Public Health and the Jobs Bill

H. Pollack: Population Health and the Jobs Bill

ON FEBRUARY 25, President Obama will host a bipartisan summit that commences the endgame of health reform. I remain optimistic that Democrats will find a way to pass a comprehensive bill. However this process ends, I can’t help noticing how necessary and yet how narrow the effort to reconstruct our health care system has become. It’s all too easy to conflate population health with the provision of health services, health services with the provision of personal medical services.

America needs comprehensive reforms to address central issues of health care access and (ultimately) cost control. Without slighting the importance of these issues, our exclusive focus on health insurance reform shifts attention away from equally essential policies to protect population health. Our nation’s annual increase in medical spending reaches the hundreds of billions of dollars. Despite this monumental medical cost growth, our public health infrastructure is fraying badly. Localities, states, and federal public health authorities struggle to finance modest investments in substance abuse treatment, HIV prevention, reproductive health services, and other basic needs. High and rising Medicaid costs (and rising medical care costs for current and retired state employees) are pushing states to make further public health cuts next year.

The present economic downturn has turned these chronic problems into a crisis. Some friends I know at big-city health departments are required to work off-hours to staff H1N1 vaccination clinics. They struggle to help uninsured people find primary care and mental health services. They face these increasing burdens while being forced to take a month of unpaid leave this year.

This is not a new phenomenon; cities, counties, and states have been cutting budgets for many years. But the resulting harm is oddly magnified by restrictions imposed by this year’s stimulus, which insulates Medicaid and some other big-ticket items. With some other areas—such as higher education and corrections—politically defended, the burden falls on more vulnerable activities: child welfare, non-Medicaid services for the disabled, and public health.

As a result, the public health infrastructure faces serious challenges that are not directly addressed through the now-embattled health care reform bill. Even if we enacted universal coverage, your doctor wouldn’t check whether there is arsenic in your water, microbes contaminating your hamburger, lead paint at your child’s daycare center. She wouldn’t pay home visits to help a teen mom breastfeed or investigate a measles outbreak at the local nursery school. She wouldn’t monitor local merchants and ensure that they keep cigarettes away from kids.

Such public health work is underfunded even in good times. States, for example, collect more than $25 billion in tobacco taxes and legal settlements with tobacco firms. But less than 3 percent of this money is used for tobacco control, despite the fact the CDC recommends that states spend $3.7 billion on tobacco control. (See Massachusetts’ recent success in helping Medicaid recipients quit smoking.) Since the recession, these public health projects have suffered even more cuts. In the past year, states have cut tobacco control programs by $103 million. Smokers pay billions of dollars in tobacco taxes. Yet when they call public quit lines to get help, they increasingly find that the lines are closed, have restricted hours, or offer newly-restricted services. The human cost, though diffuse, is high: Thousands of smokers will die from lung cancer or heart disease because they will not receive needed help.

The proposed health care reform bill would include welcome monies to improve this situation. But these funds would not offset the deep cuts that are now being imposed across the country. The National Association of County and City Health Officials (NACCHO) recently surveyed 990 local health departments across the country and found that more than half have suffered from program cuts or layoffs in the past year (and there are more in the works).

NACCHO also compiled stories from the field to show the human face of these cuts. In Lorain, Ohio’s health department, cutbacks forced it to halt mobile flu vaccination programs in high-rise public housing. “All of our staff have been put on a four-day work week,” the health commissioner reports. “We have no money whatsoever to purchase flu vaccine and have no staff to give the vaccinations.” In Jackson County, Oklahoma, the local health department used to provide mammography and other preventive screening. They can’t do that any more. The list goes on as the recession has quietly eroded our governments’ ability to accomplish basic tasks.

Democratic and Republican policymakers understand the value and cost-effectiveness of public health services. But elected officials also understand that diffuse prevention measures rarely mobilize political support. It doesn’t help that these services often serve politically marginal constituencies and that public health measures often address delicate matters such as drug use and sexuality.

Promoting Stimulus Through Public Health and Vice-versa
President Obama has an opportunity to address these challenges in a second stimulus package—oops I mean a jobs bill. This legislation provides a readily missed opportunity to promote public health while putting people to work performing useful jobs.

During last year’s stimulus debate, experts proposed many good ideas: building cheap structures to house all-weather farmers’ markets, hiring lay health workers to assist low-income people with chronic illnesses, treatment on request for substance users, and more. But few of these proposals have seen the light of day. They were strongly opposed by Senate moderates who had no problem supporting giveaways to powerful constituencies but who balked at measures in reproductive health, smoking cessation, and (as later proved embarrassing) measures to fight pandemic flu. Lawmakers’ reluctance to fund worthy prevention measures formed a stark contrast with their willingness to pack the bill with unexpected monies for National Institutes of Health bench science and advanced treatment research. These HIH funds were welcome. Yet the outcome reflected an unimaginative mindset that produced a valuable but unbalanced bill.

The list of valuable stimulus projects easily grows. Home-visiting programs provide great value for parents and children, and they also create jobs. Registered nurses can do this well. So can other health workers, who are less skilled but are also less expensive and more in need of work. HIV prevention and treatment provide other opportunities. 2006 CDC guidelines recommend broad HIV screening in many health settings. This allows patients to commence early treatment and helps prevent many new infections from being spread by people who don’t know that they are carrying the virus. Such screening would require staff that could be quickly hired and trained for counseling and testing. Compared with other stimulus investments, HIV prevention and home-visiting programs provide immediate benefits and run less of a risk that taxpayers will spend billions of dollars buying an empty hole.

Addressing Social Determinants of Health
But, most important, the jobs bill could address social conditions that are no less essential than medical care in promoting population health.(1) Epidemiologists document that our nation’s glaring failure to address these conditions is even more important than our glaring failure to provide universal coverage when explaining why America performs so much worse than other industrial democracies in global rankings of average lifespan and infant mortality.

I recently did a back-of-the-envelope calculation and found that even the flawed Senate health reform bill would be a hugely progressive public policy. By 2019, that bill would provide roughly $196 billion every year down the income scale in subsidies to low-income and working Americans. These are huge numbers, exceeding combined federal spending on food stamps and other nutrition assistance, the Earned Income Tax Credit, Head Start, cash welfare payments to single mothers and their children, all of NIH, and (possibly) the entire Department of Housing and Urban Development.

In a thoughtful response to these numbers, Marcy Wheeler raised a classic question: If we told poor and working Americans that they could have that same $196 billion in new subsidies, would they really want that money to be provided in the form of health insurance coverage?

In one way, this is idle speculation. Americans and the American political system are more willing to provide poor people with expensive health care than we are to provide commensurate resources in the form of housing, schools, and direct employment (not to mention providing cold hard cash). Health reform is therefore a unique political opportunity for progressives. If health care reform is defeated, no one will come back to offer something else. Moreover, progressive critics of health reform sometimes implicitly adopt the perspective of a relatively young person who has no plans to become ill. A healthy but poor twenty-five-year-old might prefer a more generous earned income tax credit over improved health insurance coverage. His diabetic neighbor might disagree.

These caveats not withstanding, Wheeler makes an essential point that goes beyond the politics: however the current health reform is resolved, we must revisit the social determinants of health with renewed urgency. There is a significant gap between our willingness to finance health services and our willingness to finance pretty much everything else that promotes health and well-being.

These disparities are so familiar that they almost escape notice. If you bring your child for care at some primary care clinic or Federally Qualified Health Center, you may have to wait in a crowded waiting room before you see a doctor. You may notice the paucity of staff who are graduates of elite (American) medical schools. Yet in all probability, your child will receive proficient treatment within a facility that has the financial and human resources to provide Spartan but effective care. If you take your child to the nearby school, employment, or welfare office, you will encounter the same long wait, but you are much more likely to encounter an overwhelmed and under-resourced organization that cannot provide effective help.

Widening the resource disparity between health care and everything else is unwise social policy. Millions of Americans will have improved access to decent health care if health reform is passed. Many of these same Americans will still live in communities that endure failing schools, widespread crime, poor housing, and chronic unemployment. Nurturing healthy citizens requires that we address these profound nonmedical challenges with the same determination and financial commitment that we have deployed in health reform.

In the absence of such a determined effort, America’s selective egalitarianism—so narrowly confined to the arena of health care—may prove self-defeating. A serious jobs bill, which includes strong measures focused on public health, provides one way to do better.

Harold Pollack is Helen Ross professor of Social Service Administration at the University of Chicago, where he is faculty chair of the Center for Health Administration Studies.

1 For more on this, see our co-edited book, Making Americans Healthier: Social and Economic Policy as Health Policy