The pursuit of health equity – ensuring equal access to opportunities that enable all communities to lead healthy lives – is a critical task for the U.S. The direct and indirect medical costs associated with sickness and premature death resulting from health care inequities are enormous (estimated to be $230 billion and $1.24 trillion, respectively, for the years 2003 through 2006). A key institution in the struggle to attain health equity is the American public health system. That institution is under attack.
Recent legislative proposals to repeal and replace the Patient Protection and Affordable Care Act (ACA) have included the elimination of the Prevention and Public Health Fund (Prevention Fund), a vital source of state funding awarded through the Department of Health and Human Services and its centers. Established in 2010 by Section 4002 of the ACA, the Prevention Fund enables public and private organizations within states to design and conduct prevention, wellness, and public health activities that focus on disease prevention and strengthen public health infrastructure. The core objectives of the Prevention Fund are twofold: 1) institutionalizing annual investment to improve population health while 2) restraining private and public health care costs.
The Prevention Fund also enables the public health system to cement a highly-visible platform from which to alter social and economic norms that influence health equity [PDF]. Health inequity arises when social and economic determinants of health (e.g. lack of affordable and quality housing, unsafe neighborhoods, poor education, and non-living wages) lead to significant disparities in disease burden and health outcomes among different populations. The Prevention Fund has dispersed over $7 billion since 2010 to support health equity-oriented activities that provide health-promoting opportunities for vulnerable populations. Some of these activities include establishing community coalitions to build and measure the success of strategies to eliminate health disparities; creating and disseminating evidence-based nutrition and physical activity interventions targeting obesity within workplaces; and developing and strengthening relationships between the health care system and low-income and racial/ethnic groups challenged by problematic social, economic, and cultural risk factors. Prevention funds have also been used to strengthen and diversify the public health workforce, which may lead to increased health services to racial/ethnic and low-income populations.
Achieving health equity relies heavily on a public health system that adopts integrative approaches to addressing the social determinants of health, “not only in how it actively organizes, funds, and delivers health care”, [PDF] but how it works with and influences other sectors to address health inequalities. Our public health system has produced remarkable feats in health promotion and sickness prevention. Universal childhood vaccination, surveillance for foodborne illnesses, the fluoridation of drinking water, and the implementation of motor vehicle safety policies, are but a few examples of public health’s achievements. These and many other advances in population health have been possible because of a well-integrated public health system that works cooperatively with numerous partners, including federal agencies, state and local governments, businesses, non-profit organizations, academia, and the media.
The Congressional Budget Office (CBO) estimates that eliminating the Prevention Fund will reduce direct spending by $9 billion over the 2017 – 2026 period. However, achieving total health equity in the U.S. requires addressing health disparities and the social and economic determinants of health in tandem with a well-financed public health system. Without such, interventions and policies intended to eradicate health inequities may prove ineffectual, irrespective of how concerted or cogent the effort. Currently, only 3% of total health expenditures in the U.S. are dedicated to disease prevention and public health, an astonishing amount if one considers that 86% of total health care costs are associated with preventable conditions. The Institute of Medicine and The New York Academy of Medicine have each declared the deleterious effects of long-term inadequate financial investment in public health, especially on its ability to perform essential duties, such as enforcing public health laws and regulations, assuring a competent public health care workforce, and evaluating the effectiveness and quality of health care services.
The Prevention Fund essentially buttresses against further destabilization of the public health system. In FY 2016, three agencies – the Administration for Community Living, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration – received nearly $932 million in prevention funds to award to community-based public health initiatives in all 50 states. Many of these initiatives are geared towards strengthening infrastructure to enhance health service delivery, such as improving public health systems to increase vaccines to children, adolescents, and adults and creating rapid response networks to effectively combat infectious disease threats and childhood lead poisoning. Others focus on health promotion and injury prevention among at-risk populations, including developing and implementing youth suicide prevention and early intervention programs and expanding specialty services to individuals living with Alzheimer’s and dementia.
In the face of numerous ongoing public health crises across the U.S. (e.g. the water catastrophe in Flint, Michigan; the opioid epidemic across rural areas; the Zika virus outbreak; etc.), disavowing the Prevention Fund may pose further health risks to all American residents, not just those most susceptible to the interactive effects of adverse social and economic circumstances and disproportionate disease burden. Legislative jettisoning of the Prevention Fund at this inopportune moment will not only disrupt vital prevention efforts, but also undermine the hard work achieved by Prevention Fund collaborations. One-time budgetary allotments (such as a proposed $422 million supplement in community health center funding in fiscal year 2017) do little to compensate forfeiture of steady and secure investment in the public health system.
The good news is that the pursuit of health equity will (and should) carry on at multiple levels, regardless of the fate of the Prevention Fund. Health care organizations, through support from the Centers for Medicare and Medicaid Services’ Accountable Health Communities program, are partnering with social service providers to respond to patient’s unmet health-related social needs. Community agencies, many with private support from foundations such as the Robert Wood Johnson Foundation, are forming alliances with other non-profit organizations and academia to implement and evaluate initiatives that mitigate the health impacts of disadvantageous environments.
Achieving health equity in the U.S. requires long-term, binding public health investment in cooperative and complementary strategies. Legislation that falls short of this guarantee otherwise suggests that our commitment to ensuring a robust public health system to achieve health equity is uncertain.