Government Can Create Incentives for Healthy Behavior, Says Arkansas Governor

By: Johns Hopkins Bloomberg School of Public Health – Health Policy and Management

[MUSIC PLAYING] SPEAKER 1: My name is [? Saidu ?] [? Dean, ?] and I am the chief resident for the general preventive medicine residency program here at the School of Public Health. I would like to welcome you all who've braved the snow to come out here this afternoon to our second in a series of four preventive medicine grand rounds sponsored by the residency program. Our first, some of you may remember, was by Carla [? Damus ?] from the March of Dimes and was on preterm birth in the US. Our third grand rounds will be by Dr. William [? Yasnaf ?] who's a senior advisor with the national health information infrastructure from the Department of Health and Human Services. And he will be talking about information technology and public health. We are very fortunate tonight to have a very distinguished speaker come and address us at this. And the title of our grand rounds is "Can Government Force Changes in Health Behavior?" This is one of our endowed lectureships named in honor of Douglas Coleman.

At this time, I'd like to turn over the podium to Dr. Bob Lawrence, who is our associate dean for professional practice and programs, who will briefly talk about Mr. Coleman and also introduce our special speaker.

Thank you. BOB LAWRENCE: Thank you, [? Saidu, ?] and welcome, everyone. We are in for a treat. We're very pleased to have Governor Huckabee and his wife with us today from Arkansas. Let me just say a word about the Douglas Coleman Lecture and to recognize and welcome Jane [? Lamont, ?] Dr.

Coleman's daughter, and representing the family today. There's a description of Douglas Coleman in the brochure that I commend all of you to read. I just want to pick out a couple of details, though, because the history of the relationship between linking public access to health care with private insurance really began with Douglas Coleman's work establishing the Associated Hospitals Service of Baltimore. And I'm sure as Governor Huckabee worries about the Medicaid budget in Arkansas, that he would love to have the day when it was possible for $0.75 a week, I think it was-- no, a month-- $0.75 a month to get coverage for health care in 15 of the hospitals of greater Baltimore, including the Johns Hopkins Hospital. After serving in that capacity of starting this program, having it evolve into Blue Cross Blue Shield of Maryland, Mr.

Government Can Create Incentives for Healthy Behavior, Says Arkansas Governor

Coleman served as deputy director of the Johns Hopkins Hospital. And when he died, the President Emeritus of the hospital, Russell Nelson, established the Coleman Lectureship about 30 years ago. So there's a long and wonderful tradition of bringing distinguished speakers to the school to talk in the tradition of Douglas Coleman.

So we're pleased, especially today, to have governor Huckabee with us. Governor Mike Huckabee from Arkansas is a national leader in the area of education reform. He's currently the chairman of the Education Commission of the States and will lead that until July 2006. The Educational Commission of the States helps governors, legislators, state education officials, and others identify, develop, and implement public policies to improve student learning at all levels. So I assume that some of the things you consider would be helpful to us in figuring out how to take our graduate students to new heights of learning. We have a very wonderful, active, and engaged student body here.

In addition to his education reform efforts, Governor Huckabee has been a leader in improving health care for the citizens of Arkansas. He created the Ark Kids First programs, a national recognized initiative that provides health insurance to tens of thousands of children who previously had no access to health insurance. He also led a ballot initiative five years ago that devotes all of the state's tobacco settlement money to improve the health of Arkansans. And he recently announced the Healthy Arkansas Initiative to encourage Arkansans stop smoking, exercise more, and eat healthier. In 1997, the Governor's book, Character is the Issue, was published by Broadman & Holman. It Chronicled the governor's political career and discusses the importance of character in politics and in life. The following year, the governor published, Kids Who Kill, a book that addresses the issues of juvenile violence-- a topic that many of us are concerned about here in the city of Baltimore.

And his third book, Living Beyond Your Lifetime, was released in 2007. And it examines how to establish a legacy that will live on after one's death. And any of you who were moved by that to operationalize it, Sally O'Brien would be happy to talk to you after the lecture today. We're always trying to build our modest endowment, right? The governor currently serves as vice chairman of the National Governors Association and will assume the chairmanship this coming July. And as many of you know who follow national politics, the National Governors Association is an important forum for bringing the issues of the states to focus and to influence federal policy and legislation. Finally, the governor and Mrs. Huckabee, Janet, have three grown children-- John Mark, David, and Sarah. And the Huckabees enjoy reading.

And the governor plays bass guitar in his band, Capital Offense. And unfortunately, I've been with the governor for few minutes before this presentation. I didn't see any sign of that bass guitar around. So I guess we're not going to have music today. But it is such a pleasure to welcome you to the school, and Mrs. Huckabee to have you here too. And we look forward to hearing your discussion of how government can help people be healthier. [APPLAUSE] MIKE HUCKABEE: Well, thank you very much, Dr.

Lawrence. Let me begin by saying it's a real pleasure to get an opportunity to speak to a prestigious group like this out of state. And one of the reasons is because when I'm in introduced in Arkansas, nobody believes all that stuff.

And it's a delight when you go elsewhere, and people read these lovely things in your biography. And you know that there may be someone who would be even amazingly naive enough to believe all of those things. This is an extraordinary opportunity for us to talk about health. And for me, it is more than just a topic, it's also a personal crusade that I'll share the reasons why momentarily.

When I ask, now what is it exactly you want me to do when I come up here? I said, for me to go into a room full of doctors and public health officials, it's a little intimidating. And quite frankly, like a lot of people, I don't go to the doctor until I really have to. I don't hang around professional medical people unless I really have to. Doctors and nurses have not been particularly kind to me in my life. My experience with them is not a pleasant one and not one that I would go and invite myself to experience unless it was absolutely necessary. Because I find that no matter what you say about politicians and how we are terrible about using euphemisms, and how we say one thing but really means something else-- I believe you guys are worse than we've ever been-- much worse. For example, I've been to the doctor's office. The nurse will say, you're going to feel a little stick.

[LAUGHTER] That's a lie. You're going to feel like you've been stabbed by the Hell's Angels. And she knows that. But she tells you something different. Or when the doctor says, "This won't hurt much." My favorite is-- and only the men in the room will completely understand this-- when he says, "This might make you feel a little uncomfortable." [LAUGHTER] Gentlemen, this will making a very uncomfortable, let me assure you. And the fact is that when we're finished with all of these ways in which doctors and nurses put us in these humiliating situations and go through parts of us that we've never even seen, then when they're finished, somehow, amazingly, we say, thank you so very much. And we pay a handsome bill for all of it. But I asked, exactly what is it you want me to do? And they said, well, we'd like you to talk about the relationship of government and how it can affect public policy as it relates to health.

I said, fine. Any parameters of the speech? They said, well, we'd like for you to keep it just as brief as possible to allow some time for questions. And I said, how brief? They said, well, as brief as possible. That's a very, very ambiguous thing to tell a politician.

Now I won't be as brief as the freshman student at Harvard in the literacy class who was given an assignment by his writing professor. And the student was told, now, you're to write an essay. I want you to cover four subjects-- religion, royalty, sex, and mystery. You'll be judged on your ability to touch all four of those subjects. But the primary essence of your grade will come from your ability to touch those four subjects with the greatest level of brevity possible. By the way, the winning student, who received the A for the course, had a very simple essay. It went like this. "My God," said the queen, "I'm pregnant.

I wonder who did it." That was the essay. [LAUGHTER] So I'm going to try to get to some of the issues at hand. But in doing so, I also want to say that being a governor is a great, great, great privilege. It's a wonderful job.

And every governor I know would probably tell you it's the best job he or she ever had. A lot of my governor friends who end up going to the United States Senate say, boy, that was the better job. Because in the Senate, we talk. We argue.

We never get anything done. Being a governor, you can wake up in the morning. You can have an idea.

And by that afternoon, you can often have it actually in play. And it is a fascinating opportunity because you can make things happen as the chief executive officer of a state. Governors typically are the CEO, if you will, of the largest enterprise in their states. In Arkansas, for example, as a governor, I actually oversee more employees than any other entity in the entire state. In the private sector, it would take the combined employees of both Walmart and Tyson to equal the number of state employees that we have. Now that's not all the Walmart's worldwide employees, but the Walmart entity in Arkansas, which is huge.

Because we have almost 60,000 state employees. Walmart employs about 28,000 in the state. So to put that in perspective also, it also would mean that we're responsible for overseeing the health benefit packages for those state employees and the retirees. And then in a state like Arkansas with 2.7 million people, we have 717,000 that are on our Medicaid program. So as governor, I'm also overseeing the largest health insurance concern. The amount of pharmaceuticals alone that we purchase in our state is almost twice as much as the next purchaser, which is the Blue Cross Blue Shield system of our state-- the largest insurer in the private sector. Health care, therefore, is an issue that we literally have to touch every single day.

As a governor, I do get to do some fun things. And occasionally, some of them are once in a lifetime. Flying in the cockpit of an F-16 was one of those great experiences, by the way, doing barrel rolls and all sorts of things. Because as commander in chief of the Air National Guard, I was invited to take a trip, and I did. And so if you think public health is not exactly where you want to be, you might consider running for governor because of the cool things you get to do. And that was a cool thing I got to do. Let me share another experience that was not quite as much fun. But it certainly was exhilarating.

The current Health and Human Services Secretary, Michael Leavitt was governor of Utah. Mike was a good friend of mine-- still is. At least, I hope he still is. And back in February of 2001, Michael Leavitt invited me to come to Utah for a conference he was putting together. He invited four governors to come out and spend a weekend to talk about economic development in our states and ideas to share. And so we agreed to come.

On that Friday night, we gathered at the hotel for the conference. And we spoke and answered questions. And Mike got up at the end. And he says, now tomorrow, we have a very special day planned for all of you that are here at the conference. We're going to all go out to Olympic Village, where the 2002 Olympics will be staged.

Much of it is already in place and built. And you're going to be able to experience firsthand the Olympic Village and see and meet the athletes that are in training. And we have a special treat. We'll also get to witness the first ever Governors' Bobsled Race.

I thought, oh, clever idea. He's going to get us out there. They'll name a bobsled after each of the governors.

And then we'll get to watch them and cheer them on. But as he talked, it sounded very much like he was intimating that the governors were going to be in the bobsleds. Now maybe for you that wouldn't be problematic.

But for me it was because I've never seen a bobsled in person. I live in Arkansas in the deep south. Snow is unusual for us. We don't see it often. And when we do, we don't know what to do with it-- absolutely have no clue.

And we darn sure never see bobsleds. And the only bobsled I really remember seeing was the one on the opening scenes at ABC Wide World of Sports where the ski jumper goes off, and he lands very gracefully. And the announcer says, "The thrill of victory." and then a bobsled goes careening off the side of a mountain with people most likely being decapitated. And the announcer says, "And the agony of defeat." That's my image of a bobsled. So I go up to Mike after the program. And I said, Mike, you are kidding about the bobsled deal. He said, no, no, no, it's fine. Don't worry.

I said, no, I'm going to worry. I said, Mike, I don't know anything about bobsleds. He said, don't worry we're going to give you some training in the morning before you have to actually drive the bobsled.

Drive it? My word, I thought it was going to be bad enough I was going to ride it. Now you want me to drive it? He says, don't worry. We're going to give you some training. Back at the hotel that night, I logged on with my laptop to the internet and started doing a search on bobsleds. I wanted to see, what am I getting into? Occasionally, it's better not to know. Because frankly, the more I learned about bobsleds, the more I realized I had no business getting in one. Bobsleds by the Olympic athletes go up to 92 miles an hour.

Mike had assured me that because we were amateurs, we wouldn't get about 75. What a comfort. I found out that in a two-man bobsled, you have two people. You have a driver who steers the skids by these aircraft cables attached to the front skids. You have six to eight degrees turning ratio. In the back, you have what's called a brakeman, which is a weird title for someone because there are no brakes on a bobsled.

But his job is to push you over the crest of the hill until you get some momentum. Then he jumps in behind it. And he has no other purpose other than to help serve as part of the gravity force that carries you down. And so we get out there the next day. I am absolutely terrified. I'm trying to talk the other governors out of this whole crazy idea. Because I figured that if I could get all of us to say no, we wouldn't do it. But I don't want to be the only one to say no because then they call me a wuss.

I didn't want that. I had this image, however, that late that night, there would be a little blip on CNN News. The governor of Arkansas tragically killed in Utah today when the darn fool tried to drive a bobsled when he'd never even seen one. All the other governors were from snowbelt states. And they were all in. They were excited about it. So I knew that for the honor and prestige of my state, I could not just forego this experience. Then they introduced me to my trainer-- a 16-year-old kid who's a junior Olympic athlete who's a bobsledder.

No offense, but I don't want to learn how to drive anything from a 16-year-old kid. And the way you learn to drive a bobsled, they put spikes on your boots. And you get at the bottom of the track, which is one mile in length.

And with the spikes on your feet at the bottom of the track, you walk up the entire track from bottom to top. And in each of the curves-- 13 in all-- the kid describes the curve, the nuances, of it and says, "Now when we get to like number 12, you wanna put the skids like here because if you get him way up here, you'll like go off. And that's not good. And if you get the skids way down here in the rut, then we'll bounce back and forth against the walls.

And that'll hurt." We go to number 11, he describes where it needs to be there, and then number 10, and right on up to the top. And by the time we get to the top, I'm first of all, exhausted. Secondly, I'm hyperventilating in part from exhaustion, in part because of sheer terror. And the guys at the top who are supposed to get us prepared into the bobsled say, you guys ready? My question was, what, to meet Jesus? What am I ready for? Terrified to death, they squeeze me down into the bobsled. The kid pushes off, and we go down. But before we left, he gave me a piece of advice that probably saved my life and also helped us to come in second. And it turned out that it was better than all the other things he had said, and really the only thing I needed to know about driving a bobsled. Here's what he said.

He said, now when we get up there and we come off the crest, and we're picking up our speed-- he said-- the speed is going to come at us so fast, you're going to be amazed. He said, remember this-- that the speed at which we're traveling is such that as soon as we come off the crest, look down the hill. And look at the curve in front of us. You already need to be steering for it as soon as you see it because once we're in that curve, centrifugal force is such that it's too late to make any adjustments to what we're doing. And once we're past the curve, forget about it because the ice behind us can't hurt us. And the only thing we've really got to deal with is that curve ahead. And so as soon as we get through that curve, you'll see the next one.

Steer for it the moment you see it. Don't look at anything but the curve ahead. Just keep your focus on the curve ahead.

And we'll be fine. And you know something? I got to thinking about the advice that kid gave me. And I realized he had not just given me advice for how to survive a bobsled ride. That kid had really given me pretty good advice for everything from running a business to running a marriage to being governor of a state, and now to make the application, to quite frankly, looking at the public health issue in America. Because one of the problems we're facing today in public health is that for many people, the issue is looking at the right now and saying, we have a real crisis on our hands. And we do. If you happened to see yesterday's USA Today.

And I happened to see it in an airplane. It was interesting. I just picked it up. And the front page of the front section-- "Health Care Tab Ready to Explode, Cost of $3.6 Trillion Projected by 2014." And it's a lengthy article, the front lead story on yesterday's USA Today about how the health care costs of America are absolutely overwhelming us. Then I turn to the Money section. And on the front top of that section yesterday-- same paper-- "Salads Grow into Profitable Garden of Eatin'." And it talks about how that eating at fast food restaurants are now pushing salads and that salad is the fastest growing industry because people are finally beginning to wake up to the fact that we are a very obese country and that we can't sustain it.

I can tell you that when the governors meet this weekend in Washington for the beginning of the National Governors Association, one of the topics we'll be talking about most is going to be, what are we going to do with the runaway cost of Medicaid? And Medicaid is running away from us, much like a bobsled-- out of control from the top of the hill, and there are no brakes on it. I told you that 717,000 people in my relatively small state are on Medicaid. When I became governor 8 and 1/2 years ago, we had less than 400,000 people who were recipients of Medicaid.

It's not that we've expanded the roles because we just went out and found how many people might be able to get a piece of it. It's not that we went out and opened up the eligibility roles. It's the fact that we have that many more people who are now qualifying for Medicaid, in part because we have a huge population of baby boomers who are aging, retiring, getting into long-term care, spending down their assets, and having no other place to go but the Medicaid system.

We have an enormous number of people who, because they are often single parents, have children who have no health coverage whatsoever. Their employers are no longer able to afford it. And while we can point our fingers and say, the private sector ought to be forced to it, the truth is, many companies would be out of business-- particularly small businesses-- if they were forced to pay the kind of premiums they would have to pay to insure people who could go bankrupt them because of chronic illness. And so they just dropped coverage all together. That drives those people into the Medicaid system. Our Medicaid budget in 1996, when I became governor, was $600 million.

Today, it is $3.3 billion dollars. It is growing at double digits every year. And that's not unique to Arkansas. Every state in the country is experiencing that-- every one of them. It doesn't matter whether they're led by a Democrat or a Republican governor. It doesn't matter whether it's east coast, west coast, heartland. It doesn't matter whether it's north, south, urban, or rural. It's happening across America.

And the fact is that we have a crisis on our hands that's both a financial and a health crisis. And in large measure, one of the things that's happened is that we continue to focus upon, how in the world are we going to put more money into a system to treat people's diseases, particularly chronic diseases? To put it in perspective, the Medicaid budget in my state that I just described, we did a survey. We found that 77% of the people who are getting Medicaid benefits in Arkansas have a chronic disease-- a chronic disease. You in public health know far better than me, 100 years ago, the real issues in America were the infectious diseases.

We had people dying because of infectious diseases. But because of good public health policy, we pretty well fixed that. We don't have too many people saying, oh, my nephew died of cholera. Boy that yellow fever that swept through Colorado, it got a lot of folks, didn't it? You don't hear that anymore. But we're dying because of chronic disease.

And it's killing us-- and in particular, chronic diseases caused by our own lifestyles. We eat too much. We smoke.

And we don't exercise. And those three behaviors, perhaps other than anything else, are contributing to the incredible cost. And it's finally beginning to not only catch up with us financially, but it's getting to the point that we're waking up. Those of us having to make budget decisions are beginning to realize, we've got a real problem on our hands. You know, I grew up in the South. I grew up where we fry all the food we eat.

[LAUGHTER] If you want to eat fried food, come to the south. You can't avoid it. Whatever it is that you eat somewhere else, we'll fry it before we eat it there. [LAUGHTER] Come to the state fair in Arkansas. And we literally-- I'm not making this up. This is one of those Dave Barry "I'm not making this up." You can get a fried Twinkie.

As if a Twinkie isn't bad enough, we will take the Twinkie. We will add batter, deep fry it, take it out of the batter, and then sprinkle an enormous level of powdered sugar on it, and then sell it to you for $2. Would you like one of those? Now if you don't go in for the fried Twinkies, we have fried Oreos. Take an Oreo, batter it, fry it, sprinkle the powdered sugar on it. Fried pickles, we got them. Onions, we fry them. Chicken-- fried, fish-- fried.

Vegetables, doesn't matter what kind-- tomatoes, potatoes, zucchini, whatever-- fried. We fry everything. I grew up that way. I also grew up in a family that was relatively poor.

I didn't know until I was in high school that the reason we were eating so much macaroni and gravy on everything wasn't because we were lucky. It was because that's all we could afford. And a whole lot of families in the south-- and it's true in other parts of the country as well-- end up with a cultural issue of being both culturally southern, which means we fry it, but, then also growing up poor which means we pick the foods that stretch our food dollars. But they also are the foods that stretch our waistlines. And suddenly, we have an incredible obesity crisis in America that is just about to crush us. And to us a very bad pun we're just about to die under the weight of obesity in America.

60% of the adults in Arkansas are either overweight or obese. And two years ago, we became the first state in the nation that requires every public school student to receive a test to determine his or her body mass index. And it was controversial at the beginning because a lot of people thought, whoa, what are you going to do-- go in and pinch those little kids with a caliper in front of everybody else and say, good gosh, kid, you're fat. [LAUGHTER] And so we had people so worried that's what we were going to do.

Well, it's not what we, obviously, were doing. We had to explain that a body mass index was, in essence, taking their height, and weight, and taking the scientific formula. And then we would send that report not home in the report card, not posting it on the wall so that every kid could see, but sending it discreetly and confidentially in the mail to the parents. And we said, we do vision screenings for children because we want to know, can they see the board? We do hearing screenings for kids because we don't know, can they hear the teacher? Do they need to be up front or maybe get a hearing device? Because they can't learn if they can't see or they can't hear. But the truth is if they are already seriously obese when they're seven or eight years old, and they're headed towards some serious health crises, they're not going to be able to learn because they're going to truly have some major problems. Arkansas Children's Hospital is a wonderful, wonderful pediatric hospital, a renowned hospital.

And 15 years ago, Arkansas Children's Hospital had never seen a preteen case of type 2 diabetes. They'd never had one. If someone had come in and presented for one, they probably would have said, there's something wrong with the test. Today, they're seeing seven and eight cases a week of kids as young as eight years old who are coming in who are type 2 diabetic. We no longer can even call it adult onset of diabetes because there are too many kids getting it. And the kids who are being diagnosed as type 2 diabetics when they're preteen are going to have vision problems by their 20s, heart attacks by their 30s, full kidney dialysis by 40, and they'll probably never live to see a 50th birthday. We're now living with a generation of young American kids-- the first generation since this country's founding over 200 years ago where that generation is not expected to live as long a lifespan as their parents and grandparents and all because of a lifestyle of overeating and inactivity.

Now why should I be such an expert on this? Because until two years ago, I was the poster child for everything we shouldn't do. I lived a life of inactivity. And I lived a life of my only real exercise was the second trip to the buffet. And my weight had ballooned to 110 pounds above what it is today-- to between 280 and 300 pounds. If you look at pictures of me two years ago and today, you'd say, good gosh, was this like a brother, an older brother of yours? And I'd say, no I don't know the guy.

But I didn't just know him. I was him. When my doctor sat me down a little over two years ago and said, well, congratulations. You're finally what I said you were going to be-- you're diabetic. It really shook me up. Two parents who are diabetic, two grandparents who are diabetic-- I knew better.

I'm a college educated guy. I'm not stupid. Well, you judge for yourself after the speech.

You may say that's questionable. But it wasn't that I didn't have enough information or knowledge about what causes diabetes, and what the risk factors were, and what the genetic propensity was because of parents and grandparents who had already been diagnosed that way while they were alive. It was that I just didn't really feel a sense of urgency to change my lifestyle. And frankly, when I had tried-- and I had tried. And I had succeeded dieting many, many times but then never could keep it.

I finally just had given up. And I resigned myself and I'm just big boned. You ever heard that one-- big boned? It's amazing that the bones aren't nearly as big as all the flesh that surrounds them once you gain the weight. But that was one of my excuses. Or hey, this is a genetic thing. All my family has been this way. Or I could say, hey, this is a southern thing.

This is just the way we are. We eat the foods we eat. That's what we do. I could even say it's a religious thing. And it was because I was Baptist. You wonder, what the heck does that have to do with anything? Well, you'd have to live down in the south and be a Baptist to understand this. But let me put it this way. When I was in elementary school, the teacher said, now tomorrow, we're going to have a show and tell.

And the topic is religion. So you can bring any object of your personal religion. And you can explain it to the class.

So the next day, a little Catholic boy came. And he brought a rosary. And he explained that. A little Jewish girl came. And she brought a menorah. And she was explaining that.

I was called on. And being a Baptist, I bought a covered dish. [LAUGHTER] It's the only symbol of the faith I really knew or understood. [LAUGHTER] But no matter what kind of cultural influences I had had, the truth was I was the way I was by my own choices. And I had made really, really bad ones. And I decided that I had to make some changes. There were several factors.

One was fitness. I was sick and tired of being sick and tired. That's how I felt all the time.

Secondly, my own faith really was a factor in it. I knew I was not being a good steward of my body. My faith leads me to believe that God created me, and I will go back to him. But I knew I was going back a lot sooner than he originally intended with the way I was living. And that wasn't a good thing. I saw friends, close friends, who had heart attacks-- and one in particular, a former governor, Frank White, a good friend of mine. His wife came home one afternoon and found him dead. Frank had gained an enormous amount of weight.

I had seen him the week before he died. He could barely walk across the room without huffing and puffing he was so out of breath. And I told my wife, I said, if I don't make some changes, I'm going to be just like Frank. I won't live to as many years as he did. And my doctor had set me down and said, if you don't make some changes, you're in the last decade of your life. And I was thinking, this is insane.

This isn't how I want to be. I went to our medical school in Little Rock. Dr. Philip Kern is an endocrinologist who specializes in the study of metabolism. I enrolled in the program, and I said, I need help. And so I learned really from start to scratch what I needed to be eating and how I needed to change lifestyle. As he and my family doctor have often said, this isn't rocket science.

If you consume fewer calories and you burn more through exercise, you will lose weight. But I tell people, I did not go on a diet. I did not have a weight loss goal because I'd done that before. I could tell you about every diet out there-- Atkins, Fen-Phen, The Zone-- you name them. I tried everything. They work while you're on them. Problem is they don't sustain. And I came to understand that the reason that diets don't work is because diets have a beginning and an ending.

And what we have to do is not simply get people on programs. We have to help people come to the place where they change lifestyles. And so for me when people said, how much weight are you going to try to lose? I said, I don't have a weight goal. They looked at me like I was crazy. I said, no, I don't have a weight goal.

I'm not trying to look good. I have a goal of health and fitness. And so I don't know what that weight is. But I'll know when my blood pressure, my blood sugar, my cholesterol, and all those markers look like that of a normal person my age rather than a man who's 25 years older than I'm supposed to be. What I really set out thinking mentally was if I lose 30 40 pounds, that'll be pretty good.

It never occurred to me that I'd end up losing 110. It never occurred to me that I'd go from being a total couch potato who could barely walk up a flight of stairs at the capitol always nervous that a gaggle of reporters would be at the top waiting for me with microphones, and they would ambush me with some question. And there I'd be on camera that night on the 6 o'clock news sweating like a pig, out of breath, looking like Mike Wallace had just come up against me with a microphone-- not because their questions scared me-- because I was exhausted from one single flight of stairs.

I went from that to a person who, a week from Sunday, I'll be running in the Little Rock Marathon-- 26.2 miles. And by the way, I'm going to finish that darned thing too. I'm going to run two marathons that day-- my first and my last I think. I ran my 20-miler a couple of weeks ago and lived to tell about it. You've got to understand. Two years ago, I couldn't have run 20 yards, much less 20 city blocks.

It is an absolute miracle. People every day come up to me and say, if you can do it, so can I. Now, let me get to the heart of things.

And then we're going to have some questions. We've got to change the paradigm of health care in America. I've told you my personal story. But let's translate it now into, how do we change public policy? The mission of the health care industry in America has been, how do we spend more money treating disease? That's got to change. It's got to become, how do we prevent the disease in the first place? We spend all of our assets and resources on treating the diseases rather than on preventing them and creating a culture of wellness and health. My health insurance, as a state employee if I were to have a quadruple bypass, would pay $100,000 to have that surgery done. My disability insurance would kick in and pay to cover the time I'm off. It would give me rehab.

All of those things would be covered. It would be an incredible medical bill of several hundred thousand dollars. But if I wanted to join a weight loss program, go through a group setting where I get some counseling and nutrition counseling, or if I wanted to go see a nutrition counselor-- it wouldn't pay a dime. I'm on my own. There's something really, really warped about the way we've approached it. That's why our state started saying, if we want people to quit smoking, why don't we change the rules? So we became the first state in the country to say that if you'll quit smoking and you're on Medicaid, we'll give you the tools. We'll give you the counseling.

We'll put you on the patch. We'll do what it takes. Because if we're asking you to get off the addiction of nicotine, which is killing you and killing our budget, then will help you do it. We won't just say, you oughta quit. We'll help you.

We now do-- we started in the governor's office. We're now moving it into state agencies where we realize that active employees are more productive employees. So we're giving employees 30 minutes a day if they'll exercise vigorously.

And that's not a trip down the mall. It's not like you just go shopping and call it exercise. But we'll give you 30 minutes a day so you can exercise. Because we know that if you'll get out there and move those muscles, the time you're sitting at your desk, you're going to be more productive. We know that a smoker costs the employer a month a year in lost productivity because of sitting out there in the cold smoking and because of the additional absenteeism as a result of the tobacco smoke and of all the things that go with it-- the chronic diseases, and the colds, and the flus, and all the things that a person is more likely to get because of the smoking addiction.

So we're trying to say, you'll quit smoking, we'll help give you the tools. We've declared all of our buildings smoke free. Now we're doing a lot of things incrementally because if you just got there and say one day, you can do this, and the next day you can't do anything.

We're working right now with our Department of Human Services. We're designing a program. We're going to present to the Department of Agriculture. We may be told no. But here's what I'd like to do. I'd like to let them give us the authority to do an experimental program to take the food stamp program that we operate in our state under the Department of Agriculture and to do this. To say if you'll buy healthy, organic, whole foods, fresh fruits, fresh vegetables with those food stamp dollars, we will leverage your food stamp dollars and actually give you more value to give you more purchasing power. By the same token, if you want to buy junk foods, and processed foods, stuff full of partially hydrogenated vegetable oil, and high fructose corn syrup, and stuff that will kill you, then that's fine.

But we're going to decrease the amount of your buying power on that food stamp. We use not stamps but EBT cards which are like debit cards. And we can program that in electronically and make it work. It's a matter of getting the details worked out. We're going to try to do. That I hope we can do it and prove that when people are empowered to buy healthier foods, they'll do so.

There's some good things going on out here. For the first time last summer, McDonald's in July sold more salads than they did french fries. That had never happened in their history. The market is beginning to demand some new changes. I met with the executives of Kraft Foods a couple of weeks ago in Washington. You may remember Kraft has just announced they're going to start making Oreo cookies with a non-trans fat recipe.

They are changing their marketing to kids. And they're no longer going to market their heavily trans fatty-filled foods to kids on Saturday morning during the cartoons. They're accepting some responsibility. Last week, I was in Orlando, Florida speaking to the group of executives of Novartis who manufacture Gerber, who are changing the formulas in some of their foods and trying to make a healthier product and realize some corporate responsibility.

There are some good things happening out there in the public sector, some very, very good things happening, where people are beginning to realize that's where the market is going. Now the question is, what's government's role? Well, I think government certainly has several responsibilities. But the first one is to determine its basic agenda. Dr.

Faye Bozeman, our Department of Health director puts it this way. We either have to decide if we're going to treat snake bites or if we're going to kill snakes. And frankly, we need to do more snake killing and lot less snake bite treating. And that means, start putting the focus on wellness, prevention, and helping people to adopt and adapt to a healthier lifestyle as opposed to just saying, we've got all kinds of medicine. We can treat you when you really, really get sick.

Boy, we've found some new surgical modalities so that if you really, really mess your body up, we can go in there and rewire you. Better to say, this is what you would end up being. But there's a better way. It's called a healthy lifestyle. And by not smoking; by maintaining a normal body weight; and by eating nutritious, healthy foods; getting at least three good workouts a week of 30 minutes or more per workout-- you can extend your life by 13 years. That's a more positive message. We established 24 diabetes education centers in Arkansas, primarily in the most impoverished areas of the Arkansas Delta, where we have a huge concentration of African-American population far more likely to be hypertensive and far more likely to be type 2 diabetic.

It's a partnership with Eli Lilly and Company who have worked with us. We're finding some amazing results where significant percentages of those populations are now getting real education. They're really getting a counselor to sit down with them and talk to them and walk with them through the process of grocery purchasing, and eating habits, and exercise habits, and accountability. Because quite frankly, most physicians are too busy to take the time. They can't possibly do that level and intensity of counseling. But the diabetes education centers are providing that. I mentioned already the body mass index. And to some, that was controversial, to a few.

I still get some nasty letters from people thinking that's intrusive. But my response to it is-- here's the deal. You're saying government has no business testing the body mass index of a child. But you know what? If your child is a type 2 diabetic, and he has to go on dialysis by the time he's 25, guess who's going to foot the bill? We are. So if you don't mind, we're going to go ahead and test him. We'll send it to you.

And I hope as a parent, you'll get in the game with this and realize that if you've got a kid who's ballooning incredibly in his weight condition while he's 12 years old, there's a good chance this kid's on his way to a train wreck. And he's going to hit it before I ever did. So let's do something to start working on it now.

And a whole lot of it is just activity. We found that a lot of kids, it's not that the caloric intake is so much significantly different than it was before. But what's really different is they're not doing anything other than sitting down in front of a screen with a joystick or a remote control in their hand. Some of it is because people are afraid to turn the kids loose in the neighborhoods because of predators. And kids are living behind locked doors. But some of it is just because it's easier to let a kid park in front of a computer screen than it is to insist that he get out and do some exercise and engage in some activity.

Whatever the reason is, we've got to create a sense in which the culture of America is moved toward activity. That's why we started a major program partnering with our parks and tourism department to build walking trails not only in urban areas but rural areas as well. So they can come to a central area and have walking trails. To begin things such as we mentioned our program, where we take all of our money in the tobacco settlement, and we put it back into health care, I think we're the only state still doing that. Most of the states have diverted those monies into things that are absolute nonsense.

It's really to me shameful and disgraceful what has happened with a lot of that money. I want to tell you a story about a kid named Billy. He's 16 years old in El Dorado, Arkansas.

He got his BMI test. Billy weighed 230 pounds-- 16. That BMI test was a wake-up call for Billy. He hated being teased at school.

He didn't like it that the kids picked on him. He knew he was overweight. By the way, as an overweight person who's been there, you don't have to tell an overweight person he or she is overweight. It's not like we don't know.

You know that every time you try to get up out of a theater seat, and you have to have help getting out of it. There are a whole lot of reasons. When people say, you know, you put on a few pounds. Really? Hadn't noticed.

Is that why the belt won't work anymore? [LAUGHTER] And like so many people, Billy knew he was overweight. But the BMI test that came to his parents was a wake-up call for Billy. Billy got some counseling from his school, from his doctor. And over the next several months, Billy ended up losing 72 pounds.

He graduated from El Dorado high school as a kid of almost 18 and now understands a little bit about fitness. But one of the reasons I defend the BMI test is because it's moments like that that made a difference for Billy. The mistakes that we make, sometimes we think that if we can just force people to change their behaviors, they will. Government can do many things. We can create policies that create incentives. That's what we're trying to do. We do now where if a state employee will take a health risk assessment, we'll give you $20 a month off your health insurance. It's $240 a year.

It's not a lot of money. But you know when we first offered it last fall, 18,000 state employees immediately signed up for it. We know we'll double that next year.

Because a lot of them were afraid of, what is this going to do if I reveal to you my health habits and my weight and things? But now they realize we're simply assessing the health risk. We're beginning to develop programs for state employees targeting to those risks. And if they'll give us that information so that we can begin to tailor to the specific needs, then they, in turn, are going to get a reward of $20 a month.

We're trying to move now to the second tier of that, which will be that additional discounts and even a point system so that if you don't smoke-- so many points; regularly exercise-- so many points. If you are a person who maintains normal body weight, you get additional points. If you eat healthy food, so many points. And your points add up. And you get additional days off.

We'll give you time off as a state employee. And it'll take us probably eight months to a year to get that fully integrated and developed. But what we're trying to do is to say, let's, rather than just say, we're going to penalize you for your bad behavior, let's reward you for your good behavior. Let's create an atmosphere in which the tide, if you will, or the stream is moving in the right way, rather than demanding that people swim upstream in a way they've never experienced before. What I've found that doesn't work-- and when we've tried it, it always is a disaster-- is when government is asked to become, what I call, "the grease police," monitoring and even regulating the size of a cheeseburger that someone can eat. I've not found that particularly effective.

And here's why-- Americans are many things. But what we are most is that we are independent, liberty-loving folks who are extraordinarily particular about somebody telling us what we will do. We don't mind people telling us what we ought to do.

But we darn sure don't appreciate it when someone tells us what we will do and gives us no option. And what happens is that when we make it an absolute prohibition and we take things away from people without their consent, the whole issue moves from one of good health to personal rights. We do not want this issue to become an issue of fighting over rights. We want it to be an issue of fighting over longevity and good health. That's why I've told people I'm not interested in becoming the sugar sheriff of Arkansas. What I do want to do is to, by both example and by the establishment of our public policy, make a significant difference in what we do for the people who are trying to be healthy and to make it such an attractive offering that people say, why wouldn't I want to be that way? Why wouldn't I like to trade my monthly prescription bill for a trip to Disney, or whatever it is you might want to use the money with? Why wouldn't I want to have extra days off rather than have to go and gruel out extra time because I'm wasting my employer's money with my smoking addiction or my being obese? We've never faced, perhaps, any more urgent crisis as we do the crisis of obesity and bad health. Those of you in this room, quite frankly, are the front line soldiers of that war. And like in any war, the front line soldiers are the first to get shot at.

Don't expect you're going to be met with an extraordinary sense of applause and appreciation for what you're going to try to do. But I also want to tell you the reason that I came here today and that I gladly accepted the invitation-- beyond the fact that it's an extraordinary honor and pleasure to be at a prestigious institution, like Johns Hopkins. The other reason is because I want to encourage you, as the people who are going to be setting the policy in public health, to realize that you really are on a mission that is most important and a mission that can help change America and give us years and years of good, healthy, wholesome living. You can give grandparents years to enjoy grandkids. You can give little kids the opportunity to be fit and healthy, to be able to walk up a flight of stairs and not be exhausted from it. You can help create a culture that gives us a sense of health wealth, just like we have had in financial wealth.

In part, one of the reasons I believe that we are so overweight and the reason that we are so unfit is because we are the victims of our own success as a country. We have cars-- not one. We have several in most families.

So we can ride and drive places when other people would have to walk in most countries of the world. We go into our food stores. And we don't have one or two choices of cereal, we have three shelves full. And because we have disposable wealth that most folks don't have, we ear 45% of our meals outside the home. Can you imagine that? 45% of our meals we don't even eat at home. And many of them are eating out of paper sacks and boxes. And we're eating them as we are going.

And we don't have any clue the calorie content, the fat content, saturated fat that's in those boxes. Because frankly, we don't have time to read the label. We're in a hurry because we're making more money.

We're making more appointments. We're doing things. One of the things my doctor told me, he says, adopt the philosophy that it comes through a car window, it isn't food. [LAUGHTER] I found that to be a pretty darn good rule of thumb.

And so these days, I literally carry a cooler with me because I travel a lot. People say, how do you find the time to exercise? I say, I don't find time. I make it.

You don't find time. I have appointments all day long. I make an appointment to exercise just like I do an appointment to meet legislators, our business interests, or whoever else. I do it early in the morning.

For me, I get up at 4:30. That's when I do it. But I make an appointment.

I do it because I know that if I don't make the time, I'll never find the time. We never find those times. How do we eat healthy? I don't get to choose most of the meals I eat. As a governor, I'm usually speaking at a breakfast, a lunch, at a dinner. I'm standing at some reception. Rarely is it that I'm actually just sitting there saying, oh let's just see what I'd like to eat today because I'm somewhere else with somebody else planning the menu. So what I do? Pack a little cooler with me.

I take turkey breast, and apples, and strawberries, and things that I know are healthy and whole. I carry it with me. Does it look kind of goofy walking around with a cooler? Who cares? They'll be dead. And I'll still be walking around in a cooler. But the issue here-- take charge of our own health because nobody else is going to help us quite like we can ourselves. And that's the message that we've got to get to America. You can't start and end with government.

Government definitely has a role. But I want to say you guys, perhaps as much as anybody, you're going to have to help make this all come alive for the American public. And I wish you well as you go out and help people like me to make significant, even radical, lifestyle changes that can help us live even beyond our lifetime. And with that, I'll pause.

And I'll take questions til they stand up and say, that's it. You're finished. You're through, which will probably come very soon. But just, I guess, come to this microphone if you have a question. SPEAKER 1: We can pass the microphone. Mike huckabee: ok. That's fine. Anybody-- question, comment, retort, rebuttal, rebuke? We've got one over here on this side of the room right over here.

SPEAKER 2: Sorry. This is the exercise moment. He runs from this side to that side. AUDIENCE: I guess I was wondering if you see a parallel role for government incentives in either regulating school diet in conjunction with the BMI program or encouraging availability of fresh fruit and vegetables in grocery stores where people, who use the food stamp cards tend to shop, so like a parallel regulation.

MIKE HUCKABEE: I think there is a parallel. One of the things that the BMI index gives us in Arkansas is a baseline of every student in the state. By testing 400,000 school kids-- every public school kid in every school-- we actually have a baseline, not only of individuals.

But we can sort it out by any demographic level we want. We can sort it out by school. What we're doing now is we're gauging, what's the impact of vending machines? Now, we've outlawed vending machines completely for elementary schools. They're not allowed. High school campuses can have them. The question is, how big of an impact do the vending machines really have on obesity? Some people say we ought to get rid of them. And maybe we should. And probably, we will, quite frankly.

But before we make that change, the fact is we want to see, what level of impact this it having? Here's what I think we're gonna find. It may have a minimal impact. But the bigger impact is that even if you remove the machines, the kids are bringing the powdered donuts from home. They're eating breakfast out of a paper sack from the fast food places before they ever get to the school and when they go home, they're eating pizza and other things that have very little nutritional content. I'm not sure that that's going to make a huge difference. But we're going to know because what we're going to do-- we've got three different test groups-- one, no vending machines at all. The other test group, we're gonna have vending machines but healthy choice offerings in them-- bottled water, bottled juice without the sugary soft drinks.

And the other test group will have the traditional vending machine fare. We'll know the baseline before and the baseline after and see, is there any marked change by the presence or absence of those products and the availability of them? So it's going to be a good opportunity. Then, we'll have some true scientific evidence on which I think could be made a rational decision not just for Arkansas, but for other states as well as for that one component.

But that's just one thing. As it relates to the grocery stores-- and I agree with you. We do need to start changing not only school lunch menus, but the availability of fresh fruits and vegetables. However, let me say the encouraging news-- the article that I read from US News yesterday on the issue of salads-- is that nationwide fresh cut lettuce will become a $3 billion industry this year, up from just $900 million in 1995. What's happening is the consumers are beginning to realize that lettuce might be better for them than white bread. Yes.

AUDIENCE: Hi. First I have a comment and then I have a question. My comment is just how impressed I am how you've been leading by example, both for your state, the state of Arkansas, for the rest of the nation, as well as personally what you've done with losing your weight, and changing your lifestyle, and also running a marathon. I personally also, while never overweight and have eaten healthy, I was relatively inactive.

And I personally ran my first and last marathon in Baltimore a couple of months ago. So I know what you're going through and good luck on that. MIKE HUCKABEE: Don't tell me. [LAUGHTER] AUDIENCE: It'll one of the best days of your life.

It's fantastic. It's worth everything. MIKE HUCKABEE: I just don't want it to be the last day of my life is the only thing. [LAUGHTER] Thank you. Go ahead. AUDIENCE: That was also my last one. I understand.

My question is-- I'm one of the preventive medicine residents and a full-time student here at the School of Public Health, Master of Public Health. And we're working on the state level to try to affect change here in the state of Maryland. And I was wondering what ideas, tactic, strategies you can help us-- when we're talking to legislators-- to think towards the future, the prevention, the money invested now that the state will save maybe as soon as two or three years down the line. But I feel a lot of legislators are focused on the immediate-- this year's budget. How are we going to make it? And we're asking them to think forward, to invest. And I know they've done a lot of investment in the state.

But this is just one more thing with skyrocketing Medicaid costs. How can we get them to buy the story? We give them evidence. But sometimes I don't know the final strategy or tactic you can help us with. MIKE HUCKABEE: That's a great question because what you're really focusing on is, how do you get the legislators focused on long-term rather than short-term? And boy, if I really had to do that, I'd be the best governor that's ever lived in any of the 50 states because legislators tend to think of the things in the short-term. And in fact, let me be real candid, most politicians think of the next election, not the next generation. And that's one of the reasons we have a lot of the problems we have is because we're not thinking long-term.

We're thinking very short-term-- a biennial budget, an annual budget. We're thinking about an election cycle. We need to be thinking about an entire life cycle. Part of it is, though, is to help people see that there's a balance between dealing with the immediate and dealing, then, with the important. The immediate is we've got to fix a budget. We've got to make it all work. There's not a governor in this country who's not worried about his health care budget, not one-- every one of them. Because it's eating the lunches of state budgets right now.

And a big worry to us is as we look at the proposed budget that's coming out of the little town there just south of here. A lot of the proposals are not really very promising for our states. Because if the federal government wants to balance the budget by cutting the health care budgets that flow back to the states, that's not going to save money. In the long-term, it's going to cost us because what you'll end up with is a even greater level of diseased people who will be even more acutely ill and will require more expensive treatment than had we at least intervened in some way prior to their crisis. So that's what we're trying to say to them.

But it's also important that folks like you get to know individual legislators by name. Let them get to know you. And a couple-- let me give you a little lobbying tips. Number one, when you're dealing with legislators, or governors, or whoever, never been a bridge. A lot of times, people will go, and it's like all or nothing. Give it to me now.

Or I am going to picket every speech you ever make. Well, that's not going to create a dialogue. Confrontation does not really work.

It creates adversarial relationships. Bring to that person solutions. Help him to see that he needs to take up this cause. And it's not just for his interest, but for his constituents. And the best way to do it is make it personal. Don't just give him budget numbers and figures and stats. Tell him the story of Billy.

Telling the story of Martha, this 35-year-old single mom who's trying to raise her kids. And she's barely able to buy food and put it on the table because there's not enough money between her paycheck and the benefit she gets on food stamps that really covers healthy living. Make it real. Make it personal.

And those are some very important tools. AUDIENCE: I was very glad to hear that Arkansas had used its Master Settlement Agreement funds for health care. I was wondering how much of it has gone into actual development of tobacco control programs. And the other question related to that would be, where is Arkansas in creating smoke-free restaurants and bars? We're trying to do that here in Maryland.

Mike huckabee: ok. Let me let me answer the first part. On dealing with direct smoking cessation, a big part-- 25% of that budget goes to smoking cessation. We put some in research because we think that's an important long-term use. We put some in acute treatment so that people who are currently ill can get treatment. But a big chunk of it we put in cessation both for adolescents, as well as for adults. And we're trying to cut in half the smoking rates of our populations.

Right now 26% of the people in our state smoke. That's down, by the way, from 31% five years ago. So we're seeing some real results. The second piece of that you were asking regarding AUDIENCE: Smoking in restaurants. MIKE HUCKABEE: Smoking in restaurants. Part of our initiative, called AUDIENCE: [INAUDIBLE] MIKE HUCKABEE: Right. The Healthy Arkansas Initiative that we launched-- part of what we're trying to do is create a healthy Arkansas restaurant. And they would get designation if they are smoke-free environment.

They get designated Healthy Arkansas. And also in addition to being smoke free, they have to offer healthy menu options with nutritional guidelines that they would reveal so customers would know they're getting things that are healthy and decent to eat. And they would have no health department violations for the unspeakable things within the last two or three years. And that's how it's going to be formulated.

Like all states, we're certainly looking at the idea of an outright ban in the workplace of smoking. But the political pressure for that is tough. And the reason is, it's not because we don't know it's a good idea. It's because that's when we suddenly shift the debate from

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