By David A. Kindig, MD, PhD
Last week, the U.S. Senate defeated the Johanns amendment to the Small Business Jobs and Credit Act of 2010. In doing so, legislators spared (for now, at least) the 10-year, $15 billion Prevention and Public Health Fund established by the Patient Protection and Affordable Care Act (PPACA). The purpose of the fund is “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” (For more information about PPACA’s prevention-oriented provisions, see the recent New England Journal of Medicine perspective coauthored by Assistant Secretary for Health Howard Koh and Secretary of Health and Human Services Kathleen Sebelius.)
The landmark Prevention and Public Health fund represents a tremendous victory for health advocates throughout the country, and many have offered suggestions on what to do with the money.
Secretary Sebelius announced in June how the fund’s FY 2010 $500 million would be allocated. Those of us who celebrate the fund’s creation share a desire for the dollars to actually make a difference and the 2010 allocation provides a good starting point for improving population health. But we must seek out continued opportunities for advocacy as the allocation grows over time to an annual $2 billion in 2015-2020.
I’ve tracked the dialogue and debates surrounding the fund over the last year and have some thoughts on how a population health perspective might guide our next steps.
First, keep in mind that the fund is quite small relative to ambitious goals established by the PPACA. On an annual basis, the amount is less than 0.01% of that spent on health care services. We must be both realistic in our expectations and strategic in our spending.
Second, funding should be related to the determinants of health model. While research does not yet allow the precise identification of the investment balance across determinants, we know a balance is required. The County Health Rankings assigns weights of 20% to health care, 10% to the physical environment, 30% to health behaviors, and 40% to the socioeconomic environment.
I’d suggest that the Prevention and Public Health fund take a similarly broad Community Prevention approach. The relatively small amount of money will likely have the largest impact if efforts emphasize creating policies and programs that create healthy environments, as has been emphasized by Dr. Jeffrey Levi’s Congressional testimony. The Convergence Partnership has urged for a similar approach, noting that “while clinical prevention is important…we must focus on changing the policies and systems that shape neighborhoods so that they foster health.” Additional recommendations are likely to emerge from the new National Prevention, Health Promotion, and Public Health Council, which is mandated by the PPACA to “develop and make public a national prevention, health promotion, and public health strategy” by March 23, 2011.
Third, priority should be given to communities who have the lowest health outcomes and are improving less rapidly or even losing ground. A recent letter from prominent population health leaders to Secretary Sebelius emphasizes the importance of focusing assistance on places where health outcomes are poor and health disparities are high. Communities with comparatively healthy populations should be applauded, recognized for their achievements, and serve as examples to others – but they should receive fewer new resources. If this is rationing, so be it. With limited resources, a population health perspective requires investments that produce the most health improvement and disparity reduction per dollar invested.
What we’ve got is a relatively short period of time and relatively few dollars. But ten years from now, when we assess what we’ve accomplished through the Prevention and Public Health Fund, we should be proud of the choices we make now.
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.
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