Gov. Huckabee gives student Julie Nolan a ride on his back, to demonstrate that before he changed his eating habits, it was like carrying her around all the time.

Healthy Arkansas Initiative

Even before undergoing his own personal health transformation, Gov. Huckabee had established himself as a leader in improving the quality of health care for Arkansas natives. He received national recognition for creating the ARKids First program, which provided health insurance to tens of thousands of children who previously had no access to health insurance. The governor also was instrumental in the passage of a ballot initiative in 2000 requiring that all of the state’s tobacco settlement money be devoted to improving the health of Arkansans.

In May 2004, Gov. Huckabee launched his most ambitious program to date: Healthy Arkansas (www.arkansas.gov/ha), an initiative to create incentives and offer information to help Arkansans eat healthier, exercise more, and stop smoking—in short, to transform one of the nation’s unhealthiest states into one of the healthiest.

According to a 2001 report from the federal Centers for Disease Control and Prevention (CDC), Arkansas ranked first among the 50 states in stroke mortality, sixth in deaths due to lung cancer, eight in mortality due to heart disease, and ninth in cancer mortality.

Gov. Huckabee after completing the Firecracker 5K Race.

These frightening statistics were a direct reflection of the prevalence of obesity, tobacco use, and physical inactivity among Arkansans. The 2002 Behavioral Risk Factor Surveillance Study found that 37% of Arkansas adults were overweight, 24% were obese, 27% engaged in no exercise or leisure-time physical activity, and 26% were current smokers. In the previous decade, the state’s number of obese adults had climbed 80%.

Health indicators among Arkansas youth were equally worrisome. The Youth Risk Behavior Survey of 2001 found that 14% of Arkansas youth were overweight, 34% did not get enough regular exercise, and 19% were current smokers. According to CDC projections, nearly 10,000 Arkansas youth were likely to die from smoking-related causes, a figure 11% above the national average.

“We must convince Arkansans that the key to real change is a behavioral change,” Gov. Huckabee noted in announcing the initiative. “We eat the wrong foods. We smoke too much. We don’t exercise enough. If a person maintains a normal body weight, exercises at least three times each week, and doesn’t use tobacco, that person will live an average of 13 years longer than he or she would live otherwise.”

Using existing resources and funding sources, Healthy Arkansas seeks to achieve the following goals by January 2007:

• Increase from 64% to 85% the percentage of juveniles who are active at least three times a week for at least 20 minutes.
• Increase from 15% to 30% the percentage of adults who exercise at least three times a week for at least 30 minutes.
• Reduce the percentage of obese children from 11% to 5%.
• Reduce the percentage of obese adults from 23% to 15%.
• Reduce the percentage of adolescents who smoke from 36% to 16%.
• Reduce the percentage of adults who smoke from 24% to 12%.

PARTNERING WITH PRESIDENT CLINTON Among the many people impressed with Healthy Arkansas and Gov. Huckabee’s personal health transformation is former President Bill Clinton. Earlier this year, the former president asked Gov. Huckabee to join him as co-chairman of the newly formed Clinton Foundation-American Heart Association (AHA) alliance to fight childhood obesity. Alarmed by the rising tide of childhood obesity and the threat it poses to the nation’s health and wealth, the AHA approached former President Clinton in an effort to address the problem from multiple vantage points. The threat can hardly be overstated: growing numbers of American children are afflicted by a broad range of obesity-fueled conditions that previously were not seen until adulthood, including type II diabetes, high blood pressure, and elevated cholesterol. And overweight children and adolescents have a 70% chance of becoming overweight adults, greatly increasing their risk for heart disease and other chronic diseases. The Clinton Foundation-AHA alliance will target a variety of audiences— consumers, industry, health care providers, schools, and the media—and focus on several key areas that can have a dramatic impact on the lifestyles and behaviors of children. For example, the alliance intends to work with restaurants, manufacturers of packaged consumer foods, food service companies, and other food industry groups to make changes that encourage children to eat healthier. Like Gov. Huckabee’s Healthy America campaign, the Clinton Foundation-AHA alliance will work with school and community leaders to develop healthier food options and more opportunities for physical activity during and after school hours. As Gov. Huckabee noted in announcing the Healthy Arkansas initiative, “Our society has become sedentary, and our country’s current culture of inactivity and overeating poses disturbing dangers for our nation’s young people. In the last two decades alone, the percentage of overweight youth in this country has nearly tripled, and the trends are only getting worse. If we are not careful, this epidemic will threaten the health and well-being of an entire generation of young people.”

Diabetes Education Improves Health, Controls Costs

Nowhere has Gov. Huckabee and the state of Arkansas moved more aggressively than in the area of diabetes intervention. The state’s Diabetes Disease Management Program is a unique public-private partnership that brings together agencies and organizations as diverse as Eli Lilly and Company, the Arkansas Department of Human Services, and the Arkansas Department of Health’s Diabetes Control and Prevention Program.

Working with Eli Lilly, which supplies diabetes medications to the state, Arkansas has opened 24 diabetes education centers around the state for residents who want to learn more about managing their diabetes. The program emphasizes face-to-face consultation between trained diabetes educators and patients. Patients are taught how to make positive lifestyle changes, with specific information provided on topics ranging from diabetes medications to the importance of exercise, eating healthy, and effectively managing stress.

For Arkansas and other states, controlling the rising tide of type II diabetes is more than a matter of physical health—the state’s fiscal health is equally at stake. The US Department of Health and Human Services reports that someone in the US is diagnosed with diabetes every 25 seconds. Direct medical costs attributable to the disease are estimated at $130 billion. And according to the CDC, an astonishing one in three US children born in the year 2000 will develop diabetes without proper intervention.

In Arkansas, where the prevalence of diabetes climbed 35% from 1993 to 2002, controlling diabetes is essential to reining in explosive growth in the state’s Medicaid budget. Medicaid insures nearly one quarter of the state’s population. Arkansas’ annual Medicaid budget now tops $3 billion—up from approximately $600,000 just 10 years ago—and is growing at an annual rate of about 9%.

“We must rein in the cost of this program,” Gov. Huckabee said in announcing the Healthy Arkansas initiative. “Five percent of the Medicaid cases are taking 50% of the Medicaid budget. We have to change people’s behavior. Otherwise, the growth of Medicaid will continue to erode the resources we have for public education, public safety, and other parts of the state budget.”

Pilot Program Shows Promising Results

Initial results involving a sample of Arkansas Medicaid patients with diabetes demonstrate the benefits of the state’s aggressive education and intervention approach. This trial study tracked 212 Medicaid recipients with diabetes from 60 counties. The study subjects were referred to certified diabetes education centers throughout the state, where they underwent an hour-long initial assessment of individual training needs—more than they likely have ever received from their personal physician.

Over the next year, each participant received 12 hours of group or individual instruction on nutrition and diabetes self-management. Working with nurses, registered dietitians, and diabetes educators, the program participants learned how to monitor their blood glucose levels, were taught how to self-examine eyes, feet, and skin for diabetes-related circulatory problems, received counseling on the importance of exercise and stress management, and were shown how to make healthy food choices and adopt better cooking habits. Participants were even taken on a “field trip” to a local grocery store, where educators demonstrated the importance of understanding food labeling.

Initial data from the study found a 27% increase in the number of subjects whose average blood sugar level met American Diabetes Association (ADA) recommendations. The number of patients who screened positive for symptoms of depression dropped 10%, while the number exceeding recommended blood pressure levels fell 7%. The frequency of self-monitoring of blood glucose levels rose 21%, while daily foot exams increased by 8%.

Moreover, over one year, mean HbA1c—a critical marker of blood glucose control—declined 0.4 percentage points among subjects who completed the program. “Studies show that tight blood glucose control, sustained over time (as measured by HbA1c), slows the development of diabetes-related complications, such as eye, kidney, and nerve diseases that can lead to amputations,” according to Carol Hendrickson of the ADA’s Leadership Council. “In fact, research has shown that for every 1 percentage-point drop in HbA1c (e.g., from 9% to 8%), there is a 35% reduction in the risk for diabetes-related complications.”

The Arkansas researchers believe that the state’s diabetes intervention program can reduce resource utilization among Medicaid recipients within one year and is likely to improve diabetes outcomes over time at little or no cost. The program’s success has prompted the state Department of Health to open an additional 18 ADA-certified disease management sites, targeting counties with the highest number of diabetes patients.

“We learned a lot from this effort,” Gov. Huckabee noted. “We discovered that when we can identify those who suffer from diabetes and then provide them with free, close-to-home help, it makes a huge difference in their lives, the Medicaid program, and the state’s economy.”

SHOULD GOVERNMENT BE THE “GREASE POLICE”? The growing epidemic of obesity and its associated costs have led some to call for greater government involvement in Americans’ eating choices. As Gov. Huckabee notes in his book, “some of the same people who demand that government stay out of our bedrooms are demanding that it take over the kitchen!” This is an approach the governor adamantly opposes: “We do not need the government to become the ‘grease police,’ dictating what size cheeseburger the law will allow or taxing obese people at a different rate than thin people because of the likelihood of additional health care costs associated with obesity.” Gov. Huckabee points out that efforts to dictate or restrict personal behavior in private homes or businesses invariably shifts the focus from a discussion of health to one of personal rights. Instead, he favors creating a culture of health that encourages and rewards people for making healthy choices. “Historically, telling liberty-loving Americans what they can and cannot do has not proven very successful,” he notes. “What does work is changing the culture so that individual choices become cultural choices and ultimately the behavioral norm. Smoking is increasingly considered boorish and invasive behavior, not so much because of a government-sponsored ban as because people are more aware of the health risk and find the practice annoying and disgusting.”

Rewarding Healthy Behavior

While Healthy Arkansas seeks to reduce obesity, tobacco use, and physical inactivity among all Arkansans, included in this broad initiative are several programs that specifically target Medicaid recipients and state employees.

Shortly after unveiling Healthy Arkansas, for example, Gov. Huckabee announced that the state would implement a series of steps to reduce smoking among state employees and Medicaid recipients. A policy directive ordered state agencies to ban smoking within 25 feet of the entrances to state buildings. Each state agency was directed to study a potential smoking ban on all state property. Both the state Health Department and the University of Arkansas for Medical Sciences implemented complete smoking bans on their property.

Rather than simply banning or discouraging smoking, however, the governor has implemented innovative measures to encourage healthy behavior. Although traditional health insurance policies do not generally cover services that help people quit smoking, Gov. Huckabee asked the Arkansas State and Public School Life and Health Insurance Board to amend state employee health insurance policies to cover nicotine patches and similar smoking-cessation aids. The Board oversees health insurance policies covering more than 63,000 state employees and their dependents, as well as nearly 71,000 public school teachers and their dependents. He also asked the Board to explore financial and other incentives that could be offered to state employees who voluntarily participate in programs that reward healthy behavior. Today, state employees receive nutrition counseling, “walking breaks” instead of smoking breaks, and discounted health insurance premiums if they agree to undergo a voluntary personal health-risk assessment.

Gov. Huckabee extended similar incentives to the state’s nearly 600,000 Medicaid recipients, directing the Department of Human Services to expand Medicaid coverage to pay for nicotine patches and similar smoking-cessation tools. According to a recent national study, 26% of all adult Medicaid recipients in Arkansas used tobacco products in 2002, costing the state an estimated $540 million. Nationally, approximately one of every seven dollars spent on Medicaid is related to tobacco use.

“If we’re going to urge smokers to quit, we must support their efforts by doing things such as paying for nicotine patches,” says Gov. Huckabee. “It’s not fair to ask people to help if their health insurance plans won’t cover their cessation efforts. We must make such tools available to state employees and to those receiving Medicaid benefits.

“Those who don’t smoke cost health plans less money. Allocating funds for cessation programs thus saves us money in the long run.”

BMI PROGRAM TARGETS CHILDHOOD OBESITY One of Gov. Huckabee’s first pioneering statewide health initiatives was creation of the Arkansas Body Mass Index (BMI) School Program in 2003. With this program, Arkansas became the first state in the nation to address the growing epidemic of childhood obesity. BMI assessment is used as a screening tool to determine whether a child is overweight, underweight, or at risk of becoming overweight or underweight. Because preventing and treating childhood obesity is more effective than treating obesity in adults, the American Academy of Pediatrics recommends BMI screening for all children and adolescents. Under the Arkansas program, each child’s height, weight, and BMI is measured, and an individualized report is mailed to parents, along with an explanation of BMI. If a child is overweight, additional suggestions concerning diet and activities are provided, and parents are encouraged to discuss the results with their family physician. In addition to providing individualized information to parents, the program is compiling BMI data by school district and statewide. The results will be used to target problem areas and to assess the program’s overall effectiveness.

From Healthy Arkansas to Healthy America

Gov. Huckabee hopes to see other states—and America itself—follow Arkansas’ lead in creating incentives for healthy behavior. “Ultimately, it is my hope and goal that Healthy Arkansas will spread like a highly contagious but benevolent virus that could become the genesis of ‘Healthy America,’” he writes. “I’d like to see all 50 states find creative ways to reward positive behavior rather than continually pay absurd amounts of money for the catastrophic results of bad behavior and health.”