At the AHA, advocacy leads to health impact

In the 1970s, two stubborn challenges stood between the American Heart Association and its mission to raise awareness about preventing heart disease: inadequate public funding for cardiovascular research, and pervasive tobacco use.

AHA leaders, who had largely avoided directly lobbying elected officials since the organization's founding in 1924, realized they had to engage.

So in 1981, the organization established a dedicated government affairs team and opened the AHA Office of Public Advocacy in Washington D.C., focused on educating policymakers about the most pressing scientific and public health issues impacting cardiovascular disease.

"It was really a watershed moment," said Mark Schoeberl, the AHA's executive vice president for advocacy. "We recognized that mission advocacy isn't about politics; it's about good public policy and changing societal norms."

From the beginning, AHA advocacy has been a nonpartisan and trusted voice guided by an ever-growing base of scientific evidence. Numerous peer-reviewed publications on tobacco, access to care, food and nutrition, physical activity, best medical practices and more have informed health professionals, policymakers and the public on how best to improve the nation's health.

The advocacy office's initial focus at the federal level was on increasing the research budget of the National Institutes of Health and lobbying against tobacco use — topics that remain important today. As a result of efforts by the AHA, other health organizations and the research community to protect and increase the public investment in research, the NIH's budget has increased more than fourfold since 1990.

In the 1980s and 1990s, the AHA extended advocacy efforts to all 50 states, at capitals and in communities across the country. "That's where there was and continues to be tremendous opportunity to influence public policy important to the AHA," Schoeberl said.

Over the years, the AHA has led thousands of successful advocacy campaigns powered by volunteers. What started with a small group of employees has grown into a sophisticated staff and volunteer structure covering every level of government. The ranks of the AHA's You're the Cure grassroots network, launched in 2005, have grown to over half a million voices passionate about the AHA's mission.

"Our advocacy program has been one of the most substantial ways we have achieved our mission," said AHA Chief Executive Officer Nancy Brown. "It's helped to change the fabric of communities, of states and of our nation."

Here are some AHA advocacy successes over the years.

Preventing tobacco use

The AHA works to counter a decades-long public campaign by tobacco companies aimed at undermining the scientific evidence. One initiative, the Tobacco Endgame Movement, enlists advocates ages 13 to 24 to challenge manipulative marketing and to pledge to end tobacco use and nicotine addiction for good. The tobacco industry spends more than $8 billion a year to advertise and promote cigarettes alone.

Since 1998, the AHA has led or actively engaged in more than 3,000 tobacco-related campaigns at the local, state and federal levels.

A major accomplishment, beginning in the 1980s, was the AHA's involvement in passing comprehensive smoke-free laws, which protect people from secondhand smoke in workplaces including restaurants and bars. As of January 2024, 36 U.S. states had passed such laws, protecting 262 million people, or 82% of the population.

The AHA also advocated for higher excise taxes on tobacco, one of the most impactful strategies to reduce its use. Nationally, every 10% increase in cigarette prices reduces youth smoking by 7% and total cigarette consumption by 4%, research has shown. Over the years, the association has successfully supported passage of tobacco tax increases at the federal level and in almost every state, and continues to pursue further tobacco tax increases.

The AHA and partners advocated for the 2009 Family Smoking Prevention and Tobacco Control Act. That legislation gave the Food and Drug Administration authority to regulate tobacco products and included provisions prohibiting "characterizing flavors" in cigarettes. Advocates have continued efforts to prohibit the sale of menthol cigarettes, which were exempted in the federal law, and all other flavored tobacco products including electronic cigarettes.

In 2019, advocacy efforts paid off when Congress raised the federal minimum legal sales age for all tobacco products from 18 to 21. Extensive state-level advocacy for this measure, known as "T21," helped lead to the federal law.

"All of these things fundamentally changed the trajectory of tobacco use in this country," Schoeberl said. "When we change policy, we save lives."

Young people in particular stand to benefit from ongoing efforts to eliminate flavors in tobacco products. More middle school students are currently using tobacco – 6.6% in 2023 versus 4.5% the previous year.

Youth advocate DJ Yearwood volunteered in support of the AHA campaign to restrict flavored tobacco products in Kansas City, Missouri, in 2020, and continues to advocate against tobacco on the state and federal levels. All adult members of his immediate family have used vapes, chewing tobacco or cigarettes. His grandmother, a smoker for more than 40 years, has lung cancer that's probably tied to her smoking.

"I've seen friends and peers cycle through down-spirals of addiction starting with nicotine," Yearwood said. "It should not be OK for any company to target anyone with products they know would be harmful and that they wouldn't use themselves."

Yearwood and other volunteers are advocating for the FDA to finalize proposed rules to prohibit the sale of menthol cigarettes and all flavored cigars. Removing menthol cigarettes from the market could save up to 654,000 lives, including up to 238,000 Black lives, over the next 40 years, experts estimate. Black people have been disproportionately targeted by tobacco companies with menthol products.

Yearwood hopes more young advocates will join in the efforts.

"There are more youth advocates than ever before, but there can always be more and a better representation of the communities that are impacted," Yearwood said.

Affordable, accessible health care

The AHA has advocated for changes to make the health care system work for all, including improving patient access to affordable, quality health care.

Perhaps the most significant outcome was the landmark Affordable Care Act legislation of 2010. It marked the biggest expansion of health coverage since the 1965 establishment of the federal Medicare and Medicaid programs. The Affordable Care Act incentivized states to expand Medicaid coverage to millions of low-income individuals and families, prohibited insurance companies from denying coverage to patients with preexisting conditions, created health insurance marketplaces, and created tax credits to help families afford health insurance.

"It was an important start: to champion health access for everyone," said cardiologist and 2009-10 AHA President Dr. Clyde Yancy, who spent considerable time meeting with members of Congress about the act.

Added Schoeberl: "The AHA supported the Affordable Care Act when not a lot of other organizations were willing to do so. It's a powerful example of being a relentless force on behalf of patients and families."

From 2011 to 2022, the AHA led 120 successful campaigns at the state level to improve health insurance access and coverage. So far 40 states and Washington, D.C., have expanded Medicaid coverage for families with low income, and the effort continues in the remaining states. As of May 2023, some 21.2 million people had gained health care coverage thanks to Medicaid expansion.

The AHA also has successfully urged more than 45 states to extend postpartum coverage in Medicaid.

Tina Marie Marsden began volunteering for the AHA nearly 10 years ago after she was diagnosed with heart disease at age 28, following the birth of her son. She has postpartum cardiomyopathy — a type of heart failure that develops late in pregnancy or shortly after delivery. She shared her story with lawmakers and testified before a legislative committee in 2022 in support of extending Medicaid postpartum coverage in Georgia from six to 12 months.

"For many people, heart failure is an invisible illness," she said. "There's a lack of awareness about it, and the symptoms that we suffer with in silence people can't see." Extending Medicaid's coverage window helps ensure women get the post-birth care they need.

Since the early 2020s, the AHA also has been instrumental in the passage and strong implementation of the federal No Surprises Act. The law protects people from unexpected bills for air ambulances and unplanned out-of-network care provided at an in-network hospital. Estimates show the law has prevented more than 10 million surprise bills since it was enacted in 2022.

Nutrition security

In the U.S., an estimated 38.4 million people — 11.6% of the population — have diabetes, the eighth-leading cause of death in the country, according to the Centers for Disease Control and Prevention. Meanwhile, obesity has been on the rise in recent decades, affecting about 42% of the population as of 2020.

"The obesity pandemic really began in the late '80s, and it's continued to increase over the last several decades," said endocrinologist and 2005-06 AHA President Dr. Robert H. Eckel. "With more obesity, there's more diabetes and heart disease."

AHA advocates have worked in numerous ways to improve nutrition security, reduce obesity and help people live healthier lives by making healthy foods more accessible and affordable.

In 2010, as part of the Affordable Care Act, national menu labeling was signed into law. The measure required major chain restaurants to make caloric information visible to customers before a purchase. AHA advocacy efforts helped shape those rules, which took effect in 2018.

More recently, the organization has promoted policies to ensure healthy drinks are offered as the default beverage with kids' meals and has worked to enact taxes on sugary drinks. Since the advocacy office was established, it's led or engaged in hundreds of nutrition-related campaigns, with 156 state and local campaigns from 2021 to 2022 alone.

The AHA has been integral in supporting federal and state policies that maintain benefits and maximize participation in the federal Supplemental Nutrition Assistance Program, or SNAP, helping those who qualify get groceries. In 2021, 41.5 million people participated in SNAP, up from 35.7 million people pre-pandemic, reinforcing the program's value as an essential safety net.

In schools, the AHA has helped pass policies that increase access to healthy school meals, including the Healthy and Hunger-Free Kids Act of 2010. Voices for Healthy Kids, launched in 2013 by the AHA and Robert Wood Johnson Foundation to drive policy affecting children's health, has successfully supported measures and secured funding at the state and local level to help increase access to safe drinking water.

The 'Chain of Survival'

Receiving CPR right away — the first step in a series of actions called the "Chain of Survival" — can double or triple a person's chance of survival after cardiac arrest outside the hospital. The AHA has helped get more people of all ages trained in CPR. The AHA educates more than 22 million people globally in CPR each year.

With 41 states now requiring schools to train students in CPR before high school graduation, about 2 million students could be leaving schools with this important skill, thanks in part to the AHA's advocacy efforts.

The AHA is committed to every household having at least one person who knows CPR or Hands-Only CPR. The organization is working to get all states to require schools to train students before graduation, while pressing for more widespread availability of automated external defibrillators, which can restore a normal heart rhythm to someone in cardiac arrest.

In 2023, the AHA launched Nation of Lifesavers™, a sweeping, multi-year initiative focused on training and policy change that aims to ensure anyone, anywhere is prepare and empowered to perform CPR. The AHA also joined the NFL in its Smart Heart Sports Coalition. Along with other organizations and sports leagues, the coalition advocates for state policies that can help save lives of high-schoolers who experience sudden cardiac arrest.

The association further advocates for telecommunicator CPR (T-CPR) policies that ensure when someone calls 911, the person on the other end of the line can recognize a cardiac event and coach the caller through CPR while dispatching emergency response. Twenty-five states now have T-CPR policies.

Better health for all

Cardiovascular disease remains the top killer of Americans and, with its related risk factors, accounts for nearly 40% of the disparity in life expectancy between Black and white people. Largely because of social determinants of health and historical and systemic discrimination, life expectancy at birth is about 71 years for Black people, compared with over 76 years for white people, 2021 figures show.

Women with diabetes are 44% more likely to develop cardiovascular disease than men with diabetes. Certain risk factors such as high blood pressure and diabetes increase heart attack risk in women more severely than in men.

The AHA advocates for and works with communities in their efforts to reduce health disparities, and is committed to addressing barriers to health equity so all people in all communities have the opportunity to live longer, healthier lives.

Advocacy efforts include working to further expand access to health care nationwide, addressing barriers to participation in cardiac rehabilitation, and eliminating racial and rural disparities in maternal health outcomes.

Differences in cardiovascular disease between women and men have long been a major AHA priority (and are the key focus of the organization's 20-year-old Go Red for Women movement).

One crucial victory was passage of the 1998 Women's Cardiovascular Diseases Research and Prevention Amendments to advance research and screening for cardiovascular and other diseases in women. The AHA also promotes increased federal funding for WISEWOMAN, a program that provides free screening and lifestyle intervention services to low-income, uninsured or underinsured women.

Additional areas of advocacy

Other AHA advocacy highlights include:

• Working to secure critical funding for stroke research. Deadly strokes have increased among younger and middle-aged adults. The AHA also continues to push for expanded insurance coverage of expert stroke care through telehealth.
• Helping to inform the 2018 federal physical activity guidelines, which outline how much physical activity people need to be healthy. Current priorities in this area include more and better physical education in schools, and "complete streets" that are safe and friendly for all users, not just drivers.
• Supporting legislation across the U.S. that has resulted in 8 million babies being screened each year for critical congenital heart defects. Current work includes a focus on ensuring survivors have access to psychological and other needed care.
• Advocating successfully for federal legislation to support vital research into valvular heart disease, which killed more than 23,000 people in the U.S. in 2021. That legislation has opened the door for nearly $24 million in additional funding to enhance a national cardiac arrest registry that can help improve emergency care.

As the AHA celebrates its 100^th anniversary, Schoeberl indicated that a key focus for advocacy moving forward will continue to be equitable health, ensuring all people benefit from surroundings that promote wellness and from medical advances that save lives.

"What makes the AHA so formidable in advocating for fact- and evidence-based public policy is our unparallelled staff and volunteer partnership. Together, we advance health and hope for everyone, everywhere."

Learn more about AHA advocacy.