Public Health – A Poor Step-Child

Individually-based medical care trumps public health

Prevention lags far behind medical treatment

In the US, the combination of the baby boom and increasedlife expectancy will create huge pressures on our medical system. Alas, the US spends more and achieves worse outcomes, including care for older persons, than most developed countries. Looking forward, our health care system is unprepared to provide the medical and support services needed for previously unimagined numbers of sick, older persons. A team of health experts made four recommendations as vital directions for health and health care. They include 1) develop new models of care delivery, 2) augment the elder care workforce, 3) promote the social engagement of older persons, and 4) transform advanced illness care and care at the end of life.

US health care spending accounted for 17 percent of the US economy or $2.1 trillion or $9,110 per person in 2014. A team of researchers estimated US spending on personal health care and public health during the period 1996-2013 according to 155 categories. During this period, US health care spending increased by an estimated 3-4 percent per year. Among the 155 categories, diabetes accounted for the largest health care spending in 2013, an estimated $101 billion. It’s worth noting that type 2 diabetes is almost entirely preventable by adopting healthy lifestyle choices, especially Keep Moving and Eat Better. Ischemic heart disease and lower back and neck pain tied for second and third places with estimated spending of $88 million each.

Americans aged 65 years and older accounted for 38 percent more heath care spending than any other age group. Moving from age 60-64 to 65-69 produced a larger increase in health care spending than any other age group transition. Excessive blood fats, largely attributable to poor diet, accounted for the largest increase in health care spending for Americans aged 45-64 and 65 and older. Governmental public health programs comprised a meager 2.8 percent of total health care spending. A substantial fraction of US health care spending arose from conditions, such as diabetes, ischemic heart disease, chronic obstructive pulmonary disease, and cerebrovascular disease, that healthy lifestyle choices can prevent.

A recent study found that that roughly one-fourth to one-half of US health care spending in 2015 was wasted in the sense that it didn’t improve health. The major sources of waste appear to be excessive drug costs, excessive costs of services delivered, and excessive administrative costs. Unfortunately, a popular health-related narrative asserts that reducing medical care spending requires limiting medical care coverage and reducing benefits and would lead to more lives lost. Empirical evidence does not support these ideas.

Other developed countries achieve better health outcomes, such as greater longevity, at lower cost than does the US. Countries that allocate more public money to social services and public health have longer life expectancy, lower infant mortality and fewer potential years of life lost than countries that allocate less public money to social services and public health. Researchers at UCLA used 25 years of fiscal data (1990-2014) from the State of California to determine if public funding for medical care crowded out funding for social services. Analyses showed that during the 25 years, funding for medical care (for example, Medicaid) increased by 50 percent, while spending on social services declined by 38 percent. What beneficial societal outcomes might occur if 20 percent of California’s medical care dollars were re-directed as a one-time expense to fund effective, evidence-based social programs, including high school guidance counselors, tobacco prevention and control, and pre-school over a period of 10-13 years?

The researchers found that these social programs would be highly cost-effective with benefit-to-cost ratios of 29-60:1, 12:1, and 5:1, respectively. Thus, investing $1 million in hiring more high school guidance counselors would generate at least $29 million in societal benefits by increasing graduation rates from 84 to 94 percent, thereby increasing lifetime incomes and increasing tax revenues to the state and federal governments over 10 years. A one-time re-allocation of $1 million otherwise wasted medical dollars to tobacco prevention would generate $12 million in societal benefits by reducing the incidence of smoking from 10.8 to 8.4 percent, thereby reducing annual deaths by 10,200 at the end of 10 years. The clear message: Public finding for medical care crowds out funding for cost-effective social services. California (and other states and the federal government) can do far better in spending taxpayer dollars more wisely to achieve greater societal benefits without compromising medical care.

The National Academy of Medicine’s Vital Directions for Health and Health Care for Older Adults recruited 150 experts to identify priority issues for US health care. A 2013 report from the National Research Council identified six priorities to improve care and quality of life for older Americans: 1) create an adequately prepared workforce, 2) strengthen the role of public health, 3) remediate disparities and inequities, 4) develop new approaches to care delivery, 5) allocate resources to palliative and end-of-life care, and 6) strengthen long-term services and supports.

Many Americans believe that we have the best medical care system in the world. Not so. The US rates lower than many other countries in objective measures of health including infant mortality and longevity. Atul Gawande, MD, is a practicing physician and a gifted writer. His insightful article in the August 30, 2021, issue of The New Yorker recounts what he learned about the delivery of health care during a visit to Costa Rica. Álvaro Salas Chaves, a Costa Rican public health physician, guided Gawande around the country and explained the Costa Rican model of public health.

The key is combining health care for individuals with health care for neighborhoods. Every resident in the country meets with a health-care worker at least once a year. Limited financial resources go to where they can yield major benefit. The results are astounding. Infant and maternal mortality in Costa Rica are lower than in the US and achieved at lower cost. Life expectancy is about a year greater there than in the US. And not insignificantly, the number of childrens’ teeth missing, decayed, or filled is lower than that in the US, again at lower cost. Across the US, our medical care system reflects a massive mis-allocation of resources that overfeeds individual patient care, while starving public health, resulting in poorer outcomes at higher cost.

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