle-class families’ health spending doubling, destroying family budgets (everyone paying for everyone else’s unhealthy habits)National security risk: 28% unfit recruitsAZ & EYH: achieving a lot with a littleNote: 2016 AZ legislative session; *FitnessGram = successor to Presidential Physical Fitness Test; @11/11/2016 contact: 602-513-0028


Rapid Payback in Childhood

Details & References—additional (draft)


References include:


et al, 2009; Fullerton et al, 2012;


et al, 2007; Katz et al, 2010;


et al, 2011; MACPAC, 2015; Pelham et al, 2007;

Schuch et al, 2016; Skinner et al, 2016; Thapar et al, 2012; Wang et al, 2005. More Notes & References: see Payback Details slide; includes Edunuity estimates. Slide @10/16/2016


Potential to Shift

Current HC Costs & Trajectories



Relative cost of health care by

age; actual costs in 2010.

References: Yamamoto, 2013: Society of


Slide @



Potential to Shift Current

HC Costs & TrajectoriesOlder adults – Medicare years (cont’d)



Relative cost of health care by

age; actual costs in 2010.

References: Yamamoto, 2013: Society of


Slide @



Checklist  Fit Schools

School Wellness Policy/PlanEYH Standards*

Comprehensive TrainingOn-going SupportFitnessGram (PYFP)YRBS Health SurveyFidelity & Accountability QC, M&E 60 Minutes MVPA/day[**Breakfast in Classroom][**Policies with Coalition]





PE, PA, nutrition, health)

Broadly agreed school-wide

actions; change school’s health cultureWell-trained PE teacher(s) with classroom teachersTrained & guided student-led initiatives to peersMultiple mutually reinforcing events, programsContinuously improving resultsMore nutritious yet tasty meals, less junk in schoolsMore brain capacity & higher functioningRegular oversight, monitoring, management[*Potential policies: Public accountability & transparency; pay-for-perf. = results  more $$ invested  more savings; EYH results into school grading formula as extra credit to maximize attention, effort & impact on kids’ fitness/health]99ActionsOutcomesNotes: EYH Standards include CSPAP: Comprehensive School Physical Activity Programming & recess improvement, too. FitnessGram is successor to Presidential Physical Fitness Test & is integral part of PYFP: Presidential Youth Fitness Program. QC=quality control. M&E=monitoring & evaluation. (MV)PA= (moderate-to-vigorous) physical activity. YRBS=Youth Risk Behavioral Survey. [**Policy recommendations by Edunuity are not an integral part of EYH, but would improve fitness, nutrition & academics.] Refs.: EYH/Edunuity, 2012-16. Slide @08/31/2016.




101Next Steps to

PartnerFund continued scaling of Empower Youth Health

to increase healthy behavior of hundreds of thousands of students- in lower-income & other schools TBD, with both private & public monies- HC providers/plans contribute $$ - building on prevention


e.g., 15


nonsmoker health insurance premium discounts; vaccines reimbursed

(rationale: encourage healthy nonsmoking behavior, reduce infection risk

 lower long-term health costs)  Set aside min. 0.1%+ of chronic conditions revenues/costs to invest in prevention $$ pool - (local HC providers & other county/local agencies help fund their communities) - long-term private health org. funding goal: $100-200M/year pay-for-health-outcomes-performance- Legislative appropriations: new and/or re-allocated growing to $100M/year (but not from existing ed or AHCCCS funding) - CMS/federal monies: growing to $100-200M/year (but not from existing AHCCCS funding) - %’s & $$ amounts/outcome metrics/accountability mechanisms/governance etc. to be agreedPay-for-performance: one-time commitment, then co-invest more in future only as agreed outcomes are achievedShared costs (investments in education)  shared benefits (reduced health-related costs/spending): - Low-cost, effective prevention reduces chronic condition HC costs/spending for: government agencies, health care plans & providers, school districts, employers, subscribers, taxpayers, etc. - Matching-funding: mutual motivation & cost-sharing by linking public & private investments“Speed of business” EYH w/Playworks + other health-related initiatives TBD - working title: Health Future Arizona (HFA) - Highly results-oriented, accountable culture & shared multi-sector governance including key fundersMeetings ASAP to define, launch HFA; seeking “early champions”: Founder-Partners; take concrete steps in mid-late 2016 - funding: HC industry prevention $, Foundation/other $ commitments (initial scaling + capacity-building) - then in 2017: Governor’s budget, AZ Legislature appropriations; CMS/Medicaid/AHCCCS discussion draft slide version @10/12/2016