The headquarters of the state agency that handles chronic disease sits on the seventh floor of the Oregon State Office Building in Portland.
It overlooks one of the healthiest parts of the state.
Across the Willamette River, one can see the entirety of the city’s Pearl District — a healthy living hub where it’s easy to grab a kale shake on the way to a trendy cardio-kickboxing class.
But what that view doesn’t show is the massive health crisis going on in Oregon.
One out of every two people who live here suffer a reduced quality of life and die early deaths from chronic diseases like heart disease, diabetes and stroke.
And each year, Oregonians spend a staggering $8 billion on health care related to these conditions, accounting for about 85 cents of every health care dollar spent.
The answer to the state’s most expensive health issue is largely simple: get people to move more, drink less and quit smoking. But how the state can do that remains a complex question with mostly elusive answers.
For years, the health experts in the Oregon Health Department’s Chronic Disease Section came up with extensive plans to treat individual chronic diseases.
“I have a stack of strategic plans in my office this high,” said Karen Girard, chronic disease prevention manager, raising her hand to indicate a sizable stack of health promotion materials.
Those plans created a complex web of approaches, but failed to address the symbiotic nature of chronic diseases. For example, if you smoke, you’re more likely to be overweight, and if you’re overweight, you’re more likely to develop diabetes and heart disease. Therefore, if a person has a chronic disease, they become progressively sicker over time and costs rack up.
So in 2012, the state tried a new tack. It crafted a five-year chronic disease master plan intended to address these problems comprehensively.
Over those five years, the roughly 50 state health workers who focus almost exclusively on chronic disease created informational websites, supported tobacco quit hotlines and produced videos of Oregonians whose health is affected by where they live.
They worked with lawmakers to restrict smoking across the state and helped county-level health workers develop their own programs to address chronic diseases.
And in the past five years, Oregon budgeted an average $20.4 million annually to the Chronic Disease Section.
But for all that effort, the state’s plan — which expires June 30 — has failed to meet nearly all its goals.
Where The Plan Failed
The top-tier goals of Oregon’s five-year plan were to sharply cut tobacco use, slow a surging obesity epidemic and reduce heart disease, stroke and colorectal cancer in Oregon.
But since 2012, heart attack hospitalizations have risen significantly. Colorectal cancer diagnoses are up. And diabetes has surged.
In fact, Oregon consistently leads most Western states in factors that lead to chronic diseases such as obesity, high blood pressure and smoking rate.
Oregonians are getting fatter, too; around 30 percent of adults are obese, up from 28 percent in 2012, according to survey data from the U.S. Centers for Disease Control and Prevention.
To be sure, obesity isn’t increasing as fast now in Oregon as it was around the turn of the century — rising from 11.2 percent in 1990 to more than 25 percent in 2007. But a 2 percent increase is still significant and amounts to around 80,000 more people, roughly the population of Medford.
“We have seen huge increases in obesity and overweight, which then result in real chronic disease issues,” said Kirsten Aird, the manager of Oregon’s chronic disease programs.
Data from the past five years punches a hole in Oregon’s reputation for healthy living. And that hole reveals that health problems among rural Oregonians, Native populations and the Willamette Valley’s poorest communities could cost people here billions more in years to come.
Even more troubling: The most significant increases in obesity since 2012 have been among children. That’s a bad sign for the future health of the state.
Goals for the strategic plan in 2012 were to keep obesity among 11th graders stagnant at 10 percent. As of this year, that numbers stands at 13.2 percent. Obesity is also up among eighth graders.
Though there has been a lack of progress, state health officials managing chronic disease said they’ve learned a lot from their five-year plan.
“I think for healthy eating and active living, what we have done well is collect data that continues to tell us there is more work to be done,” Aird said.
Aird and her colleagues said a major issue in reaching the least healthy Oregonians has been a lack of funding for chronic disease prevention.
“Unfortunately, we don’t have the kinds of resources in Oregon that we would like to be able to address this really complex and important issue,” Girard said.
Because states tend to take very different approaches to addressing chronic disease, it is difficult to compare Oregon to other states in terms of its spending efficiency and efficacy.
But part of the problem may be in how the state can spend money.
The Chronic Disease Section depends heavily on federal funds and grants, which carry spending restrictions to target specific problems — primarily tobacco use. That means Oregon struggles to address issues like obesity and diabetes, where there aren’t as many dollars focused exclusively on those problems.
Additionally, chronic diseases haven’t historically received as much focused spending attention as other conditions.
Oregonians may spend more than $8 billion each year on medical costs related to chronic diseases, but over the past five years the state has only spent an average $20.4 million per year to address the problem. That’s equivalent to three-one-thousandths of a penny on prevention for every $1 spent on medical costs.
Comparatively, Oregonians spend about $3.6 billion each year on medical costs related to cancer — less than half the cost of chronic disease. Yet in 2015 alone, state lawmakers set aside $200 million to help fund the Knight Cancer Institute at Oregon Health and Science University and its lofty goal “to end cancer as we know it.”
“I wouldn’t say it’s a big mystery of what we should do,” said Luci Longoria, an Oregon health promotion manager. “It’s just a matter of will and resourcing to make it happen.”
Without targeted funding, it can be challenging for public health workers to address disparities, like food deserts, that can greatly affect health in Oregon’s poorest communities.
Still, not all the five-year plan’s failings come down to money.
Many of those educational videos created by the division were posted to an obscure website and have only been viewed a few dozen times. That suggests prevention efforts are not reaching the people who need them most.
And members of the Chronic Disease Section expressed surprise OPB had even heard of the strategic plan when first contacted for this story.
Oregon media also bear some blame, often focusing health care coverage on isolated studies that make for a catchy headline or flashy projects like Phil and Penny Knight’s $500 million donation toward the cancer research institute that bears their name.
A Success And Lessons Learned
Despite the setbacks over the past five years, Oregon has seen significant improvement in one chronic disease area: smoking cessation.
In 2012, 20 percent of adult Oregonians smoked tobacco. But concerted efforts under the plan have brought that number down to 17 percent this year.
“What have we done?” Longoria said. “We’ve established smoke-free housing, smoke-free community colleges. Your K-12 grade schools are all tobacco-free campuses. Work places are smoke free.”
Oregon has also increased tobacco taxes, and lawmakers are poised to raise the statewide legal smoking age to 21 this year.
The focused efforts on tobacco have worked, with Oregon hitting every one of its smoking prevention goals listed in the five-year strategic plan.
Longoria said the state plans to keep its foot on the gas pedal when its next five-year strategic plan launches later this year. That plan will use the lessons learned from tobacco reduction efforts to reduce those smoking rates even further. It will focus mainly on tobacco use in the service industry and so-called “sweet tobacco products” aimed at children, which include fruit– and chocolate-flavored tobacco products that are often designed to look like candy packages.
Taking a page from the anti-tobacco playbook may also hold the key to fixing Oregon’s other rampant chronic diseases, Longoria said.
“How can we take what we’ve learned from that and apply it to support people’s nutrition goals? How can we take it and apply it to people’s physical activity goals?” she said.
Those lessons include finding regulations that keep tobacco out of people’s hands and creating supportive work and public areas that encourage people to avoid smoking.
Just how the state plans to achieve similar interventions for junk food and physical activity without the same kind of funding it receives for tobacco, however, remains a question.
A majority of the state’s budget for chronic disease prevention is earmarked for tobacco. Of the $102.2 million spent over the course of the strategic plan, around $51.3 million has been specifically for tobacco.
Potential funding sources do technically exist: federal grants, a sugary beverage tax likely headed to Multnomah County voters, or health care providers and businesses looking to spend on prevention.
What’s not clear is whether any of that money will actually materialize in the next five years.
But even without funding, Longoria and her colleagues said they’ve learned the state needs to spend more time trying to turn around the obesity epidemic.
She said that means creating a “supportive environment” for people who want to improve their health, just as the state did for people who wanted to quit smoking.
“Unless we really start making the investment in preventing this upstream,” Longoria said, “we’re just going to continue to increase the amount of cost we will all bear.”
Copyright 2017 Oregon Public Broadcasting