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Investing In Population Health

A Roadmap For The Future

 The U.S. public health system, like its health care system cousin, is a patchwork of services, programs and regulatory authorities that is neither designed for optimal performance nor funded for sustainability and success. Those are the findings of a recent panel from the Institute of Medicine (IOM) of the National Academies.

Their report entitled “For the Public’s Health: Investing in a Healthier Future” takes a critical look at the needs of the public health system in a reformed health environment and makes several salient recommendations. The report notes that while we have made tremendous improvements in overall health, we are not keeping pace with other nations and, as has been noted many times, we are not getting the value that we should for our health care investment. In addition, the report emphasizes the fact that our nation has underinvested in public health, spending less than 3 percent of our health care dollar on public health and prevention.
This new report, funded by the Robert Wood Johnson Foundation, seeks to provide better guidance to policymakers and resource allocators about the investment needs of the public health system in an era of health system transformation. This report is a landmark study that makes the most definitive series of evidenced-based recommendations to date, and if implemented will finally move the needle in a substantial way toward building a high-performing, sustainable public health system in the United States.
The report describes 10 critical steps the nation can take in the interest of public health. The recommendations fall into four general areas: (1) setting a national health improvement target; (2) reforming public health and its financing; (3) informing the investment in health; and (4) strengthening funding sources and structures to build public health.
Setting a national health improvement target
Author Lewis Carroll is often quoted as saying, “If you don’t know where you are going, any road will get you there.” The IOM committee recognizes that the national leadership has a responsibility to provide a national health improvement goal that we can all work toward achieving. Such a goal would help focus our efforts, as well as clarify the value that public health brings to improving health.
The committee notes that as a nation we are failing in two critical overarching areas as compared to other nations: life expectancy and per capita health expenditure. They propose that the nation work to achieve a defined level of improvement in these areas by 2030. This accomplishment, they surmise, would move us into better alignment with other nations, and they recommend that the secretary of the Department of Health and Human Services define interim improvement targets. The hope is that by having defined targets we can pick the appropriate pathways to get there.
Reforming public health and its financing
The adage that “form follows finance” is an excellent explanation for the diversity in public health approaches and capacities at the state and local level. The fact that most public health funding originates from  a complex set of specific targeted and inadequate appropriations, which over time have created funding silos with little flexibility to adapt to changing conditions, has created a funding dysfunction in the public health system that stifles productivity and innovation.
In addition, several important funding streams are the result of the crises of the moment, with the failure to institutionalize the programs once they have been built. Examples include public health preparedness and the recent influenza epidemic. In both cases funding has begun to wind down, putting critical response capacity at risk that will be needed for the next infectious disease outbreak. Of course, when the next outbreak occurs, money will be thrown at the problem, often forcing a scramble to rebuild some capacity to address what was a predictable problem. This yo-yo pattern of funding is typical for the public health system.
The lack of flexibility to use the many funding streams to address needs of a similar nature, or to use the monies to leverage capacities in other areas, is an additional barrier. The report recommends that the federal funding agencies for public health allow greater flexibility to achieve population health goals. They also recommend that both Congress and the federal agencies use their respective authorities to enhance this effort.
One of the consequences of health reform is the potential movement of many clinical services from being financed or delivered by the public health system in their current form. The committee recommends that the public health system play an active role in remodeling the service delivery needs as well as working with their resource allocators to reinvest newly freed up dollars in population health activities that benefit the broader population or specific populations in need. In order to effectively do this, the committee recommends that all parts of the public health enterprise endorse a minimum set of public health services that will be needed by all communities. Such a package of services would help people better understand what the public health system does and what value they receive from its work.
In a redesigned system for public health it is essential that public health agencies follow hockey great Wayne Gretzky’s approach and “go to where the puck is going and not where it has been.” A forward-thinking approach is essential to building the system of the future — a future where everyone has an insurance card.
Informing the investment in health
Defining the true fiscal investment in public health and linking it to defined outcomes or goals has always been a problem. In addition, the health services research base is inadequate to truly understand the value of public health interventions to improve health. To address this, the committee recommends that an expert technical panel be created and charged with crafting a new chart of accounts to track public health expenditures and link these expenditures to appropriate outcomes and outputs across agencies. In addition, they believe that the National Health Promotion and Disease Prevention Council should not only oversee, using expert panels, the development of the minimum set of services for public health, but the Council should also provide guidance on the appropriate amount of federal investment to support it.
The committee also recommends a robust research infrastructure be established to address this problem. The committee suggests that the Centers for Disease Control and Prevention, the Agency for Toxic Substances and Disease Registry, and the National Institutes of Health collaborate in this effort. I would add the Food and Drug Administration has a new effort to advance our understanding of regulatory science, which I believe is essential if we are going to continue to advance the use of public policy as a health improvement tool.
Strengthening funding sources and structures to build public health
Public health has a history of unpredictable, inadequate, uncoordinated and unstable funding as noted above. Yet, it’s because of public health measures that we’ve seen major gains in health improvement and reduction of disease. By using the proven tools of public health, we could continue to save countless lives and billions of dollars every year. However, to do this requires adequate and sustained funding. The report calls for a doubling of current federal contributions and other measures to create a more stable funding stream.
Specifically,  Congress is urged to enact a national “medical care tax” on all medical care transactions to deliver the minimum set of benefits in every community.  The report also recommends reallocating the Medicaid reimbursement that currently goes to public health to population-based services when the patients move into the broader clinical care system, and the IOM committee calls on the Department of Health and Human Services to work to ensure there is appropriate state and local co-financing for public health.
Today, we are at historic lows in funding for public health and in challenging fiscal times. These recommendations are an important step forward in defining and achieving the public health system for the future. They are a starting point for a national dialogue exploring the prerequisites for,  and estimated costs of,  delivering an appropriate set of services to improve the public’s health. It is clearly a useful roadmap for the future.
Photos courtesy of APHA

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