Editor’s note: For more on the state of prevention efforts and the impact of the cuts to the Prevention and Public Health Fund, see this Health Affairs Blog “Contributing Voices” post by Jeffrey Levi and an additional post about a Health Policy Brief on the Fund.
Two years ago with enactment of the Affordable Care Act, our nation was poised to follow a new prescription for health. The world’s biggest spender on health care and a nation whose health system — a $2.7 trillion enterprise — was largely oriented to treat those who were sick and injured had just made an extraordinary downpayment on prevention and wellness. With this one measure, we were on the cusp of transforming our nation’s health system from one that provides sick care to one that keeps people healthy as a first goal.
The prevention cornerstone of the health reform law is the Prevention and Public Health Fund, a historic multiyear commitment to invest in the capacity of public health systems and engage communities in ways that allow making the healthy choice the easy choice. While some monies from this fund have already been invested to support local prevention and public health initiatives, our hopes for an appropriate and full transformation toward population health may be slipping away.
Why should we be concerned? Let’s look at history. Our greatest advancements in health have been achieved on a population basis. Since 1900, the average lifespan of people in the United States has grown by more than 30 years; 25 years of this gain are attributable to advances in public health and prevention. Vaccinations, motor vehicle safety and other injury prevention initiatives, fluoridation, addressing the scourge of tobacco and other public health interventions have had more to do with assuring the health and extending the life of the American people than all the medical advancements of the past century.
There are some that question whether these investments are really needed. I believe they are. As a physician, I know there are many wonderful things that happen in clinical settings, but I also know that health occurs long before people get to a doctor’s office. Clinical care is not enough. Health is about safe food and water, clean air, healthy housing, good education and a range of other social determinants best addressed on a community or population basis. Public health in partnership with the community performs this important work.
Yet we spend only 3 percent of our health care dollar on true preventive services. And public health has been underfunded for years. The history of population health in this country has been one of fiscal and system instability. Ill-timed budget reductions and inadequate investments have resulted in diseases returning with a vengeance. Two recent examples are the 1970 reductions in funding for tuberculosis, which resulted in a resurgence of the disease in the 1980s and required a more costly reinvestment to treat a more virulent pathogen.
Another example is the underinvestment in the proven intervention of immunizations. Funding has never kept pace with the need and the cost of vaccines for children or adults. In the case of adults, underfunding plus the lack of awareness leaves millions unprotected, leading to as many as 50,000 preventable deaths, thousands of preventable illnesses and $10 billion in preventable health care costs annually.
The Prevention and Public Health Fund
Consider now the Prevention and Public Health Fund, a $15 billion commitment over its first 10 years. The fund was designed to: (1) build a more sustainable national funding stream for public health; and (2) give dedicated funding for strategic investments in prevention. These two overarching goals would have the dual effect of creating a healthier population with more quality life years while helping contain rising health care costs.
Wisely, the fund was also created to allow for growth. Allocations rise over the life of the fund, assuring that the investments are fiscally affordable and, more importantly, making sure the system can responsibly absorb the infusion of funds.
First year allocations. In its inaugural year in fiscal year 2010, the fund dispersed $500 million. Its first allocation directed $250 million to boost the nation’s primary care infrastructure, an essential component for ensuring access to care. The investment is being used to train more than 500 new primary care physicians by 2015, support the development of more than 600 new physician assistants, help more than 600 nursing students attend school full-time and help states plan and implement innovative strategies to expand their primary care workforce by as much as 25 percent over 10 years.
The fund’s second allocation infused $250 million into prevention and public health. Half of this went to support federal, state and community prevention initiatives, such as obesity prevention and nutrition efforts, increase physical activity and tobacco prevention and control, and to integrate primary care services into publicly funded community-based behavioral health settings. The other half went to strengthen the public health infrastructure, support research and tracking and expand the Centers for Disease Control and Prevention’s (CDC) public health workforce programs and training centers.
Second year allocations. In the second year, the fund allocated $750 million to enhance many of the efforts from the first year as well as to begin measuring the health impact of the initiative. In addition, specific efforts to improve access to clinical preventive care included increasing awareness of the new prevention benefits provided under the health care law, increasing availability and use of immunizations, and helping integrate behavioral health services into primary care. Investments helped ensure state, tribal and local health departments have adequate information technology capacity as well as adequate training to detect and respond to the full range of threats to health.
A Repeat Of Past Mistakes Instead Of A New Start
Unfortunately, what we hoped was the start of an epic new chapter in how we approach and invest in population and preventive health is now looking more like a sequel to the sordid history of prevention and public health funding.
First, the Obama administration proposed a budget that, in total, cut prevention funding and then backfilled it with monies from the prevention fund. This not only violated the spirit of the Affordable Care Act in terms of ensuring sustainable funding, but it also created an alarming precedent. That is, it allowed the reduction of core budget authority for the nation’s most important prevention agency — the CDC — laying the groundwork for inadequate funding in future years.
Specifically, the president’s budget request for fiscal year 2013 cuts CDC budget authority by $664 million and diverts money from the prevention fund to supplant these cuts. Congress then took their cue from the administration and took a $6.25 billion cut from the fund spread out over the next 10 years — 33 percent of the fund’s 10-year value. The most regressive aspect of this policy decision was the use of the funds to offset, but not fix, the pending reduction to physician fees under Medicare. Imagine failing to check or change the oil, antifreeze or transmission fluid in your car and then paying your mechanic adequately to fix it when it breaks. That’s essentially what they’ve done. The health care system and its providers must be adequately resourced but not at the expense of efforts that mitigate disease in the first place or in ways that threaten the stability of the public health system.
So what does the future look like? Funding for the prevention fund will now remain flat at $1 billion a year until 2017, when it again begins to ramp up to the previous required appropriation of $2 billion annually by 2022. But the problem is more acute than that. The fund was scheduled to grow to $1.25 billion for fiscal year 2013, which starts this October. This leaves a $250 million shortfall from the president’s proposed budget that will need to be resolved.
Novel programs like the Community Transformation Grants, which support community-level efforts to reduce chronic diseases such as heart disease, cancer, stroke and diabetes, remain a bright hope for the future. By promoting healthy lifestyles, especially among population groups experiencing the greatest burden of chronic disease, these grants are helping to improve overall health and reduce health inequities. There is emerging evidence that this approach will have a positive effect on overall health care spending. According to CDC, approximately $103 million in prevention funding has been awarded to 61 states and communities serving approximately 120 million Americans. Despite recent reductions in funding, continued investments in these programs should continue.
Funding for core infrastructure of state, local and tribal health must continue as well if we are going to have the capacity to address current and emerging threats to the public’s health. According to the National Association of County and City Health Officials and the Association of State and Territorial Health Officials, there has already been a loss of over 49,000 jobs of public health workers and this is getting worse. Urgent and emergent threats to health have not taken a holiday. In the past few weeks there have been 76 people sickened from a multistate outbreak of Campylobacter from raw milk consumption, a measles outbreak after the Super Bowl, and a white powder scare at the U.S. Capitol reminiscent of the anthrax threats after 9/11. Public health agencies are addressing these threats as best they can, but there is a breaking point and they have reached it.
We remain a nation that ranks 36th in health in comparison to other nations at twice the cost. Chronic conditions like cancer, cardiovascular disease, diabetes and asthma remain among the leading causes of premature death at an annual cost of over $1 trillion, much of which is preventable. The Prevention and Public Health Fund is one way of addressing these needs and ensuring we have a balanced portfolio between treatment and prevention. Congress and the administration should restore funding to and protect the prevention fund. It remains a wise investment in the health of the nation and one of the crown jewels of the Affordable Care Act.