A coalition of public-health organizations, including the Robert Wood Johnson Foundation (RWJF) and Campaign for Tobacco-Free Kids, has released a report criticizing most U.S. states for under-investing in smoking prevention and cessation. Broken Promises to Our Children: The 1998 State Tobacco Settlement 15 Years Later calculates that states over the past 15 years, states have collected a total of $391 billion from tobacco settlements and tobacco taxes, but spent only 2.3% of that amount on tobacco prevention programs.
The report compares states’ tobacco-prevention expenditures to the levels recommended by CDC, and finds that only North Dakota and Alaska are spending what the agency recommends. Twenty-four states are spending less than half of what CDC advises. The $481 million states are spending on tobacco prevention this year is far lower than the $717 million they spent in FY 2008, before recession-associated cuts began. "These cuts mean more kids starting to smoke, fewer smokers quitting, and more disease, death, and health care costs from tobacco use," the authors write. And, they remind us, tobacco prevention programs do get results:
Florida, which has a well-funded, sustained tobacco prevention program, reduced its high school smoking rate to just 8.6 percent in 2013, which is one of the lowest rates ever reported by any state.2 A December 2011 study in the American Journal of Public Health found that between 2000 and 2009, Washington state saved more than $5 in health care costs for every $1 spent on its tobacco prevention and cessation program by reducing hospitalizations for heart disease, strokes, respiratory diseases and cancer caused by tobacco use.
This is just one example of cuts to public health programs that allow for short-term balanced budgets but increase costs in future years. We’ve also written about “penny wise, pound foolish” cuts to poison control centers, STD screenings, programs addressing lead poisoning (here, too), and the infrastructure to identify and address foodborne illness outbreaks. These are all programs that save money in the long run, but face cuts when states and counties face declining revenues or increased expenses in another area.
Preventing health problems from occurring is often more cost-effective than treating the problems, and it also improves quality of life. In the US, however, we spend just three percent of our healthcare dollars on disease prevention. Since 2008, over 52,000 state and local public health jobs have been lost (through layoffs and attrition), and many health agencies have reduced the services they provide.
The incredible shrinking Prevention and Public Health Fund
The Affordable Care Act took a step toward improving prevention funding with the Public Health and Prevention Fund, which was supposed to contain $18.75 billion between fiscal year 2010 and FY 2022 and $2 billion per year thereafter. Fund dollars are supporting state and community programs to prevent tobacco use, obesity, heart disease, stroke, and cancer; strengthen the public-health and primary-care workforce; build public-health infrastructure; and conduct prevention-focused data collection and research. (You can see what kinds of Prevention Fund grants your state has received at the HHS website.)
The amount of money in the Prevention and Public Health Fund keeps shrinking, though, as Congress and the Obama administration decide to spend those funds on other things. As this American Public Health Association fact sheet shows, the $1.5 billion funding level originally legislated for FY 2014 has shrunk by one-third, to $1 billion. Assuming past cuts are neither reversed nor deepened, the FY 2015 amount will be $1 billion rather than $2 billion. Money has been shifted from the Fund to stave off scheduled cuts to Medicare physician payments and support enrollment in the new health insurance exchanges.
In the case of the Prevention and Public Health Fund, Congress and the Obama administration have been shifting money from public health to healthcare. Spending money on healthcare isn’t a bad thing, but taking that money from things that could lead to population-wide health improvements is not helpful in the long run.
Dedicated funding -- and more of it
Earlier this year, the Institute of Medicine released the RWJF-funded report For the Public's Health: Investing in a Healthier Future. The report notes that despite spending far more per capita on healthcare, the US lags behind other high-income countries in life expectancy and other indicators of health status. The authors state that in the US, “fixation on clinical care and its delivery eclipses attention to population-based activities that offer efficient and effective approaches to improving the nation’s health.”
The IOM committee offers 10 recommendations to improve US public-health funding. They suggest that as the ACA reduces the need for state and local agencies to spend money on clinical care, these governments should redirect those funds to disease prevention. They also urge Congress to “double the current federal appropriation for public health” and “authorize a dedicated, stable, and long-term financing structure” to generate the necessary revenue. Specifically, they recommend “enacting a national tax on all medical care transactions to close the gap between currently available and needed federal funds.”
Those are bold recommendations, and it’s the kind of thinking we need to achieve a future in which disease prevention is on par with disease treatment.