To be or not to be? The Prevention and Public Health Fund

by Kim Krisberg

"We will pay for this by taking money from one of the slush funds in the president's health care law."

That's an April quote from U.S. House Speaker John Boehner, R-Ohio, on how Republicans plan to offset the cost of stopping scheduled hikes in student loan interest rates. And the "slush fund" in question? The Prevention and Public Health Fund, the historic $15 billion investment in prevention authorized via the Affordable Care Act (ACA).

The April move by House Republicans wasn't the first attempt to raid the fund. Several tries have been made to repeal the fund entirely or shift its funds to non-health related activities. Many have been unsuccessful, but not all. For instance, earlier this year -- and to the disappointment of many public health advocates -- President Obama agreed to take $5 billion from the fund to stop cuts to Medicare reimbursement rates (more on that here).

Despite the fact that the fund addresses very real problems -- like out-of-control health care spending and rising chronic disease rates -- it's become a favored whipping boy for health reform opponents, who like to use the fund as an example of wasteful government spending (even though research shows that every $1 invested in proven community-based programs yields a return of $5.60). Unfortunately, the fund's future seems to be perpetually and frustratingly in limbo.

And it all begs the question: Can the Prevention and Public Health Fund survive? Of course, the fund's fate is tied to the (nerve-wracking) fate of the overall health reform law, which is now in the hands of the Supreme Court. But even if the law does endure, there's no guarantee that the fund will stick around.

"There's all this rhetoric out there about passing debt onto the next generation, but what opponents really seem to be saying is that they'd rather have the next generation be sicker than the current generation," Sana Chehimi, program director at the Prevention Institute in California, told me. "It's critically important that we share the outcomes of the work we're engaging in with legislators and decision-makers. Many public health workers can't lobby, but this isn't about lobbying. This is about showing how many more children are now eating healthier lunches or how many more seniors are feeling safer walking around their neighborhoods. Ours is a powerful narrative. We just have to get it out there."

Prevention funds at work

Already, more than $1 billion in prevention fund grants have been awarded to help communities confront the obesity epidemic, close health disparity gaps, reduce tobacco use, prevent HIV, administer vaccines, boost effective, evidence-based public health programs, strengthen public health systems and the list goes on.

For example in Washington state, which is in the midst of whooping cough epidemic, $2.1 million from the fund is being used to vaccinate under-served children, said Donn Moyer, a spokesman for the Washington State Department of Health.

Another $1.78 million was awarded to boost disease investigation, monitoring, testing and analysis; and $1.1 million was awarded to strengthen environmental public health tracking capacity, a critical piece of work that allows public health workers to effectively target interventions that prevent hazardous and costly environmental exposures. And thanks to a $3.3 million Community Transformation Grant via the fund, Washington communities are getting to work to find solutions to the "tremendous toll of preventable chronic disease," Moyer said.

"Public health funding is always a struggle," Moyer told me. "No one has been able to escape the cuts that happened as a result of the economic downturn. A lot of our support comes from the federal government -- it's a crucial piece of public health funding that we need to protect and improve the health of our people. It's vital."

In fact, the fund has become a bit of a lifeline for public health. While the fund was intended to be an additional source of funding, it's ended up being used to fill in declining public health budgets. In other words, if the fund goes away it'll do more than just halt new prevention efforts; it could seriously impact more traditional public health capacity as well.

For example, new prevention funds were used to fill budget gaps in the Centers for Disease Control and Prevention's 317 program, which provides immunizations to under-served kids. If the prevention fund were repealed -- as some legislators have threatened -- it would strip $190 million from the 317 program in fiscal year 2012 alone, according to the Association of Maternal and Child Health Programs.

"The funds were originally designed to be used for new and innovative approaches to the issue has been that because of the budget situation we find ourselves in, the funding has not exactly gone as planned," said Laura Hanen, chief of government and public affairs at the National Association of County and City Health Officials (NACCHO). "[The fund] has been used to backfill budgets...which makes it all the more important to local health departments."

Don Hoppert, director of the government relations at the American Public Health Association (APHA), called it a catch-22 -- "there's no way you can take for granted that appropriators in Congress can fill in gaps in discretionary [public health] funding if the Prevention and Public Health Fund goes away," he told me. (The Prevention and Public Health Fund is a mandatory stream of funding as opposed to more typical public health funding, which is discretionary.) Even though it wasn't meant to fill budget shortfalls, the fund has been a "blessing in disguise," Hoppert said.

"I'm optimistic (about the fund's survival)," Hoppert said. "The public health community has very consistently been on message and been pretty aggressive fighting back against additional cuts in the fund and I'm hopeful that will continue."

'An uphill climb'

After passage of the ACA, Rich Hamburg, deputy director at Trust for America's Health, said he didn't expect the fund to come under such regular threats, though "since that time, nothing really surprises us," he told me. Still, he expects that the "fund will survive and continue to survive."

"The good news is that the funds have been allocated and been used for life-saving and potentially life-saving public health programs," Hamburg said. "With an investment like does take time to implement these programs. And the nation will be better off for it."

That's the hope in Maryland, where monies from the Prevention and Public Health Fund are engaging communities in creating tailor-made solutions to problems ranging from obesity and tobacco use to poor nutrition and physical inactivity -- all of which are risk factors for costly chronic disease, according to Frances Phillips, deputy secretary for Public Health Services at the Maryland Department of Health and Mental Hygiene.

"[The fund] is vital for many of the public health programs that had been threatened because of previous fiscal budget cuts," Phillips said. "It's helping public health departments fill much-needed gaps, but it's also helping reduce demand [on the health care system] and improve services. It will result in healthier people at lower costs."

In Maryland -- like in all states receiving new prevention funds -- a major focus is on creating the opportunities and conditions that help people of all ages easily adopt healthy behaviors. For example, Phillips said Maryland public health staff are working with day care providers around state to improve food and physical activity standards for kids. Staff is also working with employers who want to implement workplace wellness activities that could significantly reduce their business' health care costs.

"There's growing awareness that these things matter and that steps that people take in their daily lives are as important as what's going on in the doctor's office," Phillips told me. "Prevention efforts have an uphill climb when it comes to competing for resources for treatment...that's always the case. But now there's even clearer evidence on the return on investment for prevention."

More about the Prevention and Public Health Fund, visit APHA's action page also has information about why it's important to preserve the fund.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.

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