Changing the Public’s Health Story: Reducing Wasteful Medical Care Spending—Introduction to the Special AJPH Section

This much is well known: the United States pays too much for medical care compared with other wealthy nations, lacks universal coverage, and has poorer, inequitable health outcomes than other wealthy nations. The recent events of COVID-19 and the tragic, urgent calls for racial justice have vividly demonstrated the deficiencies resulting from health care inequities and the public health system’s years of neglect. Now, when these problems are apparent to all, there is a unique opportunity to make equitable investments in affordable medical care and in the factors that make a population healthy. Key to doing this is informing stakeholders—including ourselves—of the consequences of our society’s false narrative that medical care is the predominant driver of health.

2012 INSTITUTE OF MEDICINE REPORT

Rising medical care costs and decreasing life expectancy threaten the core mission of public health: “what we, as a society, do collectively to assure the conditions in which people can be healthy.”^1(p1) For every medical care dollar wasted, there is one less dollar for public health, including universal coverage and social and environmental determinants of health and well-being. In a 2012 report from the Institute of Medicine (IOM; later reorganized as the National Academy of Medicine and the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine), the first recommendation is to set targets for life expectancy and per capita health care expenditures. This recommendation juxtaposes two important high-level measures—outcome and cost—for the performance and improvement of a health system. Specifically, the secretary of the Department of Health and Human Services should adopt life expectancy targets and establish data systems and a specific per capita health expenditure target to achieve parity with comparable nations by 2030.²

The purpose of this AJPH special section is to explore that first recommendation from the IOM report For the Public’s Health: Investing in a Healthier Future. In 2018, Kindig et al. published an assessment of the feasibility of achieving parity with Organisation for Economic Co-operation and Development (OECD) nations on life expectancy.³ McCullough et al. (p. 1735) complete the assessment with an examination of achieving parity on health care expenditures. Speer et al. (p. 1743) quantify the magnitude of medical care waste and propose categories of waste as they explore the opportunity costs to universal coverage, public health, equity, and business.

MOVING FORWARD

A thought-provoking set of opinion pieces completes this special section, focusing on the IOM recommendation and providing concepts and actions for moving forward. Kindig and Chowkwanyun (p. 1741) discuss the historical context of the US divergence from comparable OECD nations in life expectancy and health care expenditures since the 1980s. Magnan et al. (p. 1733) examine the rationale for setting life expectancy and health care expenditure targets and next steps.

Many Americans find it counterintuitive that more care does not always yield better health. However, there are unintended consequences of waste in our health system, including diverting resources from universal coverage and upstream health factors. Hughes and Meadows (p. 1749) argue that medical waste is a health equity issue. Zimmerman (p. 1755) discusses why an inverse U for life expectancy and health care expenditures is perhaps to be expected and the implications for public health and our nation.

Some argue that the problem in the United States is not overutilization but excessive prices—a waste category. Hughes-Cromwick et al. (p. 1751) elaborate on price and how COVID-19 may present an optimal moment to rationalize prices to spend less in health care.

To drive change, we need to change the arc of the US health care story and engage critical stakeholders. This will not be easy, as Niederdeppe and Gollust (p. 1753) articulate in their discussion of the challenges and some solutions for communication to policymakers and the public. Finally, the concluding editorial by Milstein and Fielding (p. 1758) is a capstone for this special section and describes common sense questions to be asked.

CHANGING THE STORY

In summary, with engaging stakeholders, setting targets, defining and exploring waste, and using actionable data to remove waste for better health investments, the US health saga can begin to be more about health and equity and less about expensive, unnecessary medical care. To be most effective, these interventions must align with health care payment systems that reward health and well-being—both for individuals and communities—as well as a more robust public health system and upstream factors that promote health.

With the disruptions of COVID-19 and the calls for social and racial justice, the country is ripe for change. We hope this special section contributes to changing the story.