Chapter 9 – Public Health and Prevention

FAST FACTS

  • Around 17 percent (13 million) of U.S. children ages 2-19 are obese and 35 percent (78 million) of U.S. adults are obese (source).
  • Between 20 and 40 percent of annual deaths caused by heart disease, cancer, unintentional injuries, stroke, and chronic lower respiratory diseases are preventable (source).
  • Cigarette smoking is the leading cause of preventable death in the U.S., and over 16 million Americans have a disease caused by smoking (source).
  • A $10 investment per person on community-based public health efforts could save an estimated $16 billion within five years (source).

BACKGROUND

Public health in the United States emerged in the early nineteenth century with a focus on water quality, sewers and other sanitation issues. In the 20th century, public health incorporated vaccinationsand early detection to address common communicable diseases such as tuberculosis and polio. Although these objectives are still important today, current public health strategies are primarily concerned with chronic diseases and disease prevention to address illnesses such as cancer, heart disease, and diabetes. In addition, public health authorities promote health lifestyles, nutrition and seek to address the social determinants of health. Public health authorities also provide lifesaving services in response to natural disasters, epidemics, and bioterrorism.

Various agencies, at the local, state, and national levels — as well as private entities — play a role in implementing public health initiatives. However, there have been funding cuts for public health within public agencies, and advocates maintain that these cuts constrain the ability to preserve and protect the nation’s health (source). In addition, many see political debates as slowing the response to public health concerns such as the opioid abuse epidemic and the Zika virus (source).

NATIONAL PUBLIC HEALTH INITIATIVES

  • In 2010, the Department of Health and Human Services (HHS) launched the Healthy People 2020, which renews an initiative started in 1990 that identifies public health benchmarks for a ten year period. The initiative chose the objectives with input from public health and prevention experts, government officials at all levels, as well as 2,000 organizations and the public. The topic areas include adolescent health; genomics and dementias; lesbian, gay, bisexual and transgender health; social determinants of health; and global health (source).
  • The Food and Drug Administration (FDA) redesigned the the familiar nutrition labels on packaged foods in May 2016. Those labels were mostly unchanged since 1994. By July 2018, the FDA will require most food manufacturers to use the new label, which more prominently displays calories per serving, and which, for the first time, breaks out added sugars from total sugar content (source).
  • The Lets Move! initiative that First Lady Michelle Obama launched in 2010 has drawn attention to the growing childhood obesity epidemic through a variety of efforts (source). As part of this initiative, the first lady and the White House promoted passage of the Healthy, Hunger-Free Kids Act, which aimed to improve the nutrition quality of snacks and meals provided by schools and increasing the number of students that could receive free or reduced lunches (source).
  • The Division of Community Health (DCH) at the Centers for Disease Control and Prevention (CDC) manages grants programs to support public health initiatives by states, localities, and national and community organizations (source). Current programs award nearly $94 million to support 93 awardees (source).

PUBLIC HEALTH AGENCIES

The jurisdiction over public health resides in multiple entities, both public and private, ranging from local to federal levels. At the federal level, eight agencies within HHS comprise the U.S. Public Health Service (PHS). These include: the Agency for Healthcare Research and Quality (AHRQ), which funds research on health care quality and delivery; the Centers for Disease Control and Prevention (CDC), which helps detect and respond to health threats; the Agency for Toxic Substances and Disease Registry (ATSDR), which researches the impact of toxic waste sites and other hazardous substances on health; and the Food and Drug Administration (FDA), which regulates consumer goods that impact health, such as tobacco, drugs, and food. Additionally, the Health Resources and Services Administration (HRSA) helps to improve access to health care for the medically underserved, the Indian Health Service (IHS) supports health care for Native Americans, the National Institutes of Health (NIH) funds biomedical and behavioral health research, and the Substance Abuse and Mental Health Services Administration (SAMHSA) funds prevention and treatment services for mental health and substance abuse (source).

In addition to HHS, several other federal agencies monitor and coordinate responses to public health issues, including the departments of Defense, Agriculture, Transportation, Housing and Urban Development, Veterans Affairs, and the Environmental Protection Agency. Public and private laboratories, hospitals, health care providers, and volunteer organizations help support the efforts of these organizations and the overall public health infrastructure. Key nongovernmental groups that complement the work of governmental agencies also include the American Public Health Association, the Association of State and Territorial Health Officials, and the National Association of County & City Health Officials.

STATES AND LOCAL GOVERNMENTS

Beyond federal initiatives to address public health issues of national scope, states and local municipalities manage ground-level implementation of efforts tailored to the needs of their specific communities.

For example, San Diego County initiated the Be There San Diego program in 2014 to reduce the prevalence of heart attacks and strokes. By collaborating with patients, communities, and providers, the program uses education and community engagement to help individuals manage risk factors including hypertension, high cholesterol, and diabetes (source).

Recently, the North Carolina Division of Public Health collaborated with North Carolina State University to create the program Diabetes Free NC. The program offers a variety of diabetes prevention efforts both online and in person (source).

In 2010, Iowa implemented its own immunization program to help reduce incidences of preventable diseases through increasing vaccinations (source). The program has already increased the number of immunizations for diseases such as HPV and Hepatitis B, and added over 200,000 people to their Immunization Registry Information System to better track immunizations (source).

FUNDING

Multiple studies have shown that increased spending on public health programs saves both lives and money (source). One such study showed clear links between local spending on public health and reductions in cardiovascular disease, diabetes, cancer, and infant mortality (source). Another report attributed recent record-breaking rates of sexually-transmitted diseases to decreases in state and local public health programs (source).

However, spending on public health makes up only a small percentage of federal spending. Federally, public health expenditures account for only about 1.5 percent of all health-related expenditures (source).  Public health service agencies receive funding from federal, state and local sources to include: discretionary appropriations, user fees, funds from the Affordable Care Act such as the Prevention and Public Health Fund, (source), private sector grants and contracts. However, funding mechanisms for national public health departments is not well coordinated and lacks predictability and flexibility. Funding may increase in response to public health emergency or decrease due to economic downturn (source)

States receive most of their public health funding from federal sources, but a significant amount also comes from state sources, with a smaller amount coming from fees and fines. Much like federal funding, state funding for public health also varies considerably. In 2015, average per capita public health spending was $86 per person, with Alaska spending the most ($227 per person), and Nevada spending the least ($33 per person) (source). Local funding for public health varies even more. In 2012, the average amount that localities spent on public health was $41, although some localities spent nothing.  (source).

PREVENTION AND PUBLIC HEALTH FUND

In 2010, ACA created the Prevention and Public Health Fund to help support local, state, and national public health programs and to increase access and improve quality of care. The fund also helps to improve public health infrastructure and the health care workforce as well as expanding research and tracking efforts.

The ACA authorized $18.75 billion between 2010 and 2020, with an additional $2 billion per after 2020. Although the original appropriation for 2016 was $2 billion, budget cuts decreased the amount to $932 million. The Centers for Disease Control and Prevention received a majority of this money for initiatives addressing heart disease, tobacco cessation, diabetes prevention, and other public health issues. The rest of the funds went to the Substance Abuse and Mental Health Services Administration and the Administration on Aging, housed within the Administration for Community Living (source).

The fund has been a source of controversy because some claim that the money from the fund can be spent without congressional authorization or oversight on projects unrelated to public health (source). With a new Republican administration in the White House and Republican majorities in both houses of Congress, the Prevention and Public Health Fund – like all of the ACA – is potentially a target for repeal legislation (source).

EMERGING CHALLENGES

  • Avian Influenza. Flu viruses that occur normally among wild birds can infect domestic poultry, and in some rare cases, human infections have occurred (source). In February 2017, the World Health Organization announced that an epidemic of Asian H7N9 had infected 460 humans, bringing the total number of humans infected since 2013 by this strain to 1,258 individuals. Since these pathogens continually mutate, and avian flu “could gain the ability to spread easily and sustainably among people,” the CDC monitors the spread of this and other bird flu viruses (source).
  • Climate Change. Health policy experts increasingly point to a relationship between climate change and human health. Climate change correlates with a higher risk of vector-borne diseases, such as diseases carried by mosquitoes, ticks, and fleas (source). Higher temperatures also make it easier for harmful pollutants to stay in the air, which decreases air quality (source). This contributes to decreased lung function and increased hospital admissions for respiratory illnesses such as asthma (source). Other health threats include extreme weather events that cause, severe storms, flooding and wild fires.
  • Health Behaviors. Some advocates argue that the government should step in to influence health behaviors to achieve better health outcomes, while opponents of such regulatory action counter that this gives the government too much power in regulating individual autonomy. For example, the New York State Court of Appeals ruled that a New York City ban on sodas over 16 ounces was unconstitutional and overstepped the government’s regulatory powers (source). More recently, a tax on soda and other sugar-sweetened beverages in Philadelphia sparked national attention. While some advocated for the law’s ability to address diabetes, obesity, and heart disease, others, including the soda industry, opposed the law as a regressive tax (source). In the 2016 general election, four additional cities including San Francisco instituted their own taxes on sugar-sweetened beverages (source).
  • Gun Violence. Recent mass shootings have sparked a national debate about gun violence and how to address gun-related injuries and fatalities. Following the worst mass shooting in the nation’s history in an Orlando night club, the American Medical Association declared gun violence a public health issue (source). Several states have already passed legislation aimed at curbing gun-related violence, such as requiring background checks for gun buyers, but similar efforts at the federal level have failed repeatedly (source).
  • Immunizations. Following the outbreak of diseases that were once rare, such as measles in 2014, some states have tightened laws mandating immunizations for children. These moves have sparked opposition from groups, arguing that mandatory immunizations violate parental rights. Recently, California joined Mississippi and West Virginia as the only states to eliminate non-medical exemptions to childhood vaccinations for students (source).
  • Opioid Abuse Epidemic. The leading cause of accidental death in the U.S. is now drug overdose: one American dies every 19 minutes as a result. This trend is heavily driven by opioid addiction (source). Many public health officials contend that the medication-assisted treatment combining counseling with addiction medication is an essential tool in addressing the epidemic. The medication used in this treatment, buprenorphine, is a synthetic opioid, which does pose risks for abuse. Because of this risk, until recently, doctors could only treat up to 30 patients in the first year they can prescribe the drug. In July of 2016, President Obama signed the Comprehensive Addiction and Recovery Act (CARA) which increased the limit to 275 patients (source). Even with this increase, some public health experts say that the limit should be even higher (source). Furthermore, medication-assisted treatment has been underutilized due to restricted access by both public and private insurance and lack of local public health funding. Advocates have called for policy changes to increase access, but these changes have yet to occur (source).
  • Zika. The Zika virus is a mosquito-borne illness that causes severe birth defects, and it has been on the rise in the U.S. Although Congress in September 2016 passed a bill to provide funding for research efforts to develop a vaccination against Zika, it will take time for the money to reach states and cities (source). States will have to apply for funding for research efforts and lab tests to help local efforts while the disease continues to affect more individuals (source). In addition to debates about funding, there are also debates about different measures to address the virus. For example, recent controversy broke out in South Carolina in September of 2016 as a pesticide spray aimed at killing mosquitoes that carried the Zika virus also killed millions of bees (source).

EXPERTS

Georges Benjamin, executive director, American Public Health Association, 202/777-2730, georges.benjamin@apha.org

Carmella Bocchino, senior adviser, America’s Health Insurance Plans, 202/778-3200, cbocchino@ahip.org

Marcia Crosse, director, health care, Government Accountability Office, 202/512-3407, crossem@gao.gov

Bruce Gellin, deputy assistant secretary for health and director of the National Vaccine Program Office, Department of Health and Human Services, 202/690-5566, bruce.gellin@hhs.gov

Marthe Gold, senior scholar in residence, New York Academy of Medicine, 212/650-7794, mgold@nyam.org

Jen Kates, vice president and director of global health & HIV Policy, Kaiser Family Foundation, 202/347-5270

Josh Michaud, associate director, Global Health Policy, Kaiser Family Foundation, 202/347-5270

David A. Ross, president & CEO, The Task Force for Global Health, Inc., 404/687-5635, dross@phii.org

Alina Salganicoff, vice president and director, Women’s Health Policy, Kaiser Family Foundation, 650/854-9400

Sally Satel, resident scholar, American Enterprise Institute, 202/489-6654, slsatel@gmail.com

Barbara Tomar, federal affairs director, American College of Emergency Physicians, 202/728-0610, btomar@acep.org

Cynthia Woodcock, executive director, The Hilltop Institute at UMBC, 410/455-6274, cwoodcock@hilltop.umbc.edu


The Sourcebook was made possible with the support of the Robert Wood Johnson Foundation, with ongoing support from the National Institute for Health Care Management (NIHCM) Foundation.