AHA Policy Recommendation - Homepage | Circulationcirc.ahajournals.org/content/circulationaha/123/7/816...AHA Policy Recommendation American Heart Association and Nonprofit Advocacy:

AHA Policy Recommendation

American Heart Association and Nonprofit Advocacy:Past, Present, and Future

A Policy Recommendation From the American Heart Association

Larry B. Goldstein, MD, FAHA, Chair; Laurie P. Whitsel, PhD; Neil Meltzer; Mark Schoeberl;Jill Birnbaum, JD; Sue Nelson; Timothy J. Gardner, MD, FAHA; Clyde W. Yancy, MD, FAHA;Raymond J. Gibbons, MD, FAHA; Ralph L. Sacco, MD, FAHA; Loren Hiratzka, MD, FAHA; on

behalf of the American Heart Association Advocacy Coordinating Committee, Council on CardiovascularNursing, Council on the Kidney in Cardiovascular Disease, Council on Cardiovascular Radiology and

Intervention, Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Councilon Cardiovascular Disease in the Young, Council on Cardiopulmonary, Critical Care, Perioperative, and

Resuscitation, Council on Peripheral Vascular Disease, Council on Arteriosclerosis, Thrombosis andVascular Biology, Council on Epidemiology and Prevention, Council on Nutrition, Physical Activity and

Metabolism, and Interdisciplinary Council on Functional Genomics and Translational Biology

Influencing public policy through advocacy is an essentialstrategy used by the American Heart Association/Ameri-

can Stroke Association (AHA/ASA) to achieve its healthimpact goals and programmatic objectives, which includehelping all Americans lead healthier lives and reducing theincidence and consequences of cardiovascular disease andstroke. This advocacy work involves and engages the asso-ciation’s national officers, researchers, volunteer advocates,staff, and the general public and is a core strategy and keywork process of the AHA/ASA. The organization’s strategicapproach to influencing public policy and leveraging itsscience and evidence base is not well known. This articleprovides the historical context of AHA advocacy, the orga-nizational and legal structure under which these activities arecarried out, the process used to develop the association’spublic policy positions and goals, the approaches used toachieve these goals, and the methods that have been devel-oped to evaluate progress. This statement also examines the

various tools and tactics that advocacy organizations use toinfluence public policy and specifically how the AHA/ASAconducts policy research, legislative and regulatory lobbying,coalition building and grassroots mobilization, and mediaadvocacy. Finally, the ways that AHA/ASA evaluates theimpact of its advocacy efforts are discussed, highlightingspecific case studies and a brief summary of the association’s2010 to 2013 public policy agenda.

Historical ContextThe AHA’s efforts to translate the science of cardiovasculardisease and stroke into meaningful public policy began inearnest in the early 1980s. The association established afull-time office in Washington, DC, in early 1981 that wasinitially focused on increasing federal research funding ad-ministered by the National Institutes of Health.1 Other earlypolicy priorities included tobacco control and support forprograms that increased access to automated external defi-

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are requiredto complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on October 21, 2010. A copy of thestatement is available at http://www.americanheart.org/presenter.jhtml?identifier�3003999 by selecting either the “topic list” link or the “chronologicallist” link (No. KB-0114). To purchase additional reprints, call 843-216-2533 or e-mail [email protected].

The American Heart Association requests that this document be cited as follows: Goldstein LB, Whitsel LP, Meltzer N, Schoeberl M, Birnbaum J,Nelson S, Gardner TJ, Yancy CW, Gibbons RJ, Sacco RL, Hiratzka L; on behalf of the American Heart Association Advocacy Coordinating Committee,Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, Council on Cardiovascular Radiology and Intervention, Councilon Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council onCardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Peripheral Vascular Disease, Council on Arteriosclerosis, Thrombosis andVascular Biology, Council on Epidemiology and Prevention, Council on Nutrition, Physical Activity and Metabolism, and Interdisciplinary Council onFunctional Genomics and Translational Biology. American Heart Association and nonprofit advocacy: past, present, and future: a policy recommendationfrom the American Heart Association. Circulation. 2011;123:816–832.

Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development,visit http://www.americanheart.org/presenter.jhtml?identifier�3023366.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier�4431. A link to the “Permission Request Form” appears on the right side of the page.

(Circulation. 2011;123:816-832.)© 2011 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31820a5528

816

by guest on June 23, 2018http://circ.ahajournals.org/

Dow

nloaded from

http://circ.ahajournals.org/

brillators (AEDs), new clinical preventive benefits in theMedicare program, and nutrition policy.

The commitment and involvement of the AHA’s nationalvolunteer officers contributed significantly to the success ofthese early advocacy initiatives. They helped establish and setan overall public policy legislative and regulatory agendaaligned with and complementary to the broader organiza-tional priorities established by the AHA Board of Directors.Initially guided by the association’s medical professionalvolunteers, the role and contribution of lay leadership, pa-tients, and community advocates grew exponentially, as didthe impact and relevance for policymakers in the nation’scapitol and state legislatures throughout the country. As earlyas 1983, the University of Chicago’s National Health PolicyProject identified the AHA as the 10th most influentialnongovernmental organization and sixth most influentialhealth association.1 Although the AHA trailed the well-established and better-funded American Medical Associationand the American Hospital Association, it led almost 50 othercomparable health organizations in influencing public policy.

Five years later, the AHA’s advocacy structure and federallobbying network included 52 affiliates and encompassedmore than 80% of all congressional districts. Many of theseaffiliates were also increasing their advocacy activity at thestate level. Today, the association’s advocacy presence con-tinues in Washington, DC, and includes efforts in all 50 statesand Puerto Rico. Similarly, the association’s public policyagenda has grown, extending across a broad spectrum ofissues from research and prevention to treatment and accessto emergent cardiovascular and stroke care at the federal,state, and community levels.

Structure of AHA AdvocacyThe AHA is a New York State–based nonprofit organizationwith its national headquarters (National Center) in Dallas, TX,and 7 organizational regions (affiliates) covering the entirecountry. Influencing public policy is one of several key workprocesses of strategic focus for the association. The NationalCenter maintains an advocacy department to guide and direct theAHA/ASA’s overall public policy work and to manage theorganization’s advocacy operations in the nation’s capitol. Eachof the affiliates has the responsibility to resource, staff, andimplement advocacy strategies and tactics directed topublic policymakers at the state and local levels. Theassociation’s vast array of lay and medical professionalvolunteers and donors supports the AHA/ASA’s advocacyefforts every year by making financial contributions,testifying before federal and state legislatures, writingcomments to regulatory bodies, lobbying federal and statelawmakers, developing policy position statements, andengaging in grassroots and media advocacy activities.

At the National Center, AHA/ASA’s advocacy work is ledby an executive vice president and a vice president for stateadvocacy and public health based in Dallas, TX, and a vicepresident for federal advocacy in Washington, DC. TheNational Center maintains a staff of more than 20 in Washing-ton, DC, who are responsible for federal legislative and regula-tory advocacy, media relations, policy research, grassroots mo-bilization, and federal agency relations. The National Center also

maintains a staff to provide strategic guidance and technicalassistance to affiliates and their advocacy operations.

At the affiliate level, state and local advocacy efforts aresupervised by a vice president for advocacy with each stateassigned at least 1 government relations director. Given thecritical role that public policy and advocacy will continue tohave to achieve the AHA’s new 2020 health impact goal,beginning in 2010, states with a population greater than 5million will be encouraged to establish a second governmentrelations director position. In these states, responsibilities willbe divided between a health systems policy director and aprevention policy director (Figure 1), each responsible forrelevant coalition development, legislative and regulatorylobbying, and gubernatorial and state agency relations. Cur-rently, the AHA/ASA has 59 government relation directors,11 grassroots directors, and 8 affiliate vice presidents ofadvocacy (Figure 2).

Legal Structure of AHA as a 501(c)3 Versus a501(c)4 OrganizationIt is legally permissible, within limits, for a 501(c)3 publiccharity to promote and influence public policy. The limitsplaced on a 501(c)3 include the amount of organizationalresources that are expended on these activities and anabsolute prohibition on participating in any campaign activ-ities. The Internal Revenue Service considers political cam-paign activity to be anything in which the reasonable conse-quences have the potential to influence voter opinion or toprovide financial, volunteer, or other aid to benefit or defeata candidate for public office. Examples of prohibited activi-ties for a 501(c)3 include endorsements, public statements oradvertisements for or against a candidate, campaign contri-butions, public distribution of candidates’ voting records,ratings of candidates, and voter guides on candidates duringelection campaigns on issues of concern to the organization.A 501(c)3 organization may, however, conduct neutral ornonpartisan educational efforts without showing favoritism orbias to a candidate. Examples of these types of permissibleactivities include sponsoring a public forum or debate be-tween candidates as long as it is structured in a neutralmanner that favors no particular candidate. The AHA/ASAengaged in such allowed activities in 2000 and 2004 (TakeHeart) and worked in conjunction with others in the 2008election cycle to raise public and candidate awareness ofhealthcare reform as a key domestic public policy priority(Are You Covered?) and the importance of funding forbiomedical research (Your Congress/Your Health).

Other permissible activities include briefings or positionpapers directed to the public and/or to all candidates on topicsof concern, educational outreach, petition drives if in supportof legislation or a referendum, letter-writing campaignssetting out the organization’s position on issues related to itsexempt purpose, and editorial board visits to educate the printor broadcast news media editors about legislation or publichealth issues. A 501(c)3 organization may also impartiallyand objectively inform its members how legislators voted.Finally, 501(c)3 organizations can conduct voter registrationand get-out-the-vote drives.

Goldstein et al American Heart Association and Nonprofit Advocacy 817


Dow

nloaded from


To remain in compliance with the Internal Revenue Ser-vice’s advocacy expense limitations (“substantial part test”),the association’s advocacy, legal, and finance departmentshave established robust internal policies and processes tomonitor and report organizational expenditures for lobbyingand related reportable advocacy expenses in a uniform andconsistent manner. AHA/ASA legal and advocacy staff meetperiodically and at the end of the fiscal year to review theseexpenses and to identify issues, trends and potential futurechallenges to maintain association compliance with the sub-stantial part test. The legal and advocacy teams also developpolicies and procedures, prepare staff resources, and period-ically conduct compliance training to educate and informstaff and volunteers of the full range of permissible andprohibited advocacy activities and requirements for reportingexpenses. AHA/ASA government relations staff members inWashington, DC, are required to comply with all existingregistration and reporting requirements. Similarly, affiliategovernment relations staff members are required to complywith applicable ethics and reporting requirements, which canvary substantially from state to state. The AHA/ASA activelymonitors legislation and rules and regulations that wouldnegatively affect a nonprofit organization’s ability to appro-priately engage in the public policymaking process.

Some nonprofit organizations are legally structured as a501(c)4 or have a separate affiliated organization that has

501(c)4 tax status. The 501(c)3 and 501(c)4 organizations aresimilar in that they are both not-for-profit organizations andtheir earnings may not benefit a private shareholder orindividual. Both types of organizations are exempt fromfederal taxes, but state tax-exempt status varies. Donations to501(c)4 organizations are not tax deductible unless they arepublic entities used for public services, whereas donations to501(c)3 organizations are tax deductible. In contrast to a501(c)3 organization, a 501(c)4 organization can engage inunlimited lobbying and participate in a political campaign, aslong as it is consistent with the organization’s purpose and isnot the organization’s primary activity.

As part of its fiduciary responsibilities, the AHA Boardof Directors periodically reviews the advocacy activities ofthe association to determine whether the current legalstructure and related restrictions are inhibiting its ability toachieve its mission, strategic goals, and public policypriorities. In 2009, the board reaffirmed its decision tomaintain the association’s advocacy operations as a501(c)3, noting that there are no immediate legal obstaclesor barriers that would limit the AHA/ASA’s capacity tosuccessfully influence public policy. Acknowledging thatthere could be circumstances that might compel the boardto reevaluate this issue in the future in an expeditedmanner, it directed its legal counsel to be prepared to acton any future board action on this question.

Figure 1. American Heart Association (AHA) National Office of Advocacy. ADV indicates advocacy.

818 Circulation February 22, 2011


Dow

nloaded from


Spectrum of Influence forAdvocacy Organizations

Nonprofit organizations use a variety of strategies and tacticsto influence public policy. Those with 501(c)4 tax statusdonate money to political campaigns to obtain access to andto influence elected officials. Often, these organizationsdevelop political action committees to raise money forpolitical candidates. Other groups gain influence throughtheir ability to mobilize extensive numbers of constituents foror against particular issues or candidates. Organizations likethe AHA/ASA, in large part, derive their influence throughthe science expertise and evidence-based policy that they canoffer public officials.

Successfully influencing public policy is usually an incre-mental, long-term process, advancing in small steps andevolving over time. Although it is not always perceived orportrayed in this manner, lobbying is a fairly open, routineactivity.2 Significant new policy initiatives usually take yearsto come to fruition because a robust and persistent effort isrequired to define issues; to gain the attention of policymak-ers, the media, and the public; and to achieve policy change.2

Successful nonprofit advocacy groups maintain a stable,persistent, focused presence on the same set of issues towhich they devote the majority of their resources. Operatingwithin a political environment fueled by exaggerated policy

differences for the benefit of a 24-hour media cycle and aconstant focus on securing a partisan gain, advocacy groupsare constantly tempted to shift their attention from headline toheadline issue or to focus only on “putting out fires.” Themost successful groups tend to remain focused on their coreissues, developing expertise, resources, and a strong reputa-tion in specific areas.2 Maintaining advocacy operations inWashington, DC, and in state capitals provides a significantadvantage for nonprofit organizations by strengthening theirpresence, enabling them to hone their lobbying expertise andto expand their advocacy capacity.3

Perhaps the greatest asset of the AHA/ASA in publicpolicy advocacy is the respect that the organization hascultivated over the years with officials at all levels ofgovernment. This respect emanates from the association’ssteadfast commitment and ability to translate credible androbust science into public policy solutions, to provide credi-ble experts from its grassroots network, and to make theseexperts available to the media. The scientific rigor that servesas the foundation for many of the AHA/ASA’s programsapplies equally to the association’s federal, state, and localpublic policy advocacy initiatives. The AHA/ASA commitssubstantial resources to developing scientific statements,guidelines, policy statements, and original reports based onrigorous, peer-reviewed research, providing a trusted resource

Figure 2. American Heart Association state advocacy staffing responsibilities. CPR indicates cardiopulmonary resuscitation.



Dow

nloaded from


for policymakers that reinforces the association’s credibility andcreates a solid foundation for its advocacy positions. For legis-lators, their staff, the media, and government agencies, thisexpertise is essential because of the increasing complexity ofmany public health issues. Organizations that base their advo-cacy on credible, robust science quickly become the “go to”organization for their particular issues.

The association’s reliance on evidence-based policy alsoimposes limitations, sometimes preventing it from adoptingpolicy positions in emerging areas for which science islacking. As a result, the AHA/ASA periodically refrains fromtaking an absolute position on an issue or joining earlycoalition efforts. Although it is recognized that the lack of anAHA/ASA endorsement of new, innovative, and untestedpolicy solutions can sometimes frustrate its public healthadvocacy partners, the strength of the association’s endorse-ment for proven policy interventions can serve as a catalystfor policy change. Sometimes, the AHA/ASA will endorsepilot initiatives (often at the local and state levels whereemerging policy approaches develop first) to gather moreevidence of impact or efficacy. This cautious approach hasbeen essential in maintaining the association’s credibility,which it is diligent not to sacrifice for an “issue of the day,”despite consequences such as forgone short-term mediaattention or policymaker interest. The AHA/ASA balancesthe need for relevance in emerging public policy with theimportance of moving forward with adequate evidence.

A recent study identified several common characteristics ofsuccessful nonprofit advocacy organizations recognized bypolicymakers and their staff, and the AHA incorporates manyof these best practices.4 First, successful organizations hiretheir staff from government positions (often Congressional/state legislative offices) because this brings governmentexperience, established personal relationships with govern-ment staff, and an understanding of the legislative process.Second, effective organizations take every opportunity tobring their grassroots volunteers and experts into directcontact with policymakers through personal visits, phonecalls, testimony at hearings, Congressional or state capitolbriefings or events, and appointments to expert advisorycommittees. Third, organizations provide expertise, offerinformation specific to the legislation, and are able to explainin nontechnical language how a bill would affect the legisla-tors’ constituents, the economy, social equity, public opinion,the quality and effectiveness of any proposed program, andthe reasons for supporting or opposing a piece of legislation.4

Finally, the most successful organizations focus priorities andresources on a few core issues.

The AHA’s Process for Developing ItsStrategic Plan and Policy Agenda

The AHA’s national Advocacy Coordinating Committee, oneof the key committees of the association’s national board, isresponsible for establishing AHA policy positions, publicpolicy agenda, and annual legislative and regulatory priori-ties. Every 3 years, the AHA undertakes a rigorous process todevelop its strategic policy agenda and to provide an overar-ching document that gives the association’s federal, state, andlocal advocacy staff strategic guidance and direction on

policy issues and positions that align with and support theAHA’s research, mission, and strategic priorities. A draftdocument is written by staff and reviewed by the associa-tion’s scientific councils, key volunteers, administrative cab-inet, and AHA leadership and then finally reviewed andapproved by the Advocacy Coordinating Committee and thenational Board of Directors.

An abbreviated policy agenda and set of state and federalpriorities are created annually from the 3-year strategic planto maximize opportunities in each legislative session. TheAHA considers various factors in establishing these annualstate and federal priorities, including the political landscapeand emerging versus mature policy issues, identifying thosewith the greatest potential for health impact and likelihood ofsuccess. For example, at the federal level, major legislativeinitiatives such as healthcare reform, child nutrition andtransportation reauthorization, and other “must pass” bills canprovide vehicles for AHA’s legislative priorities.

Six criteria recently affirmed by the Advocacy Coordinat-ing Committee for evaluating new issues and advocacyopportunities include the following:

1. Does this policy or regulatory opportunity clearly alignwith AHA’s strategic plan and priorities?

2. Does the AHA/ASA have sound science and/or aposition statement to guide advocacy efforts to makeprogress toward or to achieve the desired positioning orpolicy outcome that will have a meaningful impact?

3. Does the internal political will and organizational com-mitment exist to pursue the opportunity (eg, volunteerleadership support, business unit buy-in, dedication ofadvocacy resources necessary)?

4. Is there a reasonable likelihood of success (ie, currentrelevance of the issue, an established definition ofsuccess, acceptable timeframe, receptivity of decisionmakers)?

5. Will AHA/ASA involvement make any appreciabledifference (policy outcome, AHA positioning and visi-bility, unique contribution)?

6. Are the risks acceptable? What are the consequences offailure, the impact on image/positioning, the effect ofassociation with the issue and/or coalitions, and unin-tended consequences on patients/relationships?

There is also a rigorous process at the national level todevelop state and local advocacy priorities that are measur-able and achievable. The AHA/ASA considers intendedoutcomes and unintended consequences of its advocacyactivities. The national state advocacy staff convenes issueteams comprising National Center and field staff memberseach spring to identify policy priorities and goals for thefollowing year that are used to assess and measure accom-plishments by state advocacy staff. These state and localadvocacy goals and priorities are shared with AHA internalleadership teams and key volunteers and are submitted to thenational Advocacy Coordinating Committee for approval.Once approved, guidance documents are prepared for stateadvocacy staffs and integrated into their annual performanceevaluations.

Thus, the resulting public policy agenda and annual prior-ities are a product of a rigorous internal process that is based



Dow

nloaded from


on science, guided by the AHA’s health impact goals andstrategic plan, and informed by the expert advice and counselof AHA/ASA staff and volunteers.

Implementing the AHA’s Strategic Plan andPublic Policy Agenda

The AHA/ASA works across the public policy continuum(Figure 3) to influence policy, including planning, stake-holder and coalition development, policy research and anal-ysis, a comprehensive legislative and regulatory agenda, thecreation of media advocacy and grassroots strategies, imple-menting policy change, and then following through witheffective evaluation to assess implementation and the ulti-mate impact of the law or regulation. The AHA/ASA differsfrom many advocacy organizations in its focus on cardiovas-cular and stroke patients and its service to the general publicas a voluntary health association, not a trade associationrepresenting dues-paying members. The AHA/ASA has state,national, and international influence that is relatively uniqueamong patient advocacy groups. Whereas many organizationsorganize both their state and federal advocacy from a nationaloffice, the AHA/ASA has state advocacy staffs across thecountry and federal staff in Washington, DC. There isexceptional congruence between the association’s state andfederal advocacy efforts with complementary policy agendas,collaborative policy research, shared best practices, cultiva-tion of grassroots volunteers, identification of key contacts,and the use of researchers, healthcare professionals, and keyvolunteers to provide expertise and testimony.

There are specific roles for state and federal advocacy.Often, states are “laboratories” for policy development thatinform federal advocacy and further state policy. Sometimes,states extend or strengthen federal-level policy. Certain issuesare best addressed at the federal level where there is the need todevelop national or cross-cutting solutions, and other issues aremore appropriately addressed at the state or local level.

The AHA/ASA’s cause and public education campaignsoften complement and help promote advocacy activities. Forexample, the Go Red for Women Campaign, which raisesawareness of heart disease in women, helped build supportfor the Heart for Women legislation. Power to End Stroke, aneducation and awareness campaign that embraces and cele-brates the culture, energy, creativity, and lifestyle of Ameri-cans, helps reinforce advocacy efforts to develop effectivestroke systems of care. At the same time, the AHA/ASA’sadvocacy work raises public awareness and can help buildmomentum that inspires people to look for information or toparticipate in programming that improves their health. Thesepeople can then become passionate advocates and put theirnew knowledge into action.

Often, the most effective nonprofit advocacy organizationsshape their consumer messaging in a way that supports publicconsensus because it is extremely difficult, resource inten-sive, and typically beyond the means of even large nonprofitsto change public opinion to support a policy goal.4 Tobaccopolicy is an exception. Countermarketing campaigns bypublic health organizations, publication of the Surgeon Gen-

Figure 3. American Heart Association (AHA) public policy continuum.



Dow

nloaded from


eral’s report, and scientific evidence around the health impactof tobacco smoke gradually transformed public opinion,making it socially unacceptable to smoke for many. Agrassroots movement empowered the public health commu-nity to pursue fundamental policy change. Grassroots cam-paigns, even if they are at first unsuccessful, are powerfulinitiatives that increase awareness of a health issue, buildcommunity readiness for policy change, and can lead tohealthier social norms. These were efforts beyond the meansof one organization. The transformation in public opinioncreated the opportunity for successful policy change, includ-ing passage of smoke-free indoor air laws, tobacco taxation,the regulation of tobacco products, and tobacco cessation andprevention programs.

Policy Research: Creating the Foundation forAHA AdvocacyThe role of policy research is to translate science into policythat provides a foundation for legislative and regulatoryadvocacy activities. The AHA’s policy research staff ana-lyzes data, the scientific literature, and other health researchthat impacts legislative, regulatory, and other public policiesaffecting heart disease and stroke treatment and prevention.The policy research team coordinates scientific consensusand rigorous peer review to develop policy position state-ments, fact sheets, model legislation, and peer-reviewedpublications to guide and support AHA/ASA advocacy.These products concisely summarize the relevant science,convey urgent policy problems, and outline courses of actionand solutions. Policy statements are analytical, using factsand research to evaluate policies, to develop outstandingresearch questions, and to provide evidence for policy rec-ommendations and programs. There are regular communica-tion and integration between the AHA/ASA’s science andadvocacy departments to identify, translate, and leveragerelevant scientific statements into policy and to ensure thatthe policy recommendations included in scientific statementsare based on the latest policy research.

The policy research staff monitors trends in health policy toidentify emerging issues relevant to cardiovascular health andstroke. The staff also regularly evaluates state and federallegislation to determine whether it conforms to AHA/ASApolicy positions and science; the staff also works with regulatorystaff to help develop public comments to regulatory agencies.

Legislative and Regulatory LobbyingThe AHA’s legislative lobbyists at both the state and federallevels possess expertise on the legislative and regulatoryprocess, develop close working relationships with publicofficials and their staffs, and are able to devise strategies toimplement the policies and priorities adopted by the AHABoard of Directors. The AHA’s government relations effortscan be classified into 5 main sets of activities: (1) proactivelegislative initiatives, (2) participation in coalitions, (3) sup-port for other groups and coalitions; (4) provision of regula-tory comments, and (5) placement of key AHA volunteers ongovernment advisory groups and commissions.

The AHA/ASA is involved with numerous coalitions at thestate and federal levels. Coalition and partner development

provides the opportunity to work across sectors with manystakeholders to create policy efforts that are more effective,relevant, sustainable, and efficient compared with what couldbe achieved by a single organization.5–7 Coalitions can beestablished to achieve a short-term objective or to address abroad set of issues over a longer period of time. Accordingly,they can be formally structured with bylaws, defined roles,and a defined mission statement, or they can be ad hoc andmore loosely structured. Some coalitions require financial orin-kind contributions to participate, but others do not. Coali-tions capitalize on strength in numbers and the resources andcapacity that each member brings to the group, includingexpertise, staff resources, legislative contacts, funding, andthe opportunity to share work. Coalitions can foster newalliances, collaboration, and strategic working relationships.Regular communication, clearly defined roles, and consensuson the mission are essential for a well-functioning coalition orpartnership. A united front of a coalition with multiple sectorsworking together to achieve a common purpose is oftennecessary to impress policymakers, the news media, and thepublic.

It is not, however, always beneficial or practical to work incoalitions. Potential partners may have difficulty reachingconsensus without difficult compromises. The need for ap-proval from each organization can often delay or prolong theadvocacy initiatives. There may be differences with regard togoals, strategy, division of workload, or direction. Coalitionactivities need to remain focused on the group, not individualmembers, so organizations can lose ownership of an issue orrecognition for their work. The AHA/ASA is strategic aboutchoosing when it is optimal to participate in coalitions andpartnerships and when it is more appropriate to move forwardindependently. The AHA/ASA has different roles withincoalitions, sometimes leading and offering significant re-sources, and other times providing more tacit support, en-dorsement, and/or capacity-building.

Commercial interests that may oppose AHA/ASA healthpolicy goals may use third parties and coalitions to advancetheir own policy agenda. For example, in tobacco advocacy,industry interest groups identified several groups as allies inopposing excise tax increases. Industry provided financialand logistical support to a labor management group, whichserved as a public relations “front” to distance tobaccocompanies from their positions.8 Industry is currently backingsimilar coalitions and partnerships to oppose beverage taxessuch as New Yorkers Against Unfair Taxes and AmericansAgainst Food Taxes. These coalitions are designed to seem asthough they are consumer driven, but they are actually fundedand resourced by the respective industry or manufacturergroups with a substantial economic interest in the topic.

Regulatory ActivitiesRegulatory advocacy is the process of influencing the exec-utive branch and its agencies. Administrative agencies play avital but less visible role in the policymaking process.Although many believe the chance to influence public policyends when legislation becomes law, the regulatory processprovides a continuing opportunity to influence how a law isimplemented and enforced. Because laws and report language



Dow

nloaded from


are not always specific, state and federal agencies can have agreat deal of discretion in implementing legislation. Thisallows the executive branch and its agencies to heavilyinfluence the resulting public policy.

The AHA/ASA closely monitors federal and state agenciesto identify opportunities to influence the regulatory process.For example, agencies routinely solicit public feedback asthey develop regulations to implement a law, update existingregulations, work on past mandates, and issue guidelines orguidance documents. The AHA/ASA frequently responds tothese requests for information by submitting written com-ments or providing oral testimony at agency meetings. TheAHA/ASA shares its expertise with the agencies throughmeetings between AHA/ASA and agency staff and encour-ages the agencies to view the AHA/ASA as a resource andpartner. Additionally, the AHA/ASA alerts agencies to ex-perts in the community who can help address a specific issue;this may include nominating AHA/ASA volunteers for ap-pointments to federal and state advisory committees.

Grassroots Advocacy: You’re the CureAHA/ASA advocacy activities focus on initiating and support-ing policy changes that will improve the cardiovascular andbrain health of Americans. A key to achieving these policychanges is connecting constituents with their policymakers. TheYou’re the Cure network comprises advocates committed tousing their voices as constituents to influence policymakers andto build support for policies important to the AHA/ASA.

The AHA/ASA strives to recruit, engage, and mobilizeYou’re the Cure advocates across the country to influenceheart- and stroke-related policy issues. The network, made upof nearly 200 000 advocates, reflects a diverse group ofpeople who care about heart and stroke issues, includingsurvivors, caregivers, researchers, medical professionals, andfamilies. The You’re the Cure program seeks to continuallyincrease the size of the network and to give constituents avoice in the political process. By providing a meaningful rolefor advocates, the AHA/ASA is building a strong volunteerrelationship that can be leveraged for other programs andinitiatives.

Advocates engage in various activities to influence theirpolicymakers. At the simplest level, advocates send e-mailsto their representatives about legislation that the AHA/ASA issupporting. Advocates take an active role above andbeyond sharing those simple messages when they tele-phone their lawmakers, schedule in-person visits, partici-pate in state and national Lobby Days, provide testimony,serve as media spokespersons, recruit other advocates, andshare their stories.

It is important to build strong, long-lasting relationshipswith selected legislators (chosen for their influence andpositions on key committees) that can be further strengthenedthrough constituent contacts. Relationships with a few influ-ential members on key committees can have far more impactthan many superficial contacts. There is, however, an impor-tant role for general advocacy appeals that call on grassrootsnetworkers to write letters and to visit to their legislativerepresentatives at home. However, these more general ap-peals to “contact your representative” have to be made

strategically or they easily can be discarded by busy legisla-tive staff, especially if the number of e-mails or phone calls isnot substantial.4

Legislators take their cues from many different sourceswhen determining their positions on specific legislation.Direct contact with a constituent can have a major impact,particularly when the legislator can identify with the concern.Hearing from a passionate constituent with a meaningful,memorable story can be the difference between a “yes” and a“no” vote, and the Grassroots Advocacy Department contin-ually attempts to connect voters with their representativesthrough multiple avenues. In the end, often the best storywins. The one that means the most to the greatest number ofpeople is the one that is remembered by lawmakers.

Media Advocacy and Its Role in Shaping PolicyThe media is an important player in framing public policydebates, and media advocacy is another way of winning thenecessary support for the AHA/ASA’s policy priorities.Media advocacy aims to use mass media for advancing asocial or public policy initiative. Unlike public education orsocial marketing campaigns, which use the media to persuadean audience to change individual health behaviors, mediaadvocacy works to develop news stories to build support forpublic policies or other issues. Media coverage is one of thebest ways to gain the attention of decision makers, from localelected officials to members of Congress. Legislators taketheir cues from what they see in the morning newspapers(print or electronic) and on television news. They know theimportant role the media plays in shaping public opinion.Much of media advocacy is taking advantage of opportunitiesto advance the organization’s policy agenda and workingclosely with government relations, grassroots, policy research,and regulatory staff to integrate media advocacy in a publicpolicy campaign. Often, the approach taken in a media advocacyplan is similar to that of a political campaign in which theassociation mobilizes a base of support for its issue and targetsits messages to groups that can help attain a policy goal.

Measuring SuccessThe AHA assesses its progress and success by developingspecific annual goals for state and federal advocacy withseveral metrics. These include tracking grassroots networkengagement, media impressions, coalition work, letters ofendorsement, advocacy events that build support for theAHA’s advocacy priorities, cosponsorships on legislation,regulatory comments submitted, policy articles and state-ments published, and lobbying activity. It is important notonly to measure internal progress toward strategic policygoals but also to ensure that if legislation is passed or aregulation is established, there is timely and effective imple-mentation and it fulfills its purpose. By assessing the impactand implementation of policy change, the association candetermine whether its efforts are having a positive impact,there is need to follow up with additional legislation orregulation, or there were any unintended consequences orcosts that need to be addressed. One example is local wellnesspolicies that were adopted in the 2004 Child Nutrition andWomen Infants and Children reauthorization. The legislation



Dow

nloaded from


required school districts to establish wellness councils and todevelop local wellness policies that incorporated nutrition,nutrition education, and physical activity for the schoolenvironment. The AHA/ASA analyzed how these policieswere implemented and concluded that implementation couldbe improved with greater transparency, more accountability,and more comprehensive policy development. Accordingly,the AHA/ASA worked with its partners to create draftlanguage for the 2010 reauthorization of Child Nutrition toimprove and strengthen local wellness policies. If passed,these changes would enhance the development of healthyschool environments.

Other organizations are realizing the impact of policyevaluation and assessment. The Robert Wood Johnson Foun-dation and The Pew Charitable Trusts recently established aproject to document the increasing use of health impactassessments across the country. Health impact assessmentsallow the collection of data to identify the health benefits andconsequences of new policies; they offer a tool to developpractical strategies to minimize any adverse effects of policychange and ensure the best possible health outcomes.9 Thehealth impact assessments foster the consideration of healthneeds in policy and program decisions even in sectors that donot traditionally focus on health outcomes. Grant makers areencouraging the use of these tools as they provide funding toensure optimal impact of policy change in the area of publichealth.

Examples of AHA’s Advocacy WorkThe conceptual framework for much of the AHA/ASA’spolicy work is the social-ecological model that maintains thatan individual’s behavior is influenced by his or her surround-ing physical, social, and cultural environments (see Figure4).12 Policy has the greatest impact when it optimizes theenvironments in which people live, work, learn, and play,making healthier behaviors and healthier choices the norm,putting individual behavior in the context of multiple-levelinfluences. Population-based strategies are a critical comple-ment to preventive services and treatment programs in which

practitioners and patients work together to foster importantindividual behavior and lifestyle changes.13

Tobacco ControlAdvocacy around smoking cessation and prevention has beenan AHA/ASA priority for several decades. This policy workis a remarkable example of the impact that advocacy can haveon reducing cardiovascular disease and stroke in the UnitedStates. It also is an example of the patience required forpolicy initiatives, the importance of a sound scientific evi-dence base, the unique roles of state and federal advocacy, thesignificance of working in a strong coalition, and the need tominimize preemption so that states and localities can becreative and innovative in their approaches to change publicperception and improve health. Smoke-free indoor air laws,tobacco excise taxes, tobacco cessation and prevention pro-grams, and regulation of tobacco are the primary means ofachieving the public health impact.

The AHA advocates for comprehensive smoke-free work-place laws at the state and local levels, in compliance with theFundamentals of Smoke-Free Workplace Laws guidelines.14

These guidelines and fundamental principles were developedwith several national partners in the public health communityto guide and maximize the impact of smoke-free policyefforts and to increase the number of workers and residents inthe United States who are protected from secondhand smokein workplaces and public places. The principles incorporateexperiences and lessons learned from tobacco control advo-cates across the country over the past several decades. Someof these principles include sufficient planning, emphasis onlocal initiatives, resource allocation, strong grassroots orga-nization, community readiness, model policy language, andthe need to use expert advisors. In the case of smoke-free airpolicy, the AHA discouraged federal clean indoor air laws andfocused its efforts on local and state advocacy so that munici-palities could pass robust laws, create momentum around thecountry, and change public perception over time. By focusing atthe state and local levels, the AHA and its public health partnersforced the powerful, well-financed tobacco industry to spread its

Figure 4.The social ecological modeland social determinants of health.Reproduced from Shortell et al10 withpermission of the publisher. Copyright ©2004, American Journal of Public Health.Original data derived from Committee onAssuring the Health of the Public in the21st Century, Institute of Medicine.11



Dow

nloaded from


resources around the country, rather than concentrate them tooppose one piece of federal legislation.

The impact of advocacy around smoke-free air is becomingclear. Experimental and epidemiological studies support a causalrelationship between smoking bans and decreases in acutecoronary events. Studies from around the world provide evi-dence for a reduction in hospital admissions for acute myocar-dial infarction after implementation of smoke-free indoor airlaws.15,16 According to the American Non-Smokers RightsFoundation, at the end of 2009, a total of 30 states, in addition toPuerto Rico and the District of Columbia, had laws requiring100% smoke-free workplaces and/or restaurants and/or bars (seehttp://www.no-smoke.org/goingsmokefree.php?id�519 for up-dated statistics as new laws and regulations are passed). TheAHA will continue to work on this issue until the entire countryis covered by robust, smoke-free air laws.

National guidance and resources are often implemented bystates and localities. An example is the Centers for DiseaseControl and Prevention’s best practice guidelines for tobaccocessation and prevention that have been implemented by manystates and localities as part of comprehensive tobacco controlprograms.

Additionally, tobacco advocacy provides an example of theimportance of working in a strong coalition, in this case,the Campaign for Tobacco Free Kids. This campaign is thenation’s largest nongovernmental initiative ever launched toprotect children from tobacco addiction and exposure tosecondhand tobacco smoke. The campaign supports tobaccopolicy efforts at the local, state, federal, and global levels. TheAHA, as a leading member of the coalition, along with theAmerican Cancer Society and the American Lung Associa-tion, pays dues to support the work of the campaign staff. Thecampaign has provided tremendous expertise and capacity fortobacco policy in the United States.

The federal role in tobacco advocacy is most apparent withUS Food and Drug Administration regulation of tobacco. In ahistoric and long-fought victory, in June 2009, Congress andthe President gave the Food and Drug Administration theauthority to regulate the manufacturing, marketing, and saleof tobacco products. This new law was the result of decadesof advocacy by the AHA and numerous public health partnersand ended the special protection from regulation that thetobacco industry enjoyed for so long. The AHA and itspartners will monitor implementation of the law to ensure thatit has its intended impact on the public health of the nation.

Tobacco excise taxes are an example of a combined stateand federal approach. The federal government has imposedexcise taxes, most recently with the expansion of the Chil-dren’s Health Insurance Program. A cigarette tax increase of61.66 cents per pack went into effect on April 1, 2009. Therewere also increases in the federal tax rates on other tobaccoproducts such as smokeless products, “small cigars,” roll-your-own tobacco, and regular cigars.

At the same time, states have imposed tobacco excise taxeswith a current nationwide average of $1.45 per pack (as ofJuly 2010). As a highlight, the state of New York (June 2010)raised its cigarette tax by $1.60 to give it the highest cigarettetax in the nation at $4.35 per pack. The AHA/ASA continuesto advocate at both the state and federal levels for robust

tobacco excise taxes because evidence shows that for every10-cent increase in tobacco taxes, cigarette consumptiondeclines by 7%.

Efforts by the AHA have contributed to a decline in UScigarette consumption by more than 24% over the last decade.Despite this progress, 23.1% of men and 18.3% of women in theUnited States still smoke.17 As long as this is the case, tobaccocontrol advocacy will remain a key priority for the AHA/ASA.

AED Placement/Cardiopulmonary ResuscitationTraining and Good Samaritan LawsOver the years, the AHA has given priority to cardiopulmo-nary resuscitation training for the US population and theplacement of AEDs in public places (such as airports andgovernment buildings) to ensure optimal response when aperson experiences sudden cardiac arrest. Cardiopulmonaryresuscitation training and use of an AED are essentialelements in the chain of survival in the emergency responseto a cardiac arrest. When the AHA first tried to implement itscardiopulmonary resuscitation and public access to defibril-lation programs, one barrier was concern over civil liability(ie, a layperson who tried to use an AED or administercardiopulmonary resuscitation or the company that estab-lished the program might be subject to liability if the patientwas hurt or did not survive). The AHA then advocated forGood Samaritan Laws to remove this perceived barrier and toprotect both the individuals coming to the aid of a person incardiac arrest and those companies that established programs.These laws increased the impact of AHA’s training programsby reducing bystanders’ hesitation to assist in emergencysituations and provided support to companies and others thatestablished public access to defibrillation programs. Everystate now has some form of Good Samaritan Law, and 40states have lay rescuer protections and 26 states have programfacilitator protections that meet AHA recommendations. Thisis an excellent example of AHA advocacy efforts helping toovercome a barrier to program implementation.

Nutrition Standards in SchoolsWorking with the William J. Clinton Foundation, the AHAestablished the Alliance for a Healthier Generation, an initia-tive to address childhood obesity and to reverse the nation’sadult obesity epidemic. In May 2006, the alliance announceda landmark agreement with the beverage industry to eliminatefull-calorie beverages from schools across the nation and topromote lower-calorie, smaller-portion beverages to reducethe calories consumed by children in the school environment.In 2007, the AHA and the alliance established science-basedsnack food guidelines for competitive foods in schools topromote consumption of a healthy, balanced diet that is richin whole grains, fruits, and vegetables, with limited intake offats, salt, and calories. Subsequently, the Institute of Medi-cine published a report on nutrition standards in schools thatsome states wanted to use as the basis for legislation and/orregulation.18 Although there are some differences between theAHA’s competitive food and beverage standards and those ofInstitute of Medicine, the two are largely aligned becauseboth are based on the best available science.



Dow

nloaded from

http://www.no-smoke.org/goingsmokefree.php?id=519


The Clinton alliance beverage agreement lasted for 3 years,with the program’s effectiveness reflected in independentlyprepared annual progress reports. The final assessment in2010 showed the significant impact of this voluntary, land-mark agreement: 88% fewer beverage calories were shippedto schools between 2004 (the last comprehensive data avail-able before the agreement) and the end of 2009; shipments offull-calorie soft drinks to schools declined by 95% during thattime; and 98.8% of schools and school districts measuredwere aligned with the guidelines. Beverage companies spentthousands of hours educating and training sales forces andinvested millions of dollars in retrofitting vending machines,repackaging products, and reconfiguring production lines andequipment.

A recent report from the Centers for Disease Control andPrevention’s School Health Profiles Survey19 reiterated thesubstantial progress made across the United States in increas-ing the percentage of secondary schools in which studentscould purchase more nutritious snack foods and beveragesoutside the school meal program. The report showed thatamong the 34 states that collected data in 2006 and 2008, themedian percentage of secondary schools that did not sell sodaor fruit drinks (except those that are 100% juice) increasedfrom 38% in 2006 to 63% in 2008. The median percentage ofsecondary schools that sold candy or snacks that are low in fatincreased from 46% in 2006 to 64% in 2008. The greatestimprovements occurred in states that adopted strong schoolnutrition standards and policies for foods and beveragesoutside school meal programs, reinforcing the importance ofpublic policy change in changing an unhealthy environment.

Another recent report by the Robert Wood Johnson Foun-dation’s Bridging the Gap program found that there remainsroom for improvement in elementary schools in which sodaand junk foods are still being offered.20 However, the findingswere based on surveys of school administrators during the2006 to 2007 and 2007 to 2008 school years and may nothave accounted for the more recent developments in improv-ing nutrition standards.

The effect of the alliance’s activities illustrates the impor-tance of public policy efforts to extend voluntary agreementsto make them more sustainable. There is some disagreementabout the long-term effectiveness of voluntary agreementsand the ability of industry to regulate itself.21 Legislative andregulatory advocacy can reinforce, complement, and sustainvoluntary initiatives. For nutrition standards in schools, therehave been multiple examples at the state and federal levels inwhich advocacy efforts are strengthening the voluntary agree-ment. The AHA has advocated for robust nutrition standardsat the state level that align with the alliance criteria.

At the federal level, the 2004 Child Nutrition and WomenInfants and Children Reauthorization Act required schools toestablish local wellness policies that addressed nutritionstandards. In the current reauthorization, the AHA is advo-cating that these wellness policies be strengthened withgreater implementation, accountability, and assessment. If thecurrent Child Nutrition Reauthorization language remains inits present form and becomes law, the US Department ofAgriculture will for the first time have the authority toestablish robust nutrition standards for foods and beverages

sold in schools from vending machines, a la carte, in schoolstores, and outside the meal program. The legislation will alsostrengthen nutrition education and promotion and improvethe quality of the US commodities provided to the schoolmeal program.

Finally, grant-funding opportunities supported by theAmerican Recovery and Reinvestment Act of 2009 providemajor cities and states with the capacity through the Com-munities Putting Prevention to Work initiative to addressnutrition policy, including strengthening nutrition and bever-age standards in schools. All of these AHA-supported nutri-tion policy changes demonstrate the opportunity for advocacyto extend voluntary agreements by reinforcement throughlegislation or regulation, resulting in increased sustainability,accountability, and long-term impact.

Physical Education in Schools/Fitness IntegratedWith Teaching Kids ActStrengthening physical education has been an AHA/ASApriority for nearly a decade. Physically fit children are morelikely to thrive academically and socially.22–24 Through ef-fective physical education, children learn how to incorporatesafe and healthy activities into their lives. Physical educationis an integral part of developing the “whole” child in socialsettings and the learning environment. At the state level, theAHA/ASA advocates for daily, quality physical education(150 min/wk in elementary schools and 225 min/wk inmiddle and high school). The association supports policiesthat would:

● Require all school districts to develop and implement aplanned kindergarten through 12th grade physical educa-tion curriculum that adheres to national and state standards

● Hire a physical education coordinator at the state level toprovide resources and to offer support to school districts

● Offer regular professional development opportunities tophysical education teachers that are specific to their field

● Require physical education teachers to be highly qualifiedand certified

● Add valid fitness, cognitive, and affective assessments inphysical education that are based on student improvementand knowledge gain

● Encourage students to be active in moderate to vigorousphysical activity for at least 50% of physical educationclass time

● Provide appropriate equipment and adequate facilities● Require physical education for graduation● Not allow students to opt out of physical education to

prepare for other classes or standardized tests● Not allow waivers or substitutions

Advocating on these issues has been challenging, given thepressures of limited time in the school curriculum, strainedresources, and the emphasis on preparing for standardizedtests. Even if laws are passed, they may not be fullyimplemented if schools do not have the resources to hireenough teachers and to maintain or build adequate facilities.The 2010 Shape of the Nation Report revealed that despiteincremental improvements in making physical education a



Dow

nloaded from


requirement, an increasing number of states have allowedwaivers and exemptions from physical education classes; noprogress has been made in requiring daily physical educationin all grades from kindergarten through 12th grade.26

At the federal level, there was significant pressure to insertphysical education as part of the core curriculum require-ments in the Elementary and Secondary Education: Improv-ing America’s Schools Act (ESEA), which reauthorizes thefederal act that provides funding for services to low-achieving students and a variety of other educational pro-grams. The AHA did not feel it was able to navigate thecontentious education debate as a public health organization.Working with congressional staff and an educational consul-tant, the advocacy team crafted legislation that holds schoolsaccountable for providing students with high-quality physicaleducation and activity every day. These provisions provideinformation that can help parents, Parent Teacher Organiza-tions, and others shape approaches to increase physicalactivity among students based on available time and re-sources. The Fitness Integrated With Teaching (FIT Kids)Act provides information to parents and the public byrequiring all schools, districts, and states to report on stu-dents’ physical education programs on school report cardsalready required under ESEA. FIT Kids also supports profes-sional development for teachers and principals to promotechildren’s healthy lifestyles and physical activity and funds astudy to examine the impact of health and physical activity onstudent achievement.

The AHA took the lead in finding congressional sponsorsfor the FIT Kids Act and used grassroots and media advocacystrategies to promote the bill in both the House of Represen-tatives and Senate. Over the past 3 years, the AHA sponsoredor participated in events on Capitol Hill with the NationalFootball League, the National Association for Sport andPhysical Education, and celebrities and developed a sophis-ticated and engaging grassroots campaign. Government rela-tions staff also built a coalition of supporters for the bill thatincludes more than 70 organizations, provided witnesses forhearings on the legislation, and conducted numerous meet-ings with Capitol Hill staff to explain the legislation.

As of June 2010, FIT Kids had 111 cosponsors in theHouse of Representatives and 23 in the Senate. It enjoyswidespread support among members on the relevant Houseand Senate committees. First Lady Michelle Obama began acomplementary “Let’s Move” initiative to encourage physicalactivity and healthy eating habits among children. In responseto momentum created by the Let’s Move campaign, theHouse passed a streamlined version of FIT Kids in April2010. The AHA will continue to work to incorporate the morecomprehensive language into any future authorization ofESEA or other opportunities that arise at the federal level.

The AHA’s work in physical education policy illustratesthe need to tailor an advocacy strategy based on the potentialcontributions at each level of government; the value of acomprehensive and integrated strategy that includes policy,government relations, grassroots, and media advocacy compo-nents; and the need to assess the environment for opportunities

Table. AHA Strategic Policy Agenda 2010–2013

AHA Strategic Priority Advocacy Plan to Achieve this Priority

Support heart disease and stroke research andthe research environment

Provide support for basic, clinical, translational, health services, outcomes, genomics, and comparativeeffectiveness research and the overall research environment, as well as community health services,public health programs, policy evaluation and economics. Lift barriers that impede the conduct ofmedical research

Promote cardiovascular health Promote public policies aimed at promoting and improving health for all Americans. Obesityprevention, diagnosis, and treatment; nutrition; physical activity/physical education; tobacco control;and prevention of air pollution

Support high-quality/high-value heart diseaseand stroke care and reduce health disparities

Promote public policies aimed at improving healthcare quality, reducing health disparities, andpromoting high-value, evidence-based cardiovascular care. Improve healthcare quality. Promotesafe, evidence-based, and high-value treatments for cardiovascular disease and stroke

Ensure appropriate and timely access to heartdisease and stroke care

Advance comprehensive coverage and timely access to appropriate care for heart disease, peripheralartery disease, and stroke with a focus on adequate and affordable coverage, appropriate systemsof emergency care, telemedicine, and surveillance

Healthcare reform and implementation

Systems of care

Stroke

STEMI

Out-of-hospitalcardiacarrest

Telehealth

Rehabilitation

Other emergency care

Surveillance

Protect the nonprofit environment Ensure the continued societal contributions and viability of nonprofit organizations by monitoring and,as appropriate, including legislative and regulatory efforts that attempt to restrict or prohibitcharitable giving and other nonprofit efforts and activities

AHA indicates American Heart Association; STEMI, ST-elevation myocardial infarction.



Dow

nloaded from


to move provisions that achieve AHA strategies objectives inlarger, “must pass” legislation. It also represents the patience andpersistence required in advocating on an issue for a long periodof time and conducting effective leadership on a signature issuefor the association.

Future AHA Advocacy: 2010 to 2013Recently, the AHA developed its strategic policy agendafor 2010 to 2013 with an emphasis on all of the criticalareas that will help the association reach its 2020 goals ofdecreasing death and disability from cardiovascular dis-ease and stroke and improving the cardiovascular health ofthe population (Table; the complete agenda can be found athttp://www.heart.org/HEARTORG/Advocate/PolicyResources/Policy-Resources_UCM_001135_SubHomePage.jsp). These in-clude strategies focusing on increased funding for heart diseaseand stroke research; promoting cardiovascular health throughobesity, nutrition, physical activity, and clean air policies; andsupporting high-quality/high-value heart disease and stroke careand timely access to heart disease and stroke care. Included ineach of the strategic areas is the association’s commitment to

proactively confront and address, through public policy, thehealth inequities and disparities that exist in the United States.

ConclusionThe AHA’s advocacy activities are of critical importance ifthe association is to achieve its 2020 goals to decrease deathand disability from heart disease and stroke and to improvethe cardiovascular health of all Americans. Public policy is akey component of transforming the public health. The asso-ciation’s advocacy work fosters a well-grounded enthusiasmamong the AHA’s staff and volunteers. This is reflected in theAHA’s passionate, engaged volunteers and supporters, legis-lative lobbying, regulatory activities, policy research, andmedia advocacy that extend across the country and affectevery level of government. The scope of the AHA’s advocacyactivities and particular tactics and strategies will evolve inresponse to the policy environment and to the needs ofindividuals who have heart disease and stroke. Ultimately, theAHA strives to transform the environments in which peoplelive to promote health, to create quality health care, toimprove medical treatment, to support robust scientific re-search, and to help people live longer, healthier lives, free ofheart disease and stroke.

Appendix A. Stroke Advocacy

EMS indicates emergency medical services; tPA, tissue-type plasminogen activator; GWTG, Get With The Guidelines; CDC, Centers forDisease Control and Prevention.



Dow

nloaded from

http://www.heart.org/HEARTORG/Advocate/PolicyResources/Policy-Resources_UCM_001135_SubHomePage.jsp

http://www.heart.org/HEARTORG/Advocate/PolicyResources/Policy-Resources_UCM_001135_SubHomePage.jsp


Appendix B. Policy Strategies to Achieve Ideal Cardiovascular Health

Measure of Cardiovascular Health Advocacy/Policy Solutions

Smoking status Comprehensive clean indoor air laws

Ideal for cardiovascular health: Excise taxes on tobacco products

Adults: never smoked or quit �1 y ago Increase/sustain funding for state smoking cessation/prevention programs

Children: never tried or never smoked a whole cigarette Comprehensive implementation of FDA regulation of tobacco

Go to www.americanheart.org/tobaccontrol for additional policy resources Implement clinical guidance and monitor health claims around smokelesstobacco and other “harm reduction” products

Comprehensive smoking cessation benefits in Medicaid, Medicare, andother health plans

Eliminate tobacco sales in pharmacies and other health-relatedinstitutions

Physical activityIdeal for cardiovascular health:

Adults: �150 min of moderate or �75 min of vigorous physical activityeach week.Children: �60 min of moderate to vigorous physical activity a day.

Go to www.fitkidsact.org, www.americanheart.org/workplacewellness, andwww.americanheart.org/obesitypolicy for additional policy resources

Address the built environment and support efforts to design workplaces,communities, and schools around active living; integrate physicalactivity opportunities throughout the day

Fund and develop walking/biking trails that connect key aspects of thecommunity; increase safe routes to school; implement zoning/buildingordinances that encourage walking/stair use, wider streets to allow forbiking and walking, pedestrian-friendly streets and roadways withappropriate crosswalks, sidewalks, traffic lights, etc, and slower speedlimits in walking/biking areas

Implement shared use of school facilities within the community andsupport the construction of school fitness facilities

Increase sports, recreational opportunities, parks, and green spaces inthe community

Increase the quantity and improve the quality of physical education inschools; support 60 minutes of supervised, moderate-vigorous physicalactivity per day integrated throughout the school day

Help implement the national physical activity plan;

Body mass indexIdeal for cardiovascular health:

Adults: Between 18.5 and 25 kg/m2

Children: Between the 15th and 85th percentilesGo to www.americanheart.org/obesitypolicy for additional policy resources

Adequate prevention, diagnosis, and treatment of overweight and obesityin the healthcare environment

Robust surveillance and monitoring

Comprehensive worksite wellness programs

Implement and monitor strong local wellness policies in all schools.

Adequate funding and implementation of coordinated school healthprograms

Comprehensive obesity prevention strategies in early childhood anddaycare programs;

Healthy dietIdeal for cardiovascular health:

Adults and children should achieve 4 of the 5 following key components of ahealthy diet:

Fruits and vegetables: �4.5 cups a dayFish: 2 or more 3.5-oz servings a week (preferably oily fish)Fiber-rich whole grains (�1.1 g fiber per 10 g carbohydrates): three1-oz-equivalent servings per daySodium: �1500 mg/dSugar-sweetened beverages: �450 kcal (36 oz) per week

Go to www.americanheart.org/obesitypolicy for more specific policy resources

Work to eliminate food deserts and to improve access and affordability ofhealthy foods

Strengthen nutrition standards in schools for meals and competitivefoods and in all government nutrition assistance or feeding programs

Improve food labeling

Menu labeling in restaurants

Continue to monitor the removal of industrially produced trans fats fromthe food supply and ensure the use of healthy replacement oils

Address food marketing and advertising to children

Nutrition education/promotion in schools

Limit added sugar and sodium in the food supply

Total cholesterolIdeal for cardiovascular health:

Adults: �200 mg/dLChildren: �170 mg/dL

Ensure adequate healthcare coverage for prevention and treatment ofdyslipidemia Increase funding for programs that eliminate healthdisparities

(Continued)



Dow

nloaded from


Appendix C

The American Heart Association: AddressingHealth Disparities Through AdvocacyThe AHA pursues a comprehensive advocacy agenda toaddress a range of issues in the areas of heart disease andstroke research, cardiovascular health (nutrition, physicalactivity, obesity treatment and prevention, tobacco cessa-tion and prevention, and air pollution), the quality andvalue of heart disease and stroke care, and appropriate andtimely access to care. Embedded throughout our advocacywork at the local, state, and federal levels is a commitmentto confront proactively and to address, through publicpolicy, the health inequities and disparities that exist in ourcountry. In addition to prioritizing policy goals to servediverse and disparate populations, AHA also works toengage these individuals in its grassroots advocacy cam-paigns. Recruitment materials reflect diverse populations;advocates engaged in grassroots and media advocacyopportunities represent a diverse audience; and outreach isconducted through cultural health initiatives to engage adiverse audience.

If the AHA is to achieve its 2020 goals to reduce death anddisability resulting from cardiovascular disease and stroke by20% and to improve the cardiovascular health of all Ameri-cans by 20%, the association has to prioritize opportunities toaddress social inequities, issues specific to vulnerable popu-lations (ethnic and racial minorities, those with low income orless education, children, blue collar workers), and the impor-tance of removing barriers and obstacles for risk reductionand behavior change. Often the most disadvantaged membersof the population have the greatest need for preventivescreenings, health promotion, or programming and have theleast access to or are the most reluctant to participate in theseopportunities. The fundamental causes of vulnerability arerooted in issues of daily life, most often beyond the scope oftraditional public health, so it will be important for the AHAto consider engaging with nontraditional partners to considerways to reduce health disparities in communities.

The following list is a summary of some of the specificways AHA advocacy addresses issues around health dispar-ities and vulnerable populations.

● Support delivery system reforms throughout the continuumof care aimed at improved care coordination (including

disease management, transitional care, hospice, and end-of-life interventions), as well as initiatives aimed at sup-porting family caregivers of persons with cardiovasculardisease and stroke.

● Support the development, implementation, evaluation, anddissemination of effective public health policies and pro-grams to promote cardiovascular health and to reduce theburden, disparities, and costs of cardiovascular diseases.

● Work to eliminate race, sex, and geographic disparities inhealth care.

● Address the adequacy of the healthcare workforce to meetthe needs of disparate populations in underserved areas.

● Promote reporting on healthcare quality measures, includ-ing by sex and ethnicity.

● Advocate for additional research to determine how best toreach and engage underserved populations and to optimizepolicy interventions for people of all races, age, ethnicities,educational attainment, and income levels.

● Support health plan coverage that includes essential health-care services such as hospital and ambulatory care, pre-scription drugs, preventive services, emergency care, andrehabilitation.

● Eliminate financial barriers to preventive services in publicand private health insurance plans.

● Ensure that personalized healthcare services are accessibleto everyone.

● Remove barriers for rehabilitation and treatment of heartand stroke patients.

● Improve access to preconception and prenatal care forwomen of reproductive age to reduce modifiable riskfactors for congestive heart disease.

● Protect individuals undergoing genetic tests from discrim-ination of any kind.

● Strengthen nutrition standards in schools for meals andcompetitive foods and in all government nutrition assis-tance or feeding programs.

● Establish sustainable funding for tobacco cessation/preven-tion programs that meet or exceed Centers for DiseaseControl and Prevention recommendations.

● Ensure comprehensive smoking cessation benefits in Medi-care, Medicaid, and other health plans.

● Establish a National Heart Disease and Stroke SurveillanceUnit to produce annual reports on key indicators ofprogress in the prevention and management of heart diseaseand stroke, including progress in disparate or vulnerablepopulations.

Appendix B. Continued

Measure of Cardiovascular Health Advocacy/Policy Solutions

Blood pressureIdeal for cardiovascular health:

Adults: �120/80 mm HgChildren: �90th percentile

Reduce sodium in the food supplyIncrease funding for state heart disease and stroke prevention programsEnsure the availability of essential cardiovascular disease preventivebenefits in private insurance and public health programs;

Fasting plasma glucoseIdeal for cardiovascular health:

Children and adults: �100 mg/dL

Ensure adequate healthcare coverage for early treatment and preventionof diabetes mellitus

FDA indicates US Food and Drug Administration.



Dow

nloaded from


● Advocate for robust health promotion and obesity preventionprograms in early childhood programs, including Head Start.

● Address the issue of food economics so that healthyalternatives are less expensive and less nutritious foodscost more, bringing subsidies/incentives and other pric-ing strategies more in line with the AHA’s Diet andLifestyle Recommendations and the Dietary Guidelinesfor Americans.

● Advocate for healthy food retailing in underserved areas.● Encourage the availability, affordability, and appropriate

distribution of fruits, vegetables, fiber-rich whole grains,fish (especially fatty fish), and low-fat dairy products toat-risk or vulnerable populations.

● Support the creation of and sustain existing Offices ofMinority Health (or Multicultural Health) and Offices ofHealth Equity in state health departments.

● Secure and protect public funding and state appropriationsthat support eliminating health disparities initiatives.

● Secure state-level public funding for the WISEWOMAN(Well–Integrated Screening and Evaluation for WomenAcross the Nation) (or like) programs, which providelow-income, underinsured, or uninsured 40- to 64-year-oldwomen with the knowledge, skills, and opportunities toimprove their diet, physical activity, and other life habits toprevent, delay, or control cardiovascular and other chronicdiseases.

Disclosures

Writing Group Disclosures

Writing GroupMember Employment Research Grant

OtherResearchSupport

Speakers’Bureau/Honoraria

ExpertWitness

OwnershipInterest

Consultant/Advisory Board Other

Larry B.Goldstein

Duke University andDurham VAMC

None None None None None None None

Jill Birnbaum American HeartAssociation


Timothy J.Gardner

Christiana CareHealth System


Raymond J.Gibbons

Mayo Clinic None None None None None Molecular InsightPharmaceuticals*

None

LantheusMedical Imaging*

Therox Corp*

Loren Hiratzka Cardiac, Vascular andThoracic Surgeons

Inc; TriHealth Inc; VailResorts Inc


Neil Meltzer Sinai Hospital ofBaltimore/Lifebridge

Health


Sue Nelson American HeartAssociation


Ralph L. Sacco University of Miami,Neurology

NINDS grant; NorthernManhattan Study, PI;University of Miami†

None None None None None None

Mark Schoeberl American HeartAssociation


Laurie Whitsel American HeartAssociation


Clyde W. Yancy Baylor UniversityMedical Center


This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on theDisclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the personreceives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or shareof the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under thepreceding definition.

*Modest.†Significant.



Dow

nloaded from


References1. Christopulos D. Time, Feeling, and Focus: A Newly Designed Culture:

The Evolution of the American Heart Association, 1975 through 1997.Dallas, Tex: American Heart Association; 2000.

2. Berry JM. Effective advocacy and nonprofits. In: Reid EJ, Montilla MD,eds. Nonprofit Advocacy and the Policy Process. Washington, DC: TheUrban Institute; 2001:1–8.

3. Heinz JP. The Hollow Core: Private Interests in National Policy Making.Cambridge, MA: Harvard University Press; 1993.

4. Rees S. Effective advocacy on limited resources. In: Reid EJ, MontillaMD, eds. Nonprofit Advocacy and the Policy Process. Washington, DC:Urban Institute; 2001:9–16.

5. Stoto MA, Abel C, Dievler A. Healthy Communities: New Partnershipsfor the Future of Public Health. Washington, DC: Institute of Medicine,National Academy Press; 1996.

6. Hill A, De Zapien JG, Staten LK, McClelland DJ, Garza R, Moore-Monroy M, Elenes J, Steinfelt V, Tittelbaugh I, Whitmer E, Meister JS.From program to policy: expanding the role of community coalitions.Prev Chronic Dis. 2007;4(4):A103.

7. Roussos ST, Fawcett SB. A review of collaborative partnerships as astrategy for improving community health. Annu Rev Public Health. 2000;21:369–402.

8. Campbell RB, Balbach ED. Building alliances in unlikely places: pro-gressive allies and the Tobacco Institute’s coalition strategy on cigaretteexcise taxes. Am J Public Health. 2009;99:1188–1196.

9. The Health Impact Project. http://www.healthimpactproject.org/?cid�xem-emc-ca. Accessed December 17, 2010.

10. Shortell SM, Weist EM, Sow MS, Foster A, Tahir R. Implementing theInstitute of Medicine’s recommended curriculum content in schools ofpublic health: a baseline assessment. Am J Public Health. 2004;94:1671–1674.

11. Committee on Assuring the Health of the Public in the 21st Century,Institute of Medicine. The Future of the Public’s Health in the 21stCentury. Washington, DC: National Academy Press; 2002.

12. Eriksen M. Lessons learned from public health efforts and their relevanceto preventing childhood obesity. Preventing Childhood Obesity: Health inthe Balance. Washington, DC: National Academies Press; 2005:343–376.

13. Kumanyika SK. Environmental influences on childhood obesity: ethnicand cultural influences in context. Physiol Behav. 2008;94:61–70.

14. Fundamentals of Smokefree Workplace Laws. 2008. http://kuneman.smokersclub.com/PDF/CIA_Fundamentals.pdf. Accessed December 17,2010.

15. Committee on Secondhand-Smoke Exposure and Acute Coronary EventsPractice. Secondhand Smoke Exposure and Cardiovascular Effects:Making Sense of the Evidence. Washington, DC: Institute of Medicine;2009.

16. Glantz SA. Meta-analysis of the effects of smokefree laws on acutemyocardial infarction: an update. Prev Med. 2008;47:452–453.

17. National Health Interview Study. Atlanta, GA: National Center for HealthStatistics; 2008.

18. Nutrition Standards for Foods in Schools: Leading the Way TowardHealthier Youth. Washington, DC: Institute of Medicine; 2007.

19. Centers for Disease Control and Prevention (CDC). Availability of lessnutritious snack foods and beverages in secondary schools–selectedStates, 2002–2008. MMWR Morb Mortal Wkly Rep. 2009;58:1102–1104.

20. School Policies and Practices to Improve Health and Prevent Obesity:National Elementary School Survey Results. Princeton, NJ: Robert WoodJohnson Foundation; 2010.

21. Sharma LL, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public healthfailures. Am J Public Health. 2010:100:240–246.

22. Geier AB, Foster GD, Womble LG, McLaughlin J, Borradeile KE,Nachmani J, Sherman S, Kumanyika S, Shults J. The relationshipbetween relative weight and school attendance among elementary school-children. Obesity (Silver Spring). 2007;15:2157–2161.

23. Shore SM, Sachs ML, Lidicker JR, Brett SN, Wright AR, Libonati JR.Decreased scholastic achievement in overweight middle school students.Obesity (Silver Spring). 2008;16:1535–1538.

24. Cooper KH, Everett D, Meredith MD, Kloster J, Rathbone M, Read K,Texas statewide assessment of youth fitness. Res Q Exerc Sport. 2010;81(suppl)ii–iv.

25. Active Education: Physical Education, Physical Activity and AcademicPerformance. Princeton, NJ: Robert Wood Johnson Foundation; 2009.http://www.activelivingresearch.org/files/Active_Ed_Summer2009.pdf.Accessed December 17, 2010.

26. The 2010 Shape of the Nation Report: Status of Physical Education in theUSA. Reston, VA: National Association for Sport and Physical Educationand the American Heart Association; 2010.

KEY WORDS: AHA Scientific Statements � public policy � healthcare �advocacy � heart disease � stroke

Reviewer Disclosures

Reviewer EmploymentResearch

GrantOther Research

SupportSpeakers’

Bureau/HonorariaExpert

WitnessOwnership

InterestConsultant/Advisory

Board Other

Diana Aviv Independent sector None None None None None None None

Julia Coffman Center for EvaluationInnovation


Barry A. Franklin William BeaumontHospital

None None None None None Smart Balance* None

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the DisclosureQuestionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or moreduring any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns$10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “Significant” under the preceding definition.

*Modest.



Dow

nloaded from

http://www.healthimpactproject.org/?cid=xem-emc-ca

http://www.healthimpactproject.org/?cid=xem-emc-ca

http://kuneman.smokersclub.com/PDF/CIA_Fundamentals.pdf

http://kuneman.smokersclub.com/PDF/CIA_Fundamentals.pdf

http://www.activelivingresearch.org/files/Active_Ed_Summer2009.pdf


HiratzkaNelson, Timothy J. Gardner, Clyde W. Yancy, Raymond J. Gibbons, Ralph L. Sacco and Loren

Larry B. Goldstein, Laurie P. Whitsel, Neil Meltzer, Mark Schoeberl, Jill Birnbaum, SueRecommendation From the American Heart Association

American Heart Association and Nonprofit Advocacy: Past, Present, and Future: A Policy

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2011 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/CIR.0b013e31820a5528

2011;123:816-832; originally published online January 18, 2011;Circulation.

http://circ.ahajournals.org/content/123/7/816World Wide Web at:

The online version of this article, along with updated information and services, is located on the

http://circ.ahajournals.org//subscriptions/

is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer this process is available in the

click Request Permissions in the middle column of the Web page under Services. Further information aboutOffice. Once the online version of the published article for which permission is being requested is located,

can be obtained via RightsLink, a service of the Copyright Clearance Center, not the EditorialCirculationin Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions:


Dow

nloaded from

http://circ.ahajournals.org/content/123/7/816

http://www.ahajournals.org/site/rights/

http://www.lww.com/reprints

http://circ.ahajournals.org//subscriptions/


Documents

AHA Policy Recommendation - Homepage | Circulationcirc.ahajournals.org/content/circulationaha/123/7/816...AHA Policy Recommendation American Heart Association and Nonprofit Advocacy: