Both houses of Congress have now passed, and President Obama has signed, the omnibus spending bill, and it’s a welcome relief from budget battles through the end of this fiscal year (September 30, 2014). I was especially curious to see what the bill contained for the Prevention and Public Health Fund, an important part of the Affordable Care Act that has suffered under previous budget manuevering.
Section 4002 of the Affordable Care Act established the Prevention and Public Health Fund "to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs." It authorized and appropriated $500 million for the Fund in its first year (FY 2010), with the amount rising gradually up to $2 billion in FY 2015 and each year thereafter. The money is to be used for "prevention, wellness, and public health activities."
Under the original legislation, the Fund in FY 2014 should have contained $1.5 billion. Due largely to past cuts, the total Fund amount in the just-passed spending bill is nearly $1 billion (it comes in at $928 billion, after the mandatory $72 million sequestration cut). Congress also did something it hasn't done in previous years, and specified how that money should be doled out among different public-health programs. That's a welcome step, given that the money could otherwise get shifted toward less-prevention-focused priorities.
Some news outlets have apparently been reporting erroneously that the fund has been cut. The American Public Health Association's Public Health Newswire blog features a video clip of Senator Tom Harkin (D-Iowa) clarifying that 100% of the Fund resources have been allocated to prevention and wellness activities.
An important investment, competing with other worthwhile priorities
The Fund’s creation was a welcome step toward redressing US under-investment in public health. In a fact sheet about the Fund, the American Public Health Association notes that in the US, “only 3 percent of our health care spending is focused on prevention and public health, when 75 percent of our health care costs are related to preventable conditions.” The Department of Health and Human Services website gives examples of the kinds of programs the Fund supports in each state, including anti-tobacco and anti-obesity campaigns, vaccine modernization efforts, and prevention-focused data collection and research. As Kim Krisberg wrote in post for the 2013 National Public Health Week, such programs can pay off in later healthcare savings, and that knowledge informed the Fund's creation:
In 2008, the nonprofit [Trust for America's Health] released an oft-cited report on the cost savings related to investments in disease prevention. The report found that an investment of $10 per person per year in proven community-based efforts that increase physical activity, improve nutrition and prevent tobacco use could save the nation more than $16 billion annually within five years — that’s an ROI [return on investment] of $5.60 for $1 invested. In fact, [TFAH President Jeff] Levi said that one of the reasons for passage of the Prevention and Public Health Fund, the landmark funding stream included in the Affordable Care Act, was that advocates were able to show the potential for ROI.
Savings from prevention investments don't materialize immediately, though, and current budget holes tend to command more immediate attention. Back in early 2012, Congress voted to take a total of $5 billion from the Fund as part of a "doc fix" deal to avert scheduled cuts to Medicare providers' reimbursement rates. In 2013, the Obama administration announced that it would use nearly half of the year's remaining Fund dollars on building the federal health-insurance exchange. Medicare payments and the federal exchange are both worthwhile things to spend money on. Under-investing in prevention, though, means that we're likely to keep facing unsustainable healthcare-cost growth -- and that means we'll keep facing tough decisions about how to pay Medicare bills.
Spending prevention money on prevention
Congress's decision to allocate FY 2014 Fund dollars to specific programs means the money isn't available to plug holes in the healthcare budget -- instead, it will actually be used for prevention. CDC will get most of the Fund dollars for various programs; in addition, the Administration for Community Living will get $27.7 million for Alzheimer's Disease prevention, chronic disease self management, and falls prevention; the US Preventive Services Task Force will get $7 million; and the Substance Abuse and Mental Health Services Administration will get $62 million for Access to Recovery and suicide prevention.
The CDC activities supported by the Fund in 2014 include programs to prevent cancer, diabetes, heart disease, and stroke, as well as efforts to tackle healthcare associated infections, smoking, and lead poisoning. The agency will also make grants for immunizations, workplace wellness, and building epidemiology and laboratory capacity.
The spending bill also specifies that of the Fund's nearly $1 billion "$5,000,000 shall be available to conduct an extension and outreach program to combat obesity in counties with the highest levels of obesity" -- defined as counties in which 40% or more of the population is obese, as determined by the Behavioral Risk Factor Surveillance System (BRFSS). CDC's analysis of 2007 BRFSS data found that "counties with the highest obesity prevalence largely were in the South, western Appalachians, and coastal Carolinas."
I hope this is the beginning of a trend toward spending Prevention and Public Health Fund money on prevention activities rather than on healthcare. The more funding we direct to prevention efforts now, the more we'll learn about how best to prevent diabetes, heart disease, and other conditions that sap years of healthy life from the US population. With continued investments in prevention and public health, we can not only save money on healthcare costs, but help people live longer, healthier lives.