CHAPTER 12 - PUBLIC HEALTH
|NOTE: Charts and graphs for this chapter are listed in the right column of the page.|
Content Last Updated: 11/8/2012 4:43:40 PM
Graphics Last Updated: 3/14/2012 12:54:18 PM
Note: Terms in green will show glossary definitions when clicked.
Originally written by Deanna Okrent, Alliance for Health Reform, and updated by Susan Polan, Ph.D., Georges Benjamin, M.D., and colleagues at the American Public Health Association. Updated most recently by Deanna Okrent on November 6, 2012.
This chapter was made possible by the Robert Wood Johnson Foundation.
- More than $2.5 trillion was spent nationally on health care in 2010.1 Of that, only $82.5 billion or 3.2 percent was spent on government public health activities.2
- An estimated 250,000 more public health workers will be needed by 2020.3
- The U.S. public health system is not a single entity. It is a network that encompasses several federal agencies, local, state, and territorial health departments, community-based organizations, health delivery settings and much more.
- There is an epidemic of obesity in the U.S. Two-thirds of adults and nearly one in three children are overweight or obese. 4
- The effects of climate change can affect human health. Heat waves, drought, flooding, and air pollution can cause increases in heat stroke, respiratory illnesses and diseases caused by contaminated food and water supply.5
- The health reform law, the Patient Protection and Affordable Care Act of 2010 (also known as ACA), provides important support for public health in the U.S.
What is Public Health ?
Health care is vital to all of us some of the time, but public health is vital to all of us all of the time."
– C. Everett Koop, former Surgeon General
In late 2009, the public was shocked into the reality of the incidence of foodborne illness because of salmonella detected in spinach. Suddenly, a food that had been considered healthy wasn’t, and no one wanted to eat spinach at home, or in restaurants, either cooked or in fresh salads. The Centers for Disease Control and Prevention (CDC) estimates that each year roughly 1 out of 6 Americans (or 48 million people) gets sick, 128,000 are hospitalized, and 3,000 die from foodborne diseases.6 Keeping our food supply safe is a major public health concern.
In the previous century, vast improvements in morbidity and mortality were gained through a focus on preventing the spread of communicable diseases. Immunization, disease screening (especially tuberculosis screening), clean water, hand washing, and other sanitation techniques we now take for granted reduced the spread of communicable diseases and were important factors in increasing life expectancy and improving the health of the population.
While clean air, water and food are still important concerns, the modern public health agenda focuses on new challenges, the social conditions and systems that affect everyone’s healthful living within a given community. The new epidemics are diabetes, obesity and smoking related illnesses. The leading causes of death are heart disease, cancer and chronic lower respiratory diseases.7 For people age 1 to 24, the three leading cause of death are accidents, homicide and suicide – all external causes.8 Childhood obesity rates have tripled over the last thirty years: one third of all children born in 2000 or later will suffer from diabetes at some point in their lives; many others will face chronic obesity-related health problems like heart disease, high blood pressure, cancer, and asthma.9 In 2008, more than two-thirds of adults were overweight or obese.10 (See Adult Obesity Chart)
A law to improve child nutrition and combat obesity was enacted in December 2010. The Healthy, Hunger-Free Kids Act11 provides $4.5 billion for federal school nutrition programs – a ten-fold increase over the previous reauthorization of this law. (See text box for additional information on the law.)
Public health emphasizes prevention through a whole array of actions which promote healthy lifestyles, including policies and campaigns to improve diets at home, at school and in the workplace; support for tobacco prevention, substance abuse treatment, bike and pedestrian paths to increase physical activity, seat belt use, helmet laws and clean air laws.
Public health professionals are concerned with emergency preparedness in case of a pandemic, bioterrorism or natural disaster occurrence. They also deal with environmental health and climate change, sprawl, anti-biotic resistance and other threats that were not on the radar screen when public health as a discipline and profession was in the developmental stages.
The U.S. Surgeon General’s Office released a report in 2010 entitled The Surgeon General’s Vision for a Healthy and Fit Nation. The report outlines ways of achieving several important goals:12
- Individual healthy choices and healthy home environments, including making healthier food choices and being more physically active.
- Creating healthy child care settings and healthy schools that include physical activity and good nutrition
- Creating healthy work sites with wellness programs that promote healthy eating in cafeterias and participation in physical activities.
- Mobilizing the medical community to explain the connection between a lifestyle of healthy eating, exercise and good health.
- Improving our communities to increase safe access to supermarkets and outdoor recreational facilities.
PUBLIC HEALTH IN HEALTH REFORM
The 2010 health reform law (the Patient Protection and Affordable Care Act of 2010, or ACA) does much to strengthen the public health system, invest in prevention and improve the health of the American people.
A wide array of programs in the law addresses population health, including:13
- A National Prevention, Health Promotion and Public Health Council chaired by the Surgeon General.14
- A Prevention and Public Health Fund to support core public health functions, community prevention initiatives, increased support for the public health workforce, and public health prevention and research activities
- Community Transformation grants to state and local governmental agencies and community-based organizations.15
- Health education16
- Workforce development programs and grants.17
There are many other important provisions within the law that are not strictly public health but will have positive implications for changing the health. These include access to preventive services and programs, and promoting primary care and disease management.
HEALTHY PEOPLE 2020
HHS released the Healthy People 2020 objectives in December 2010, building on the successes and challenges realized in the Healthy People 2010 initiative.18 Healthy People 2010 was a comprehensive, national health promotion and disease prevention agenda developed and promoted by the U.S. Department of Health and Human Services (HHS).19 It was a roadmap for improving the health of all people in the United States.
It had two primary goals: to increase the quality and years of healthy life, and to eliminate disparities in health status among segments of the population.20
The vision for Healthy People 2020 “is a society in which all people live long, healthy lives”.21 It differs from earlier objectives by stressing the underlying environmental and social determinants of health. Healthy People 2020 strives to:
- Attain high quality, longer lives free of preventable disease, disability, injury and premature death.
- Achieve health equity, eliminate disparities, and improve the health of all groups Create social and physical environments that promote good health for all.
- Promote quality of life, healthy development, and healthy behaviors across all life stages.
PUBLIC HEALTH INFRASTRUCTURE
Public health in the U.S. is not embodied in a single entity. It is a network that encompasses several federal agencies; county, city, state, territorial and tribal health departments; local boards of health; and other public and private entities.
The federal public health component rests primarily in the agencies of HHS.22 These include the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Agency for Healthcare Research and Quality (AHRQ), Substance Abuse and Mental Health Administration (SAMHSA) and the National Institutes of Health (NIH).
Other agencies involved in health programs at the federal level are the Departments of Defense, Agriculture, Transportation, Housing and Urban Development and Veterans Affairs; the Environmental Protection Agency; and the Indian Health Service, which coordinates tribal health agencies. Other components of the public health infrastructure include public and private laboratories, hospitals and other healthcare providers, and volunteer organizations such as the American Red Cross and others.23
Major non-governmental public health associations complete the picture of the public health enterprise and include such groups as the American Public Health Association (APHA), Association of State and Territorial Health Officials (ASTHO) and the National Association of City and County Health Officials (NACCHO). These organizations complement the work of federal, state and local governments.
THE ROLE OF PUBLIC HEALTH
The job of maintaining population health through disease and injury prevention, health promotion and protection is carried out in a number of ways. Public health agencies monitor immunization activities and distribute vaccines through local health departments. The CDC and the FDA conduct environmental surveillance and research and assure the availability of healthy water, air and food. Research institutions and laboratories investigate outbreaks of foodborne and waterborne diseases and educate the populace about avoiding or seeking treatment for such diseases.
CDC allocates close to 75 percent of its funds directly to states and local communities for public health activities.24
For example, WISEWOMAN25 , a competitively awarded state-based heart disease and stroke screening and prevention program for uninsured and underinsured low-income women, received $20 million to provide increased resources to the 20 currently funded states in FY 2010.26
HEALTH THREATS FROM DISASTER, DISEASE AND CLIMATE CHANGE
Some threats to our nation’s health come from beyond our geographic boundaries. With travel between countries and continents being easier and faster, so too can be the spread of disease.
H1N1 (originally referred to as “swine flu”) was a new influenza virus first detected in March 2009. It was declared a pandemic emergency by the World Health Organization in June 2009 and a national emergency by President Barack Obama in October 2009. The flu afflicted 90 million people in the United States alone. This could have been catastrophic had the virus been more virulent and potentially lethal. Fortunately, it was a mild strain. Also, with the development and availability of H1N1 flu vaccine and the Public Health Service involvement in vaccinating as many people as possible, the threat, concern and fear have diminished somewhat.27 However, the question that many public health professionals, political leaders, health care providers and others raise is: Are we prepared for a potential virulent pandemic?
Man-made disasters such as the Deepwater Horizon oil spill may have long term health consequences, and such events require long term follow-up. Immediate health effects in cleanup workers include respiratory symptoms and nausea as well as lower-respiratory-tract problems from inhalation of volatile organic compounds. People living in the surrounding coastal communities could also experience more extreme health consequences, including long-term neurological effects on children and developing fetuses, and hereditary mutations. Health officers in the Gulf states and epidemiologists have determined the research agenda to study the effects of this disaster.28
Climate change, specifically global warming, has been observed by research scientists in the U.S. and around the world. The CDC believes these changes can affect human health.29 CDC’s Climate-Ready States and Cities Initiative is helping states and cities partner with local and national climate scientists to understand the potential climate changes in their areas, and is assisting states and cities in developing and using models to predict health impacts, to monitor health effects, and to identify the areas most vulnerable to these effects.30
PUBLIC HEALTH WORKFORCE
Estimates suggest that 250,000 more public health workers will be needed by 2020, and that 23 percent of the current workforce will be eligible to retire by 2012. 31
The National Association of City and County Health Officials (NACCHO) in the first half of 2011 completed a series of surveys measuring the impact of the economic recession on local health departments (LHDs). The surveys found that between January 2011 and June 2011, LHDs lost 5,400 jobs to layoffs and attrition. This followed a previous attrition of 23,000 jobs lost from January 2008 to December 2009. Between July 2010 and June 2011, 55 percent of all LHDs were subjected to at least one program cut in areas such as population-based primary prevention, maternal and child health, and environmental health. 32
Factors working against recruitment in this field include: budget constraints; uncompetitive salaries and benefits, especially in local health departments; and lack of enthusiasm for public health as a career choice.33 Among the public health workers in short supply are public health nurses, epidemiologists, microbiologists, other environmental health scientists, and information technology specialists.34
In September 2010, a helping hand came from the federal government to enhance public health workforce training programs. The U.S. Department of Health and Human Services awarded $16.8 million to support 27 Public Health Training Centers at schools of public health and other public or non-profit institutions across the country. Most of the funding – $15.4 million – is made available by the Prevention and Public Health Fund included as part of the Affordable Care Act.35
Diversity of the public health workforce is also an issue. The workforces of local public health departments are often less diverse than the populations they serve.36 (See chart, “Diversity: How Local Health Department Workforces Compare to the Population Served.”) However, because of the overall concern about the workforce shortage and the already limited pool from which to hire, many communities have found it difficult to increase the diversity of their public health workforce.
LIKELY POLICY DEBATES
Population health plays an important role in the health of the nation. Yet its importance is sometimes overlooked in debates on health care reform issues. It is not well understood that public health is about avoiding illness and thus avoiding unnecessary use of the health care delivery system.
Many public health concerns, though focused on populations, not individuals, cannot be separated from health care delivery. For example, chronic disease prevention – a focus of health promotion public awareness campaigns – is being much discussed in health care delivery circles.
Financing Public Health
Though public health services are considered the first line of defense against disaster and disease, government public health expenditures amount to only 3 percent of national health care expenditures.37 Of the $2.5 trillion in national health expenditures in 2010, just $82.5 billion was spent on government public health activities.38
In the wake of the recent economic downturn, states have cut hundreds of millions of dollars from public health programs, leaving many communities around the country struggling to deliver basic public health services. 39 In 2011, 40 states and Washington, D.C. cut state public health funds; 15 of those cut funding for three years consecutively.40
In a climate of health reform, some advocates assert that more dollars for prevention would buy better value and save money in the long run on health care delivery.41
Accountability and Quality
Several organizations founded in the last several years address the twin issues of accountability and quality. The National Board of Public Health Examiners offers public health graduates the opportunity to prove they have met minimum standards and can become certified public health professionals. The National Public Health Accreditation Board focuses on the public health system and is charged with improving the quality and performance of state, local, tribal and territorial health departments.
The Task Force on Community Preventive Services evaluates and then helps to prioritize in its Community Guide population-based programs and policies to improve health and prevent disease in communities.42 The U.S. Preventive Services Task Force is an independent task force that reviews the effectiveness and makes recommendations for clinical preventive services.
Do these entities begin to offer a more comprehensive approach to a public health system that too often offers inconsistent quality and accountability depending on where it is located?
Climate change can have dramatic public health consequences – increasing the likelihood of heat waves, drought and flooding, reducing potable water supplies, displacing populations and spreading infectious diseases.43 Though populations are affected, individuals become ill and interact with their health care providers, putting stress on the health care system. A public policy debate on climate change or global warming might be centered on energy issues but will also have a public health component. The American Public Health Association Executive Director Georges C. Benjamin has stated, “Climate change is one of the most serious public health threats facing our nation. Yet few Americans are aware of the very real consequences of climate change on the health of our communities our families, and our children” 44 Is climate change the new public health challenge? Cities such as Chicago, New York City and San Francisco have developed climate change action plans.45
Addressing Social Determinants of Health
Many different policies and programs have implications for the public’s health, but are not considered public health. Examples are community development with regard to safe housing, transportation spending and school nutrition and physical education programs that fall under the education budget. What role should the public health sector have in the development and implementation of such policies? Should health concerns be considered when establishing new policies outside the traditional realm of public health? What are the obstacles and challenges?
TIPS FOR REPORTERS
- Keep in mind that there is no one source for information about public health agencies. The U.S. Department of Health and Human Services (HHS) is the lead agency. But information about this complex network requires digging deeper. In addition to HHS components such as CDC, NIH, FDA and HRSA, other federal agencies and departments such as FEMA and Homeland Security all play a role.
- Be aware that on the local level, most public health functions are carried out through local health departments. Their budgets depend on federal, state and local budget allocations. They likely will continue to make tough budgetary choices in the next few years.
- The private sector plays a role in funding public health and delivering public health messages. Its role may be even more critical in the current economic climate.
- It’s hard to separate public health issues and concerns from those of the health care delivery system. Keep in mind that an important role of public health is to prevent illness and thus avoid unnecessary use of the health care delivery system.
- In a time of tight budgets, how are public health departments in your area faring? What programs are suffering – vaccination programs, health awareness campaigns, smoking cessation programs? What is the role of private sector contributions? Are these contributions increasing or decreasing?
- How do your local and state public health officials feel about climate change as a public health threat? What are the health impacts of climate change in your region? What role are public health agencies and programs playing in reducing the threat posed by high energy consumption and climate change?
- Are health departments involved in land use and transportation decisions in your community? In bringing supermarkets and outdoor recreation facilities into neighborhoods?
- Did schools of public health in your area get workforce dollars? If so what are the plans for their use? Which programs and professions will benefit?
- How can new graduates be inspired to enter the public health workforce? How can students entering college be encouraged to study the public health sciences such as epidemiology, microbiology, biostatistics, etc? What incentives have worked in your community to motivate graduates to pursue these careers? What are the obstacles that graduates are experiencing to entering the public health workforce?
- What public health programs in your state receive public health funding? What are their achievements? Are these programs being cut, maintained or expanded?
- In its 2013 budget plan, the Obama Administration has proposed a $5 billion cut to the Prevention and Public Health Fund in an effort to reduce the federal deficit.46 What are the potential ramifications for state and local governments?
- Natural disasters and acts of terrorism threaten our health security. Could our infrastructure, including hospitals, laboratories, information systems and public health workforce handle the expanded need in the event of such emergencies? Would our surveillance systems provide sufficient warning to protect people from exposure and prevent the spread of disease? Would we have sufficient surge capacity to handle the results of bioterrorism? Three years after the H1N1 national emergency, these questions are still being discussed, and real world lessons learned being evaluated. Are public health officials in your community working with hospitals and other health officials in preparation for potential catastrophic health needs? Is there an emergency preparedness plan in your community?
1 CMS Office of the Actuary. “National Health Expenditure Report.” http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf
3 Association of Schools of Public Health. Confronting the Public Health Workforce Crisis. (http://www.asph.org/document.cfm?page=1038).
4 The Surgeon General’s Vision for a Healthy and Fit Nation Fact Sheet http://www.surgeongeneral.gov/library/obesityvision/obesityvision_factsheet.html
5 CDC.(2010) “Climate change and public health.” (http://www.cdc.gov/climateandhealth/effects/default.htm)
6 CDC “Estimates of Foodborne Illness in the United States.” http://www.cdc.gov/foodborneburden/2011-foodborne-estimates.html
7 Leading Causes of Death: Final 2009 data. Centers for Disease Control and Prevention, FastStats http://www.cdc.gov/nchs/fastats/lcod.htm
8 National Center for Health Statistics,Data Brief, June 2012 http://www.cdc.gov/nchs/data/databriefs/db99.htm
9 Let’s Move. http://www.letsmove.gov/learnthefacts.php
10 UnitedHealth Center for Health Reform Modernization (2010). “The United States of Diabetes: Challenges and opportunities in the decade ahead, November. http://www.unitedhealthgroup.com/hrm/UNH_WorkingPaper5.pdf
11 For the text of the bill, see http://thomas.loc.gov/cgi-bin/query/z?c111:S.3307: Also see American Medical News. Dec 20, 2010. http://www.ama-assn.org/amednews/2010/12/20/gvsb1220.htm
12 U.S. Department of Health and Human Services (2010). The Surgeon General’s Vision for a Healthy and Fit Nation. Office of the Surgeon General, January.(www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf)
13 Health Care and Education Reconciliation Act (Public Law No: 111-152); and
Patient Protection and Affordable Care Act (Public Law No: 111-148)
14 The Council will develop a national prevention strategy, working with federal departments and agencies on prevention, wellness and health promotion practices, the public health system and integrative health care providers in the U.S.
15 These grants will support evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence base of effective prevention programming. The first awards were made in 2011 to 61 state and local government agencies plus non-profit and community-based organizations. In 2012 the grant program was expanded to 40 smaller communities such as towns and neighborhoods. See http://www.cdc.gov/communitytransformation/.
16 Examples include healthy aging, diabetes prevention, prevention research, nutrition labeling of standard menu items at chain restaurants and employer-based wellness programs
17 The grants aim to enable state partnerships leading to health care workforce development strategies and for loan repayment for those individuals who, upon graduation, agree to work in the federal, state, local and tribal public health agencies.
18 Healthy People 2020 Objectives –http://www.healthypeople.gov/2020/TopicsObjectives2020/pdfs/HP2020_brochure.pdf
19 U.S. Department of Health and Human Services (2000). “Healthy People 2010: With Understanding and Improving Health and Objectives for Improving Health.” 2nd ed. Midcourse Review Summary of Progress. (http://www.healthypeople.gov/data/midcourse/html/execsummary/progress.htm).
20 Latest reported findings indicate that significant racial and ethnic disparities persist, even though life expectancy generally increased in all groups through 2007. Arias E. United States life tables, 2006. National vital statistics reports; vol 58 no 21. Hyattsville, MD: National Center for Health Statistics. 2010. (http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_21.pdf)
21 Introducing Healthy People 2020. “Vision”. http://www.healthypeople.gov/2020/about/default.aspx
22 Tilson, H.; Berkowitz B. (2006). “The Public Health Enterprise: Examining our Twenty-First-Century Policy Challenges.” Health Affairs, p. 904. (www.healthaffairs.org).
23 Congressional Research Service (2005). “An Overview of the US Public Health System in the Context of Emergency Preparedness.” (www.fas.org/sgp/crs/homesec/RL31719.pdf).
24 Public health programs on the local level funded by CDC include chronic disease prevention and health promotion, diabetes control, environmental health, HIV prevention, immunizations, infectious disease prevention and bioterrorism preparedness. Shortchanging America’s Health A State by State look at how public health dollars are spent and key facts, Trust for America’s Health March 2010 http://healthyamericans.org/assets/files/TFAH2010Shortchanging05.pdf
25 WISEWOMAN Program. http://www.cdc.gov/wisewoman/
26 American Heart Association (2009). http://yourethecure.blogspot.com/2009/12/cdc-heart-disease-and-stroke-prevention.html
27 Michael Specter (2010) “The Doomsday Strain.” The New Yorker; Dec 20 , p 50; http://gvfi.org/docs/Specter%2012-20-10.pdf
28 IOM Report (2010) Review of the Proposal for the Gulf Long-Term Follow-Up Study: Highlights from the September 2010 Workshop - Workshop Report
29 CDC Climate Change and Health. http://www.cdc.gov/Features/ChangingClimate/
30CDC Climate Change and Health. “CDC's Climate-Ready States & Cities Initiative” http://www.cdc.gov/climatechange/climate_ready.htm
31 Association of Schools of Public Health. Confronting the Public Health Workforce Crisis. ((www.asph.org/UserFiles/WorkforceShortage2010Final.pdf) new source: http://www.asph.org/document.cfm?page=1040.
32 National Association of County & City Health Officials (2011). “LHD Budget Cuts and Job Losses and Program Cuts: Findings from the July 2011 Survey.” January/February.(http://www.naccho.org/topics/infrastructure/lhdbudget/upload/JobLossRepor122011FINALUpdated.pdf )
33 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (http://www.hschange.org/CONTENT/979/).
34 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (http://www.hschange.org/CONTENT/979/).
35 News Release. “HHS awards $16.8 million to train public health workforce”. September 2010. http://www.hhs.gov/news/press/2010pres/09/20100913a.html
36 Draper, Debra; Hurley, Robert; Lauer, Johanna (2008). “Public Health Workforce Shortages Imperil Nation’s Health.” Center for Studying Health System Change. Research Brief No.4. (http://www.hschange.org/CONTENT/979/).
37 Public health programs are funded through a combination of federal, state and local dollars and private sector contributions. Local health departments, for example, receive 29 percent of their funding from local tax revenues. Another 23 percent comes from state revenue; and federal funds distributed through states account for 13 percent. Direct funding from federal agencies, such as CDC, accounts for 7 percent. Trust for America’s Health (2008). Issue report: “Shortchanging America’s Health 2008: A State-by-State Look at How Federal Public Health Dollars are Spent.”. (www.healthyamericans.org)
38 CMS Office of the Actuary. “National Health Expenditure Report.” http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf
39 Trust for America’s Health (2010). Issue report: “Shortchanging America’s Health : A State-by-State Look at How Federal Public Health Dollars are Spent.” March. (http://healthyamericans.org/report/74/federal-spending-2010).
40 (December 2011) Ready or Not? 2011: Protecting the Public from Diseases, Disasters and Bioterrorism. Trust for America’s Health. http://healthyamericans.org/report/92/
41 Some researchers caution that what often is labeled as “prevention” – clinical screenings, medications for many chronic conditions, etc. – often add more to medical costs than they save. See, e.g.: Russell, Louise (2009). “Preventing Chronic Disease: An Important Investment, But Don’t Count On Cost Savings.” Health Affairs, January/February, p. 42-45. www.healthaffairs.org).
42 Community Guide (2010). Task Force on Community Preventive Services. (www.thecommunityguide.org/about/Conclusion_Report_050510.pdf)
43 AMedNews (2008). “AMA meeting: Global warming has health toll, delegates warn.” (http://www.ama-assn.org/amednews/2008/12/01/prsh1201.htm).
44 Conney, CM (2011). “ Preparing a People: Climate Change and Public Health. Environmental Science & Technology and Chemical Watch http://ehp03.niehs.nih.gov/article/info%3Adoi%2F10.1289%2Fehp.119-a166
45 Conney, CM (2011). “ Preparing a People: Climate Change and Public Health. Environmental Science & Technology and Chemical Watch http://ehp03.niehs.nih.gov/article/info%3Adoi%2F10.1289%2Fehp.119-a166
46(2011) The Prevention and Public health Fund. Health Affairs. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=63