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Building Healthier Communities

Public health gets least money, but does most

Jayne O'Donnell, and Laura Ungar
USA TODAY

WASHINGTON — Just three cents of each U.S. health care dollar goes to public health even though it plays a far bigger role in keeping Americans well than medical care, a top federal official said at a forum presented by USA TODAY and insurer Cigna.

State and local public health departments were hit especially hard by the recession and haven't recovered, said physician Karen DeSalvo, acting assistant secretary of health at the Department of Health and Human Services.

USA TODAY's Laura Ungar, right, with Georges Benjamin, executive director of the American Public Health Association, center, and Richard Hamburg, deputy director of the Trust for America's Health, at the USA TODAY and Cigna's Building Healthier Communities event.

“Public health infrastructure has a history of being there when necessary, but on the other hand increasingly being marginalized and under-funded year after year after year," said DeSalvo, a former health commissioner of New Orleans. “We are starving the infrastructure.”

Even though 80% of people's health is influenced by what happens outside of doctor's offices and hospitals, about 97% of funding goes to pay for medical services, DeSalvo said.

Public health focuses on prevention rather than treatment — things such as reducing communicable diseases, educating people about the importance of diet and exercise and making sure they have access to nutritious foods and all the ingredients of a healthy life.

There is a "social and a societal opportunity" in keeping people well rather than just treating them when they are sick, said Cigna CEO David Cordani. But there's a strong economic argument too, he said.

"If you want to go at it from a financial standpoint, right now the cost of health and health services is about the No. 1 budget item, Cordani said. "The more effective we can be there, you'll free more capacity to invest more in education (and) in transportation. This is a winning proposition no matter which door you walk through."

No one was suggesting public health is the government's job alone. It's crucial for communities, states, doctors and individuals to collectively work to improve the health of their whole population, speakers agreed.

Dr. Karen DeSalvo, acting assistant secretary for health at the Department of Health and Human Services, at USA TODAY and Cigna's Building Healthy Communities –forum.

Some lamented the nation's comparatively meager investment in public health considering the potential savings — both human and financial.

• A Trust for America's Health analysis found the $30 billion invested nationally in chronic disease — which includes conditions ranging from arthritis to cancer and heart disease — was $20 billion shy of what was needed. "Chronic disease is chronically under-funded," said Richard Hamburg, TFAH's deputy director.

• Another TFAH study last year found 22 states reduced public health spending in the previous two years — some for two and three years running. State funding also varied greatly, with one state devoting $150 a person to public health and another just $3 a person. This is despite the fact that research shows every dollar spent on prevention saves $5.60 in health spending.

•`When she was New Orleans' health commissioner, DeSalvo said she had $4.62 per resident per year to spend, which was about in the mid-range of what other states had. “That amount of money doesn’t allow you to do very much," she said, adding she couldn’t even afford a flu shot with that.

• Public health funding is there during emergencies but is generally not sustainable over the long haul, said physician Georges Benjamin, executive director of the American Public Health Association. Overall, federal funding for population health "has come in fits and starts," Hamburg agreed.

For example, Benjamin said cuts in funding for tuberculosis in the 1980s led the disease to come back with a vengeance in a drug-resistant form.

More recently, preparedness money devoted to public health after the terrorist attacks of Sept. 11, 2001 — which included building infrastructure in health departments that still used rotary phones at the time — dissipated in later years, Benjamin said.

"The dollars are always there when something horrible happens," Hamburg added. "But those are emergency funds. They come and they go.”

Everyone bears the cost when the nation fails to consistently spend enough on keeping people healthy, Benjamin said, After all, if an uninsured patient gets care in an emergency room and can't pay his bill, the rest of society pays through higher medical bills and insurance costs.

“There’s just one pot of money. It’s just how we move the money around," Benjamin said. "We have a system which simply has each other paying out of each other’s pockets."

While many countries spend a lot on health care, the United States leads the world in per capita health spending, Cordani said, "yet our health status and health outcomes continue to be challenged."

DeSalvo was more blunt. Some parts of the United States, such as areas in Baltimore, she said, have worse health than developing countries, such as North Korea.

Life expectancy also varies greatly by location, Benjamin said; it's 72 years in Washington but 82 years 20 miles away in Maryland, in part because parts of Washington are hurt by violence and lack of access to health food and safe places to exercise.

"It really matters where you live, what your income is and a range of other things that help make the healthy choice the easy choice," Benjamin said.

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