Sanne Magnan Comments

RESOLVE’s Public Health Leadership Forum¹ on financing public health infrastructure and DeSalvo et al. are commended for exploring dedicated funding for core public health capabilities. The authors succinctly outline the need, functional capabilities, funding gap assessment, principles for any fund, and a process for fund distribution to sustain a public health system that keeps our nation healthy and safe. There is no doubt that these resources are necessary for our country’s prosperity. However, with national budget deficits, multiple funding requests, long-term inadequate investment in population health, and the recent raid on the Prevention and Public Health Fund (PPHF), what different approaches can be taken to secure these funds? One consideration is for the public health sector to explicitly address health care costs.

The 2012 Institute of Medicine’s For the Public’s Health: Investing in a Healthier Future (FPH) includes as its first recommendation that the Health and Human Services Secretary adopt a life expectancy target as well as a per-capita health expenditure target for the United States to achieve average parity among similar nations by 2030.² Per FPH, “Excessive spending on medical care also presents opportunity costs—less money remains for investment in other socially important activities. . . .”^(p4) Comparing us to similar wealthy countries, the United States, on average, spends about twice as much per capita—$10 244 versus $5280 (2017 dollars). The report focuses on the “centrality of public health”^2(p34) in improving the health of the population, but also notes the need to address rising health care costs.

Recently, Fraser³ reflected on learnings from the PPHF and recommended that public health advocates tie their “fund advocacy to efforts to lower costs.”^3(p576) Inexorable rising health care costs are a major concern to Democratic and Republican lawmakers, especially for Medicare and Medicaid budgets. In Minnesota, public health successfully advocated in 2008 for borrowing $50 million from the Health Care Access Fund (HCAF) to address tobacco and obesity across the state with proven policy, systems, and environmental changes over 2 years. As these changes were being implemented, in 2011, the difference between projected and actual health care spending was $50 million or greater, which the Legislature defined as “savings,” and the dollars were returned from the general fund to the HCAF.⁴

As health care providers become more responsible for the total cost of care for populations with changing payment models, they are increasingly interested in the social determinants of health and relationships with community-based organizations such as public health. Kindig wrote in Purchasing Population Health: Paying for Results, “population health improvement will not be achieved until appropriate financial incentives are designed for this outcome.”^5(p174) Is it time to align health care and public health’s incentives to achieve shared health and cost outcomes for populations—both attributed and geographic—in a joint accountability model?⁶

The Public Health Leadership Forum also brings together health care and public health entities to explore community well-being. How can the efforts on financing public health infrastructure and partnering to catalyze community wellness lead to additional common ground for incentives and targets for population health and per-capita health care costs that prompt investment by policymakers per DeSalvo et al.? How may these measures align with summary measures and targets for the development and implementation of Healthy People 2030, including the use of complex systems science to reduce the likelihood of unintended consequences?⁷

Two truths: we need to invest more in public health, and we need to lower health care costs. The question is how to align allies, incentives, resources, and policies this time around for both to happen.