For the Public's Health Investing in a Healthier Future (2012) / Chapter Skim
Currently Skimming:
1 Introduction and Context
1 Introduction and Context
Pages 13-44
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From page 13... ...
Committee on Public Health Strategies to Improve Health asserts that merely reaching the average of comparable high-income countries in health status would require considerable national effort. Despite spending far more on medical care than any other nation, and despite having seen a century of unparalleled improvement in population health and longevity, the United States is now falling behind many of its global counterparts and competitors in such health outcomes as overall life expectancy and the incidence of preventable diseases and injuries.
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and that comprises the governmental public health agencies and various partners, including communities, the health care delivery system, employers and businesses, the mass media, and the education sector. At a time when expenditures on medical care are limiting its ability to make crucial investments in other arenas that are critical for the quality of life and economic health of Americans, the committee believes that a strong governmental public health infrastructure can mobilize strategies that reduce the occurrence of disease and injury, offset the need for ever 2In its report on measurement, the system was redefined by the committee as simply "the health system" because "the modifiers public and population are poorly understood by most people other than public health professionals and may have made it easier to misinterpret or overlook the collective influence and responsibility that all sectors have for creating and sustaining the conditions necessary for health.
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Research and experience have demonstrated the effectiveness of some approaches, but the knowledge has not been operationalized for reasons that include lack of funding, insufficient political will, and the requirement to change societal norms. In this report, the committee offers a vision for a revitalized governmental public health enterprise, and discusses the financial resources that are needed to ensure an effective public health infrastructure in all communities.
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THE NATION'S HEALTH The health of a nation's population is determined by the conditions that it creates for living, the equity in opportunity that it affords, and the access to and quality of its medical care delivery system.3 Health in the United States advanced during the last century, adding approximately 30 years to life expectancy between 1900 and 1999 (CDC, 1999b)
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. The nation's poor health status and the expense of its medical care delivery system place an enormous burden on the still-weak U.S.
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Ranking (U.S./Total) Source Life Expectancy Infant Mortality Maternal Mortality UN 28/146 32/146 n/a (2005-2010 data)
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were shown to incur $1,261 more in annual health care costs than workers who had low health risk (two or fewer risk factors) , and those who had high risk (five or more risk factors)
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Better public health efforts can reduce the rising prevalence of chronic diseases and influence other high-priority outcomes, such as injuries, mental illness, and substance abuse -- and simultaneously attenuate the downstream medical care costs associated with them. Improving the effectiveness of the nation's governmental public health infrastructure can contribute to offsetting medical costs in three ways: 7See Figure 4 in Homer and Hirsch (2006, p.
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2. Public health agencies can use their data surveillance, analysis, and reporting capabilities to assist the medical care delivery system in identifying ineffective or inappropriate clinical care and in creating opportunities to advance population health in the clinical setting.
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Other approaches to cost containment that use public health skills and competencies would rely on an improved governmental public health infrastructure to accelerate the movement toward more effective and more efficient strategies for medical care delivery. For example, some public health departments are uniquely positioned (although not many have the capacity)
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. By coupling analytic capabilities with an expanded information system, public health departments can provide leadership in measuring, monitoring, and reporting the performance of medical care delivery systems, and enhancing the transparency of their costs, quality, and outcomes.
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Because data analysis and surveillance are fundamental tasks of public health, public health agencies in collaboration with medical care delivery systems are well positioned to develop mechanisms for tracking and analyzing inputs into and outputs of the medical care delivery system that allow the identification and early resolution of system problems. Some jurisdictions that serve smaller populations may never achieve local capacity of this kind -- in some states or territories, it may require a more centralized function -- but governmental public health should be able to provide information to the medical care delivery system, and to the public it serves, on the effectiveness and efficiency of the latter's operation.
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. Others are risk factors more proximate to the outcomes, such as behaviors including poor eating habits and inactivity, and yet others pertain to the availability, quality, and appropriateness of clinical care services.
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and for non–health care social spending (measured by life expectancy, infant mortality, and potential years of life lost) , demonstrating the favorable health effects of other social domains on health (Bradley et al., 2011)
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3. Figure 1-1 Bitmapped Spending More Prudently In the United States, public health and prevention strategies are financed through a complex and often ad hoc patchwork of funding streams with federal, state, local, and private sources that vary widely among communities and exhibit considerable instability (this is discussed in detail in Chapter 2)
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level of support for the governmental public health infrastructure is inadequate to deliver the health and economic benefits of prevention. Although more than 75 percent of health care costs is attributable to preventable conditions, estimates consistently indicate that as little as 3 percent of U.S.
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. The modern history of governmental public health has demonstrated its capacity in the not-so-distant past to mobilize large-scale, multi-faceted solutions related to such issues as tobacco control, vaccine preventable diseases, and lead poisoning prevention (CDC, 2011b)
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SETTING A NATIONAL TARGET FOR IMPROVED HEALTH There is a broad consensus among labor, business, and government that the U.S. health status and the health system are in urgent need of improvement.
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The committee reviewed evidence that other high income countries that have sophisticated medical care achieve better value for their health investments. This is shown in research and analyses of the OECD that built on a body of work involving multiple international organizations -- including the World Bank, the World Health Organization, and the World Economic Forum -- that measured system cost-effectiveness or assessed value per dollar spent by comparing health spending with life expectancy (see, for example, Anderson, 2008; Cutler and Lleras-Muney, 2006; Darzi et al., 2011; Murray and Frenk, 2010; Poullier et al., 2002; WHO, 2010)
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. Two-thirds of the increases in life expectancy observed in the United States
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Recommendation 1: The Secretary of HHS should adopt an in terim explicit life expectancy target, establish data systems for a permanent health-adjusted life expectancy target, and establish a specific per capita health expenditure target to be achieved by 2030. Reaching these targets should engage all health system stakeholders in actions intended to achieve parity with averages among com parable nations on healthy life expectancy and per capita health expenditures.
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life expectancy to a level comparable with the average of its peers. THE CENTRALITY OF PUBLIC HEALTH IN ACHIEVING HEALTH SYSTEM IMPROVEMENT Governmental public health plays pivotal roles in a health system that comprises of multiple societal subsystems whose dynamic interactions create living conditions that determine health ("social determinants")
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The well-known inequalities that class differences confer are important obstacles to achieving healthy life expectancy comparable with that of other wealthy nations. Creating health more efficiently throughout the population will require both addressing the social and environmental determinants of health and taking a more systematic and concerted look at the clinical care delivery system's effectiveness in creating health through the services that it delivers.
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The national strategy to address the health crisis is directed predominantly downstream at the locus of care delivery and only weakly upstream at the causes of poor health that continue to generate large volumes of new cases in the medical care delivery system. CONCLUDING OBSERVATIONS Beginning with its first report (IOM, 2011b)
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. California Department of Public Health Tobacco Control Program.
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2011d. Rising Health Care Costs are Unsustainable.
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2011. Program, policy, and price in terventions for tobacco control: Quantifying the return on investment of a state tobacco control program.
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2001. The California Tobacco Control Program: A Decade of Progress, Results from the California Tobacco Surveys, 1990-1998.
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Health Affairs 21(6)
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2005. A potential decline in life expectancy in the United States in the 21st century.
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2005. State tobacco control spending and youth smoking.
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American Journal of Public Health 97(4)
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