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Committee on Public Health Strategies to Improve Health Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract 65863 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclu- sions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Public Health Strategies to Improve Health. For the public’s health. Investing in a healthier future / Committee on Public Health Strategies to Improve Health, Board on Population Health and Public Health Practice, Institute of Medicine of the National Academies. p. ; cm. Investing in a healthier future Includes bibliographical references. ISBN 978-0-309-22107-8 (pbk.) — ISBN 978-0-309-22108-5 (pdf) I. Title. II. Title: Investing in a healthier future. [DNLM: 1. Financing, Government—United States. 2. Public Health— economics—United States. 3. Health Care Reform—United States. 4. Outcome Assessment (Health Care)—economics—United States. WA 100] Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. For the Public’s Health: Investing in a Healthier Future. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PUBLIC HEALTH STRATEGIES TO IMPROVE HEALTH MARTHE R. GOLD (Chair), Professor and Chair, Department of Community Health and Social Medicine, Sophie Davis School of Biomedical Education, City College, New York, NY STEVEN M. TEUTSCH (Vice Chair), Chief Science Officer, Los Angeles County Department of Public Health, CA LESLIE BEITSCH, Associate Dean for Health Affairs; Director, Center on Medicine and Public Health, Florida State University College of Medicine, Tallahassee JOYCE D. K. ESSIEN, Director, Center for Public Health Practice, Rollins School of Public Health, Emory University; Retired Medical Officer, Captain, Centers for Disease Control and Prevention, U.S. Public Health Service, Atlanta, GA DAVID W. FLEMING, Director and Health Officer for Public Health, Seattle & King County, WA THOMAS E. GETZEN, Professor of Risk, Insurance and Health Management, Fox School of Business, Temple University; Executive Director, International Health Economics Association (iHEA), Philadelphia, PA LAWRENCE O. GOSTIN, Linda and Timothy O’Neill Professor of Global Health Law; Director, O’Neill Institute for National and Global Health Law at Georgetown University, Washington, DC MARY MINCER HANSEN, Chair, Masters of Public Health Program; Adjunct Associate Professor, Department of Global Health, Des Moines University, IA GEORGE J. ISHAM, Senior Advisor, HealthPartners, Inc.; Senior Fellow, HealthPartners Research Foundation, Bloomington, MN ROBERT M. KAPLAN, Director, Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, MD WILFREDO LOPEZ, General Counsel Emeritus, New York City Department of Health and Mental Hygiene, NY GLEN P. MAYS, F. Douglas Scutchfield Endowed Professor in Health Services and Systems Research, University of Kentucky, College of Public Health, Lexington PHYLLIS D. MEADOWS, Associate Dean for Practice, Office of Public Health Practice; Clinical Professor, Health Management and Policy, University of Michigan, Ann Arbor POKI STEWART NAMKUNG, Health Officer, Santa Cruz County Health Services Agency, CA MARGARET E. O’KANE, President, National Committee for Quality Assurance, Washington, DC v

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DAVID A. ROSS, Director, Public Health Informatics Institute, Task Force for Global Health, Decatur, GA MARTÍN JOSÉ SEPÚLVEDA, Fellow and Vice President, Health Industries Research, IBM Research, IBM Corporation, Somers, NY STEVEN H. WOOLF, Professor, Department of Family Medicine; Director, Center on Human Needs, Virginia Commonwealth University, Richmond Study Staff ALINA B. BACIU, Study Director AMY GELLER, Program Officer ALEJANDRA MARTÍN, Research Assistant ALLISON BERGER, Senior Program Assistant (until August 2011) ROSE MARIE MARTINEZ, Board Director, Board on Population Health and Public Health Practice vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Bobbie Berkowitz, Columbia University Medical Center Jo Ivey Boufford, New York Academy of Medicine Leah Devlin, University of North Carolina at Chapel Hill Daniel M. Fox, Milbank Memorial Fund Tom Hoerger, RTI International David Kindig, University of Wisconsin School of Medicine and Public Health Kenneth Kizer, Kizer & Associates, LLC David Meltzer, University of Chicago Marcia Nielsen, Patient Centered Primary Care Collaborative Edward Norton, University of Michigan Pierre Vigilance, The George Washington University Alan Weil, National Academy for State Health Policy Derek Yach, Pepsi Co., Inc. vii

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viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, Flinders University, and Donald M. Steinwachs, Johns Hopkins University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments The committee wishes to thank colleagues, organizations, and agencies that shared their expertise and time during the writing of this report. Their contributions informed the committee and enhanced the quality of the re- port. Speakers at the committee’s meetings imparted a wealth of information about funding structures and sources at the local and state levels, public health financial management and spending, the impact of health care reform on public health and medical care, and the value that public health can add through prevention. The meeting agendas provided in Appendix H include the names of all speakers. The committee’s work was considerably enhanced by the expertise and advice of consultants who volunteered their time, and the committee thanks Helen Halpin, Mark Horton, Craig Jones, Paula Lantz, and Mary Wellik for their thoughtful input. The committee learned much from its reading of commissioned papers individually written and prepared by Sara Rosenbaum, Eileen Salinsky, and Samuel Y. Sessions (see Appendixes B, C, and D, respectively). Many local public health leaders participated in a survey to inform the commissioned paper by Salinsky, and the committee is grateful to Susan Allen, Kaye Bender, Bobbie Berkowitz, Gus Birkhead, Leah Devlin, Paul Halverson, Peggy Honoré, Paul Kuehnert, Pat Libbey, Pat McConnon, Michael Meit, Tom Milne, Bruce Miyahara, Herminia Palacio, Bobby Pestronk, Phred Pilkington, Doug Scutchfield, and Kathy Vincent. The commissioned papers were critical to the committee’s deliberations. Jonathon P. Leider assisted the committee by preparing a figure depicting the flow of public health funding. Finally, the committee thanks the Institute of Medicine (IOM) staff ix

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x ACKNOWLEDGMENTS members who contributed to the production of this report, including study staff Alina Baciu, Amy Geller, Alejandra Martín, Colin Fink, Thor Young, Rose Marie Martinez, and Hope Hare, as well as other staff of the Board on Population Health and Public Health Practice who provided occasional support. The project also received valuable help from Norman Grossblatt (senior editor); Christine Stencel (Office of News and Public Information); Amy Przybocki, Doris Romero, and Anton Bandy (Office of Financial Administration); and Clyde Behney, Laura Harbold DeStefano, Diedtra Henderson, and colleagues (IOM Office of Review and Communication). The IOM staff offers additional thanks to the executive assistants of com- mittee members, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Jennifer Borchardt, Esther Day, Mary Gibbons, Carol Grant, Melody Hall, Karen Adamo Henry, Collette Holloway, Angela Jones, Nancy Langer, Elishia Nelson, Denise Parodi, and Angie Villarreal.

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Contents Preface: Introduction to the Series of Reports xiii Summary 1 1 Introduction and Context 13 The Report’s Scope, 15 The Nation’s Health, 16 Setting a National Target for Improved Health, 30 The Centrality of Public Health in Achieving Health System Improvement, 34 Concluding Observations, 36 References, 37 2 Reforming Public Health and Its Financing 45 The Impact of Public Health Action, 48 Dysfunction of the Current Public Health Funding System, 51 Defining the Minimum Package of Public Health Services, 57 Using Financing Reform to Strengthen 21st Century Public Health, 64 The Relationship Between Public Health and Clinical Medicine: A New Partnership, 65 Financing and Refashioning Public Health Departments, 68 References, 69 xi

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xii CONTENTS 3 Informing Investment in Health 75 A Need for Financial Analysis and Research, 76 Data and Information to Support Practice, 84 Concluding Observations, 97 References, 97 4 Funding Sources and Structures to Build Public Health 101 Current Public Health Funding, 103 Estimates of Need, 107 New Funding Sources, 111 Concluding Observations, 121 References, 122 APPENDIXES A Acronyms 127 B The Patient Protection and Affordable Care Act: Opportunities for Public Health Agencies and Population Health, by Sarah Rosenbaum (Commissioned Paper) 129 C Financing Mission-Critical Investments in Public Health Capacity Development, by Eileen Salinsky (Commissioned Paper) 153 D Financing State and Local Public Health Departments: A Problem of Chronic Illness, by Samuel Y. Sessions (Commissioned Paper) 205 E Funding Diagram for Public Health 253 F For the Public’s Health: The Role of Measurement in Action and Accountability Report Summary 257 G For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges Report Summary 269 H Meeting Agendas of the Committee on Public Health Strategies to Improve Health (March 2011-September 2011) 281 I Committee Biosketches 287

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Preface: Introduction to the Series of Reports In 2009, the Robert Wood Johnson Foundation asked the Institute of Medicine (IOM) to convene a committee to examine three topics in rela- tion to public health: measurement, the law, and funding. The committee’s complete three-part charge is provided in Box P-1. The IOM Committee on Public Health Strategies to Improve Health explored the topics in the context of contemporary opportunities and challenges and with the pros- pect of influencing the work of the health system (broadly defined as in the report summary) in the second decade of the 21st century and beyond. The committee was asked to prepare three reports—one on each topic—that contained actionable recommendations for public health agencies and other stakeholders that have roles in the health of the U.S. population. This report is the third and final in the series. The committee’s three tasks and the series of reports prepared to re- spond to them are linked by the recognition that measurement, laws, and funding are three major drivers of change in the health system. Measurement (with the data that support it) helps specialists and the public to understand health status in different ways (for example, by determinant or underlying cause where national, local, and comparative evidence is available), to un- derstand the performance of the various stakeholders in the system, and to understand the health-related results of investment. Measurement also helps communities to understand their current status, to determine whether they are making progress in improving health, and to set priorities for their next actions. Although the causal chains between actions of the health system and health outcomes are not always clearly elucidated, measurement is a fundamental requirement for the reasons listed above. xiii

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xiv PREFACE BOX P-1 Charge to the Committee Task 1 (completed) The committee will review population health strategies, associated metrics, and interventions in the context of a reformed health care system. The committee will review the role of score cards and other measures or assessments in sum- marizing the impact of the public health system, and how these can be used by policy makers and the community to hold both government and other stakeholders accountable and to inform advocacy for public health policies and practices. Task 2 (completed) The committee will review how statutes and regulations prevent injury and dis- ease, save lives, and optimize health outcomes. The committee will systematically discuss legal and regulatory authority; note past efforts to develop model public health legislation; and describe the implications of the changing social and policy context for public health laws and regulations. Task 3 (accomplished in the present report) The committee will develop recommendations for funding state and local health systems that support the needs of the public after health care reform. Recom- mendations should be evidence based and implementable. In developing their recommendations the committee will: • Review current funding structures for public health • Assess opportunities for use of funds to improve health outcomes • Review the impact of fluctuations in funding for public health • Assess innovative policies and mechanisms for funding public health ser- vices and community-based interventions and suggest possible options for sustainable funding. Laws transform the underpinnings of the health system and also act at various points in the complex environments that generate the conditions for health. Those environments include the widely varied policy context of multiple government agencies—such as education, energy, and transporta- tion agencies—and many statutes, regulations, and court cases intended to reshape the factors that improve or impede health. The measures range from national tobacco policy to local smoking bans and from national agricultural subsidies and school nutrition standards to local school-board decisions about the types of foods and beverages to be sold in school vend- ing machines. Funding that supports the activities of public health agencies is provided primarily by federal, state, and local governments, and it varies widely

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xv PREFACE among states and localities. However, government budgets must balance a variety of needs, programs, and policies, and the budgets draw on dif- ferent sources (including different types of taxes and fees), depending on jurisdiction. Therefore, the funds allocated to public health depend heavily on how the executive and legislative branches set priorities. Other funding sources support public health activities in the community, including “con- version” foundations that are formed when nonprofit hospitals and health insurers became privatized (such as the California Wellness Foundation). Funds for population health and medical care activities are also provided by community-based organizations that have substantial resources, by not-for- profit clinical care providers, and by stakeholders in other sectors. The subjects addressed in the committee’s three reports are not inde- pendent of each other and, indeed, should be viewed together. For example, measurement of health outcomes and of progress in meeting objectives can provide evidence to guide the development and implementation of public health laws and the allocation of resources for public health activities. Laws and policies often require the collection of data and can circumscribe the uses to which the data are put by, for example, prohibiting access to person- ally identifiable health information. Similarly, statutes can affect funding for public health through such mechanisms as program-specific taxes or fees. And laws shape the structure of governmental public health agencies, grant them their authority, drive partnerships with other sectors, and influence policy. In its three reports, the committee has made the case for increased ac- countability of all sectors that affect health—including the clinical care de- livery system, the business sector, academe, nongovernment organizations, communities, the mass media, and various government agencies—with coordination, wherever possible, by the governmental public health agency that is leading or coordinating activities and sectors. The committee’s first report, released in December 2010, focused on measurement of population health and related accountability at all levels of government. The second report, released in June 2011, reflected the commit- tee’s thinking about legal and public policy reform on three levels: the public health departments’ powers, duties, and limitations as defined in enabling statutes (that establish their structure, organization, and functioning); the use of legal and policy tools to improve the public’s health; and other sec- tors of government at the national, state, and local levels and diverse private and not-for-profit sector actors. This third report on funding, in a time of declining resources, considers resource needs and approaches to addressing them in a predictable and sustainable manner to ensure a robust population health system.

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