Celebrating National Public Health Week

I am happy to join in the celebration of National Public Health Week. Although the readers of this journal are already keenly aware of the contributions of public health to the health of the nation, it is important for the rest of the country to be more aware as well. So much of our attention has been on how much we spend on health care or how many uninsured remain among us—both important issues—that sometimes we seem to lose track of where we are in terms of the health of the country and what we can do to improve it.

All three of these issues are related of course—being without insurance coverage makes people medically and financially vulnerable, can lead to medically inappropriate delays in seeking health care, and stresses the communities where they live because most people will receive some health care (through a complex set of safety net hospitals and community or religiously supported clinics) if they become sick enough. Spending disproportionate amounts on medical care, as many believe is reflected by our current level of 17.5% of the gross domestic product (GDP), means less funding available to spend on other areas that affect health:education, housing, and nutrition—the social determinants of health.

Focusing on the social determinants of health requires a greater emphasis on the overall environment where people live and work, and is important if the United States is to achieve better health than it has by predominantly focusing on medical care per se. It is not that we should expect a focus on the social determinants of health to redirect attention away from the (short-term) need for medical care, because it is unlikely to do so, but we should expect this focus to improve the health outcomes reported for the United States, which historically have placed the country behind most developed countries and some developing countries, despite spending a much larger share of our GDP on medical care.

There are some hopeful signs that, at least in terms of preventive health measures, we may be slowly moving in this direction. The Affordable Care Act (ACA) has mandated coverage of many preventive services with no cost sharing (based on recommendations from expert groups). Unfortunately, many people do not seem to know this or may be receiving care where preventive health is not a priority. However, as more people become part of managed care groups, where care coordination and focusing on preventive services are easier to have as part of routine protocols than sometimes occurs in the more stove-piped fee-for-service delivery system, this may start to change.

MANAGE CARE GROWTH

Medicare and Medicaid, as well as private plans, have reported substantial managed care growth. As of 2014, 258 million people were enrolled in some type of managed care. Preferred provider organizations are the most popular with 153 million and the somewhat more structured type of managed care; health maintenance organizations (HMOs) are second with 75 million people.¹

Kaiser Family Foundation reports that Medicare Advantage (the private sector alternative to the traditional fee-for-service Medicare program) enrolled almost 17 million people in 2015, about one third of the Medicare population. Medicaid has an even higher percentage, with more than half of the enrolled Medicaid population in a risk-based managed care plan, which effectively makes it an HMO.² More information is available about the Medicare Advantage plans than about the Medicaid plans because the state data systems have been less robust than the federal data and because there is more variation in coverage, even after the ACA.

A study that compared the quality of ambulatory care from 2003 to 2009 between Medicare Advantage enrollees and beneficiaries in traditional Medicare found that HMO enrollees (almost two thirds of Medicare Advantage enrollees) were consistently more likely to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease than those in fee-for-service Medicare. Also, the larger, not-for-profit, and older HMOs performed better than other HMOs.³ Because this was before the star rating program was introduced into Medicare, which gives Medicare Advantage plans a strong financial incentive to score well on preventive health screenings and consumer satisfaction among other measures, the difference between Medicare Advantage and traditional fee-for-service Medicare is probably larger than it was during the 2003 to 2009 period.

SUCCESSFUL SMOKING-REDUCTION EFFORTS

In addition to the changing nature of the delivery system, the United States continues to report a very positive experience with its smoking-reduction efforts. After plateauing for several years in the last decade, smoking in 2014 was reported at an all-time low of less than 17% of adults older than 18 years.⁴ This is a remarkable reduction compared with a rate of 42% in 1965, the year after Surgeon General Luther Terry released his report on smoking.⁵ Unlike many immunization or other preventive health measures, the United States has achieved lower smoking rates than other parts of the world including Japan, which continues to have the highest longevity rate. The smoking-reduction success in the United States seems to show that the results of a sustained public campaign, combined with outreach to the schools, the substantial use of excise taxes to increase the price of the product, and laws making smoking increasingly difficult, can have a major effect on behavior—even in a country as large and diverse as the United States.

This is an important reminder of what the nation can accomplish. The smoking threat of the last century has been replaced by the near-epidemic rates of obesity in the United States in this century. Obesity is not just a US problem. A majority of the population and 20% of the children in Organisation for Economic Co-operation and Development countries are either overweight or obese, with no countries showing a reversal of trends.⁶ In the United States (along with New Zealand and Mexico), more than one third of adults are obese, with rapid growth rates in obesity reported in Australia, England, and the United States since the 1990s.⁷ Japan’s low obesity rate of 3.5% seems to overwhelm its high smoking rate because it continues to have the highest longevity rate.

APPALLING OBESITY NUMBERS

Our obesity numbers should be enough to make obesity the number one health issue in the United States. The consequences are enormous, with as many as one third of US adults potentially having diabetes by 2050 if current trends continue (vs 1 in 10 now).⁸ Not only would this have substantial monetary consequences—with diabetes having medical costs that are twice those without diabetes—but also it would increase the likelihood of death and blindness.

An effective diabetes prevention program, such as those being organized by the Centers for Disease Control and Prevention and other organizations, will require lifestyle interventions for obese and overweight people, and most especially for children. The campaign against smoking is a good indicator of what can be accomplished when a sustained campaign is mounted. The move to more capitated health systems, with a greater focus on the overall health of the individual and where plans can do well financially by keeping people healthier and treating people in the lowest acuity settings medically appropriate, may facilitate the type of sustained effort that an obesity-reduction program would require.

More focus on the social determinants of health, particularly strategies involving better nutrition and safer communities, would also be helpful in encouraging more healthy food habits and healthier lifestyles. Helping low-income families understand how to prepare low-cost nutritious meals, cleaning up recreation areas in inner cities and protecting them from drug users, and enlisting the help of retirees to help young mothers understand the importance of proper nutrition for their babies and toddlers would be useful places to start.

FOCUS ON PREVENTION AND PUBLIC HEALTH

A greater focus on preventive and other public health measures might actually improve the health of the population—unlike spending more on medical care. We spend plenty on medical care. We need to learn to spend it smarter.