The Promise of and Lessons From the Prevention and Public Health Fund

The article by Fraser in this issue of AJPH, “A Brief History of the Prevention and Public Health Fund” (p. 572), is a useful reminder of the challenges faced in promoting good health and strengthening the public health system in the United States. Our health care system spends billions of dollars on the latest technology and medications that show limited efficacy (or, in the case of prescription opioids, unleash an epidemic). But create the opportunity to initiate programs and pass policies to keep people healthy through the Prevention and Public Health Fund (the Fund), and an uproar occurs.

To be fair, there was certainly opposition to other components of the Affordable Care Act (ACA) beyond the Fund. The expansion of insurance coverage to 20 million additional people through the ACA continues to face major opposition. Despite that opposition, expanded health care coverage is largely intact, resulting in millions more Americans accessing needed health services. By contrast, the Fund has been repeatedly reduced and often used to support and expand programs at the Centers for Disease Control and Prevention (CDC) that existed before the ACA was passed.¹

We can and should applaud the continued existence of the Fund. My organization, Trust for America’s Health, which advocated for the ACA, designated the Fund as a top priority during the 2017 ACA debates. Together with many other organizations, we have worked tirelessly to defend it. Although the congressional attempts to repeal the ACA and eliminate the Fund have subsided for now, we are prepared to protect this critical investment moving forward. Before we once again direct all our available energy to such preservation, it is worth taking some time to consider what was learned from the Fund’s existence.

Perhaps the first and most important lesson is that it is necessary to fight to prioritize primary prevention efforts before illness or injury occur and do so for the entire population. This may sound obvious and hardly worth noting. But because of the enormous challenges in striving for high-quality, affordable, and accessible health care, advocacy for primary prevention can often seem less urgent. It can be difficult to convey the importance of investing in prevention to policymakers when they may not see an immediate outcome. Yet quality, coverage, and prevention are three legs of the same stool—protecting Americans’ health. Over the years, the Fund has been raided to support the training of primary care clinicians, avoid cuts to physician reimbursement, finance a small portion of the 21st Century Cures Act, and briefly extend the Children’s Health Insurance Program—even over the objection of medical professionals and hospital groups. Although these are important efforts, they should not be achieved at the cost of prevention and public health. To do so is robbing Peter to pay Paul.

We have come to a new understanding of what is needed for people to be healthy—a recognition that health care alone is insufficient. In a noteworthy speech in 2018, US secretary of Health and Human Services Alex Azar recognized this and emphasized the importance of addressing the social determinants of health as a component of health care delivery.² Although necessary, screening and attempting to address these factors through existing health care systems is insufficient. Unless there is a simultaneous focus on primary prevention and population-level policy changes—such as those that address racial and ethnic discrimination, economic opportunity, and the availability of affordable housing—these efforts are likely to fall short.

The second lesson is that scientific knowledge and innovation must guide upstream efforts to promote good health. The Community Transformation Grant program, an early use of the Fund, was a significant effort to promote community-based, evidence-informed primary prevention. Begun in 2011, the Community Transformation Grant program funded proven programs that prevent chronic conditions such as obesity, diabetes, and heart disease. Local awardees worked with public health and other sectors, such as transportation and education, to promote interventions as American as apple pie: more physical education classes in schools, support for local farmers and accessible farmers markets, and protections against secondhand smoke exposure.³ Yet the program became politicized in the fight over the ACA, and Congress eliminated funding. Multisector local community coalitions found their burgeoning efforts abruptly ended, and these programs never fully realized their impact on improving health and reducing health care costs.

Despite all this, the Fund has made many effective public health investments possible. It provided more than $8 billion in public health funding in a time of strict budgetary spending caps and line-item reductions, likely protecting the CDC’s core budget and division activities. Some innovative programs with relatively modest budgets were and still are supported by the Fund, including the Tips From Former Smokers campaign, an initiative to prevent health care–associated infections, the Diabetes Prevention Program, and the development of state-of-the-art laboratory capacity to detect emerging infectious diseases. Most of the Fund was and is still used to support the continuation or expansion of long-standing CDC programs—for vaccines, the Preventive Health and Health Services Block Grant, and tobacco prevention—which otherwise might have stagnated or been cut. But the promise embodied in the ACA “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 health care costs” was not fully achieved.⁴

Nonetheless, the debate over the Fund offers some cause for optimism. A unified and strategically organized movement effectively made the case for public health interventions. The odds were against the Fund during the ACA repeal debate in 2017. However, organizations such as the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and Trust for America’s Health were relentless in their efforts and strove to demonstrate that the benefits derived from the Fund were nonpartisan and of great value to the nation. State-specific summaries of the benefits of the Fund’s expenditures effectively highlighted its impact on each state’s jobs, economy, and health.⁵

Advocates also mobilized people around the country to urge their members in Congress to maintain the Fund. Even those in Congress opposing the ACA were encouraged to support the services paid for by the Fund. These strategies broadened the base of support.

The fight for the protection, let alone the expansion, of prevention and public health initiatives is far from over. Public health advocates must make the case that these investments are essential, even in times of fiscal constraint. The budgets of the CDC and state and local public health agencies are not keeping pace with the growing public health challenges of the devastating substance abuse and suicide epidemics and the proliferation of weather-related emergencies. And although health care systems and insurers are increasingly focusing on population health and prevention, most of the strategies being considered are confined to a limited number of very sick high-cost patients in clinical settings. For the United States to improve the health status of all residents, neither the promise of the Fund nor the lessons learned from the fight to protect it should be forgotten.