Last week I summarized the IOM’s new report on For the Public’s Health: Investing in a Healthier Future. The entire 3-part series is extremely important from a policy perspective and should be on every population health advocate’s reading list.
I praised the report as a whole but also promised a critique. The crux of my argument is that to achieve the Committee’s ambitious goals, we need to think beyond governmental public health. The suggested doubling of the budget for governmental public health, which seems reasonable for the set of minimum public health services, is necessary but not nearly sufficient to achieve their population health improvement goals.
The members of the Committee certainly know this, and their charge was quite narrowly defined. But when goals like life expectancy reduction are called for, and the rest of the report deals exclusively with governmental public health funding, it is possible for policy makers draw the conclusion that this is all that is required. This would be a mistake because much more is needed across all health factors and we should not get lulled into thinking otherwise.
There is brief discussion of this broader point in Chapter 1; the report asserts, “The United States seems to lag behind most high-income nations in the deployment of socially protective strategies that appear to correlate with better population health. Excessive allocation of national spending on medical care services poses major societal opportunity costs and restricts funding opportunities for other essential sectors such as education, energy, water, transportation, agriculture, and employment. For example, the rise of medical care costs, and the recent recession, has contributed to a decline in state appropriations for public higher education.”
The report includes Figure 1-1 below, which shows the relative proportions of health care spending and social service spending across developed nations.
This figure illustrates these differences and prompts speculation as to what a more appropriate balance should be. The Committee determined that the implications of these differences and the opportunity cost of the nation’s social spending were beyond its role. However, an upcoming report from a joint National Academy of Sciences–Institute of Medicine committee will consider the effect of national attention to such factors on health differences among high-income nations. Recognizing the urgent need for better understanding, the committee recommends the development of a “robust research infrastructure for establishing the effectiveness and value of public health and prevention strategies, mechanisms for effective implementation of these strategies, the health and economic outcomes derived from this investment, and the comparative effectiveness and impact of this investment.”
In addition, I believe population health advocacy also requires precision with respect to terminology. Despite these figures solely reflecting resources for health care and governmental public health, the term “health expenditure” is repeatedly used throughout the report – including for the initial recommendation regarding health care expenditure reduction. Calling these health expenditures may inadvertently send the message that health care and public health are the only or the main expenditures necessary to improve health. The committee clearly understands this, but the language leads us, perhaps unconsciously, down that path. I suggest reserving the term health expenditure for all investments for improving health, with the explanation that necessary data and accounting systems do not exist at present, but are critical for accountability and financing in the future. Although a bit more clumsy, national accounts should use the longer but more accurate term health care and public health expenditures, while evidence and accounting systems develop the capacity to report on true total health expenditures that reflect investments across all health factors.
I respectfully offer this critique with the hope that the IOM and other policy groups will address these issues going forward. Just as health care is not the whole answer, neither is health care and governmental public health. I fully recognize that even this important set of reports cannot cover the full breadth of our evolving national population health policy. The investment strategy for reaching the Committee’s ambitions goals must involve a multisectoral balanced portfolio of resources not yet identified or attempted in practice. However, knowing that our progress will be incremental should create an enormous imperative to define our terms in ways that maximize – rather than limit – our reach.
David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.
Full Reference for Figure 1-1: Bradley, E. H., B. R. Elkins, J. Herrin, and B. Elbel. 2011. Health and social services expenditures: associations withhealth outcomes. BMJ Quality & Safety 20(10):826-831.