Improving Health, Not Merely Health Care
To its detriment, the United States suffers from a fixation on clinical care and its delivery, crowding out the ability to undertake population-based strategies that offer opportunities for larger and less expensive gains in health. This affliction is evident in the nation's resource allocation decisions and in its public policy discourse. For example, the national dialogue about the Affordable Care Act (ACA) has centered on questions about the financial aspects of medical care and the government's role in ensuring broader coverage. Reforming the financing of health care is certainly at the heart of the ACA, but other objectives may be far more important. Those objectives are to advance "prevention, health promotion, and public health" and are reflected in the law's provisions calling for the establishment of a National Prevention, Health Promotion, and Public Health Council and of a Prevention and Public Health Fund ([S]4001 and [S]4002 of Pub L No. 111-148, respectively). The public health components of the ACA represent less than 2% of its estimated cost, yet already the Administration and Congress have cut the fund by a third to pay for other initiatives, including a deferment of the scheduled reduction in Medicare payments to physicians.1
Although medical care coverage is needed, the nation's health is mostly determined by factors that reside outside of the clinical care system. Medical care accounts for only 10% to 20% of the factors that shape health but accounts for about 97% of all health spending.2-4 As public health care professionals know, poor health outcomes begin in the community, in social and physical environments that are not primarily built with health in mind, and are sometimes inimical to good health. The nation is suffering the consequences of misplaced investment. Despite the highest level of health spending in the developed world, the United States has too little to show for it, ranking below averages on standard health measures compared with other high-income nations with sophisticated clinical care delivery systems. Compared with other advanced nations, a far greater proportion of US social spending is invested in clinical care as opposed to expenditures that boost other important contributors to health, such as education. For every dollar spent on health in most developed countries, $2 are spent on other socially valuable services, but for every dollar spent on health in the United States, only $0.83 goes to other social spending.5
The US health investment portfolio needs to be rebalanced, shifting the asset allocation to achieve a higher return. Clinical care expenditures must be reduced, while core public health functions of assessment, assurance, and policy development are expanded to sustain economic growth and continue gains in labor force participation and longevity. Filling the clinical care gaps (the seventh "Essential Public Health Service," to address unavailable personal care) diverted resources and focus from public health's core mission. The public health system that was vital in helping to build the modern United States in the 20th century has lost momentum and may be in decline, with serious cuts to its workforce and cuts to already inadequate funding.
These patterns of investment must change or the United States is likely to slide further and further behind peer nations in health and in economic competitiveness-in part due to the escalating direct and indirect costs of poor health to employers. To help rectify this, the Institute of Medicine (IOM) report For the Public's Health: Investing in a Healthier Future, released in April 2012, recommends that the Secretary of Health and Human Services set 2 targets for the nation: improving life expectancy and decreasing per capita health expenditure levels to reach the average among international peers (ie, wealthy nations with highly developed clinical care systems) by 2030. These targets are shocking both for their modesty and how controversial they are likely to be.
Public health helped vanquish old foes, such as infectious diseases that once decimated hundreds of thousands of Americans. The nation's public health departments, argues the IOM report, must now take up the fight against the chronic conditions, injuries, mental health disorders, and substance abuse responsible for most of the burden of disease. But they can do so only if they are adequately resourced. The current government spending on public health amounts to about 3% of the total of $2.5 trillion spent on health. That is $251 of $8086 spent per person.6 The report's recommendations provide guidance to strengthen the public health system, so it can help the nation improve the value on its health investments.
Why Invest More in Public Health
There are several reasons why investing in public health even in these rough economic times is a sensible course of action.
* The United States is not investing in the right things: too much is spent on medical care and not enough on other things that improve the nation's health, including strong public health departments. And the more we spend on medical care, the less is left to fund other societal actions that contribute to health.4,7
* A history of achievement shows that public health interventions work and offer good value for the money.
* Public health possesses the knowledge and skills to lead or inform and contribute to multisectoral efforts to improve population health.
* Although 2012 may not be a propitious time to increase spending, the United States cannot afford to delay, as the costs of chronic conditions and an aging population skyrocket. The status quo is not working, and we cannot afford to maintain it. The nation's health and economic competitiveness depend on finding a sufficient and sustainable way to support public health.
The Solution to the Funding Problem
The underfunding of public health is a chronic illness8 that will require a 2-pronged solution: improve efficiency and increase funding levels. First, the productivity and efficiency of the public health system should be increased. The system, and especially funders, can facilitate more productive and efficient use of existing resources by transforming the way public health funding is allocated, structured, and used. The inflexible, poorly coordinated, and fragmented way in which federal funding streams flow to states and localities must be more rational and facilitate achievement of the shared goals of multiple programs. To this end, the report recommended that public health funders change how they design funding mechanisms. Another step toward greater coherence and flexibility is to identify and reach agreement on a minimum package of public health services, consisting of both foundational capabilities, such as research and evaluation, policy analysis and decision support, and information systems, and basic program areas that every health department should have (see the Figure).
By reorienting funding to support the foundational capabilities, funders would acknowledge that promoting child health, controlling chronic diseases such as diabetes and heart disease, and preventing injuries all require similar communication skills, resources, and capacity. They also require a common ability to conduct policy analysis and communicate with legislators and to build community partnerships and mobilize stakeholders around shared interests that further objectives in a given area. These examples build on the existing lists of capabilities that include laboratory, surveillance and behavioral science.
The basic programs category refers not merely to the "bread and butter" health-promotion activities that public health departments have traditionally conducted but also to the strategies that have emerged and expanded over the past 1 to 2 decades, often on a shoestring budget. The cutting edge of public health efforts involves working across sectors, including among different government agencies, to implement policies that improve the social and environmental conditions that support or interfere with improving health. For example, health departments have worked with planning, transportation, and education departments to address factors (such as parks and other green spaces, complete streets, and school nutrition offerings) that influence a community's health outcomes. Public health cannot change national policies and investments in early childhood development, education, and other determinants of health, but it can use its considerable skills and knowledge to shed light on those factors and to inform and mobilize multiple stakeholders to change the most upstream causes of poor health.
Another way to increase the effectiveness and efficiency of the public health system is to better inform decisions; this will require enhancements both in research and in the transparency and uniformity of how revenues and spending are recorded, tracked, and reported. More research is needed to shed light on the effectiveness of population-based preventive interventions, to compare different interventions, and to identify best ways to organize and operate public health systems to deliver these services. A robust research and information infrastructure will allow the nation's public health system to reduce the cycle time required to learn what works and to target its strategies at the largest opportunities for reducing preventable disease burden and costs. Consequently, the IOM committee's report calls for:
* a dedicated stream of funding for research and evaluation (and other components of research, ie, a national agenda, data systems and measures, and methodologies to undertake comparative effectiveness research on population health strategies), and
* a uniform chart of accounts for use by all public health departments to enable more effective management systems as well as comparisons and other analyses based on accurate and complete financial data.
Second, although doing better with what we have is crucial, it is not enough. Instructing public health agencies to live within their means is inadequate advice when these means have always been limited and are currently shrinking, and while the needs-including protection against novel threats, such as pandemics, and maintenance against old foes, such as tuberculosis-have not diminished. New funds are required to establish a sufficient, stable, and sustainable source of revenue to support the basic needs of the nation's public health departments.
How Much Does Public Health Need?
What level of funding does public health need to ensure its fundamentals are sound and can sustain a reasonable national, state, and local effort? There are at least 2 different ways to answer the question. One is to respond in exasperation-the data are limited and weak-and to simply provide principles and guidance for thinking about the funding problem, skirting the question of estimates entirely. Another is to develop and offer an estimate, with the caveat that the data are, indeed, limited and weak to arrive at a reasoned and conservative estimate. The latter was the path taken by the IOM committee that authored For the Public's Health: Investing in a Healthier Future. The committee called for doubling the federal government contribution to public health from about $12 billion to $24 billion, in part to increase the federal share of public health funding that has shrunk to 15% compared with the 85% contributed by state and local public health agencies.6,9
To secure the increased funding needed, various options were reviewed by the committee, but it recommended a national medical care services tax as the preferred approach.7,10 However, there are obstacles to enacting any tax. Overcoming them will require communicating clearly to diverse constituencies on the compelling reasons to enact such a tax:
* The tax would add only minimally to the medical care delivery system's costs and is easily outpaced by natural annual increases in medical care expenses.
* The nation's current course is unsustainable. The current system of medical care delivery cannot be sustained, and the nation is losing its competitiveness because employers are burdened by the escalating costs.11
* The tax meets 3 criteria identified by the IOM committee including a coherent connection to population health, the potential to raise sufficient funds, and a low likelihood of deleterious economic effects.
A tax on medical services may increase costs slightly in the short run, but it has the potential to constrain longer-run cost trends by turning the tide of patients pushed into the system by preventable conditions. Can the nation afford the cost of such a tax? Given the economic forecast of escalating medical care costs, the United States should not delay pursuing a viable way to raise revenues to support public health.
Conclusion
For families, businesses, and nations, health is critical to their physical, mental, and economic well-being. The national debate on health reform has lost sight of this fundamental truth. It is not sufficient to just improve the coverage, financing, and quality of medical care. Most of the factors that shape a population's health reside outside the emergency department, outside the doctor's office, and outside even the most advanced medical care center. The nation's public health departments can lead, inform, and motivate communities. They pilot and present individuals, companies, congregations, schools, and other stakeholders with ways to engage and alter the social and physical environment to improve health. To do this work, public health will need tools and resources. Most of these are ordinary and not expensive, but they require funding through a budget that is stable and adequate to the tasks at hand. If we fail to strengthen our public health system now, we can look forward to falling further behind other developed nations and it will become more and more difficult to restore our health and competitiveness.
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