The Future of Public Health

By Thomas R. Frieden, M.D., M.P.H.
The New England Journal of Medicine, October 29, 2015

The Role of Government

A responsive government can maintain that people are responsible for their own health while also taking public health action that changes default choices to make it easier for people to stay healthy. Key public health actions do one of three things, all of which are now well accepted but were initially controversial. The first is to promote free and open information — such as truth-in-advertising laws and nutrition-facts panels. The second is to protect people from harm caused by others — for example, by detecting adulterated food, prohibiting alcohol-impaired driving, and protecting workers and the public from second-hand smoke. Legal and policy changes in this area often both reflect and accelerate changes in social norms. The third is to implement societal interventions when individuals cannot efficiently or effectively protect their own health through such policies as vaccination mandates, clean air regulations, water fluoridation, micronutrient fortification of food, and elimination of lead in paint and gasoline — interventions that have all greatly improved the health of Americans.

The Future

In the future, clinical medicine could see costs increase without substantial improvement in health outcomes. Alternatively, new delivery models and technology could substantially increase healthy life expectancy. The public health field, for its part, may not be able to keep pace with changing risks and increased opposition to core public health actions that promote healthy living — or it could expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.

By working more closely together, clinical medicine and public health can help each other improve health maximally — and emphasize society’s responsibility to promote both healthy environments and consistent, high-quality care. Public health organizations can publicize information on health outcomes and risks that clarifies the need for, or achievement of, substantial progress. Clinical experts can identify and validate preventable harms and effective interventions to protect patients.

The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success. Everyone benefits when people are healthier.

Accountability for outcomes is essential — public health’s obsession with denominators can reduce the number of people missed by interventions that improve health and save lives. Working together, clinical medicine and public health can ensure that people live active and productive lives far longer than was ever thought possible.

(Thomas R. Frieden, MD, MPH, is the Director of the Centers for Disease Control and Prevention [CDC])

http://www.nejm.org/doi/full/10.1056/NEJMsa1511248

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Public Health’s Falling Share of US Health Spending

By David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH
American Journal of Public Health, November 12, 2015 (online ahead of print)

Abstract

We examined trends in US public health expenditures by analyzing historical and projected National Health Expenditure Accounts data. Per-capita public health spending (inflation-adjusted) rose from $39 in 1960 to $281 in 2008, and has fallen by 9.3% since then. Public health’s share of total health expenditures rose from 1.36% in 1960 to 3.18% in 2002, then fell to 2.65% in 2014; it is projected to fall to 2.40% in 2023. Public health spending has declined, potentially undermining prevention and weakening responses to health inequalities and new health threats.

Discussion

An analysis of the economic and political forces driving public health funding is beyond the scope of this brief report, but it is clear that public health funding has languished over the past decade. It is projected to continue falling as a share of overall health spending, although, like any projection, this should be interpreted cautiously.

The Affordable Care Act originally promised a $15-billion boost in public health funding. However, a 2012 law cut funding for the Affordable Care Act’s Prevention and Public Health Fund by $6.25 billion. Sequestration, which cut federal spending across the board beginning in 2013, reduced it even further; fiscal year 2015 appropriations are less than half the $2 billion originally budgeted.

Meanwhile, many state and local governments — the main source of public health dollars — have faced fiscal challenges. Whereas state medical care spending has continued to increase, public health spending has not.

There is no absolute measure of the optimal level of public health spending. However, an Institute of Medicine panel recently concluded that public health agencies are markedly underfunded, and that US health spending is out of balance, with spending for clinical care disproportionately high compared with spending for “population-based activities that more efficiently and effectively improve the nation’s health.” The current trajectory of health spending seems unlikely to close the funding gap identified by the Institute of Medicine panel.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302908

A century ago life expectancy was 54. Today it is 79. Public health has played a much greater role in realizing this gain than has clinical medicine. Although most health funds are being directed to clinical services, public health services will need support to continue and to expand the gains that have been more important to society as a whole.

Government must remain responsive to the nation’s health needs. Recognizing that, Congress included in the Affordable Care Act a $15 billion boost in public health funding. However, that was reduced in 2012 legislation by $6.25 billion, and then further reduced by sequestration. Public health appropriations for 2015 are less than half of the $2 billion budgeted.

How can these reductions be justified? The need for austerity? Not based on the billions of dollars being fed into the coffers of the wealthiest amongst us. Less need for government public health services? Not unless we are willing to accept a surge in preventable disease epidemics and injuries from public hazards. Can we justify these reductions based on the ideological principle that the responsibility for health should be shifted from the government to the individual? Even ideologues can suffer or die from uncontrolled epidemics, from uncorrected public hazards, or because of a lack of beneficial interventions that were not implemented.

In addition to these important public health actions, we would also benefit by adopting a government-run health care financing system – a single payer national health program. The failure to act makes our Congress one of the greatest public health hazards that we face. Electing the right people to Congress may be the most important single measure that we could take to maintain and improve the health of our nation.