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Not So Super

[Guest post by Harold Pollack. Cross-posted from The Incidental Economist]

It’s disappointing but unsurprising to read that Super-committee Democrats may cut the Affordable Care Act’s ten-year $15 billion Prevention and Public Health Fund. The Obama administration had already signaled a willingness to scale back the initiative, having previously proposed of a 25 percent cut as part of one of its deficit reduction deals. Super-committee Democrats have now called for cuts roughly twice as big, or $8 billion.

The Fund is less than two percent of new spending initiated under health reform. The idea is popular with voters. Yet the Fund has proved politically vulnerable. Sarah Kliff reported last year that Republicans regarded the Fund was one of the "top three" items in ACA to cut. In that same story, a Senate aide quipped that the Fund was a "slush fund for jungle gyms." Previously, Republicans had sought (unsuccessfully) to eliminate this fund altogether, most memorably when they proposed using the savings to pay for elimination of more stringent tax collections from small business.

This  fight highlights two verities about the politics of American public health policy. The first is encouraging. Virtually every side in our political debate preaches the gospel of prevention. Rare is the political candidate, Democrat or Republican, who does not praise the virtues of wellness, or note the importance of smoking and obesity in promoting the nation’s health.

The American public generally shares these values. A November, 2009 survey conducted by the Trust for America's Health and the Robert Wood Johnson Foundation found that “71 percent of Americans favor an increased investment in disease prevention and that disease prevention is one of the most popular components of health reform.”  The poll’s other questions yielded equally supportive responses. And this is a case where good politics makes for good policy. Increased expenditures for public health are among the simplest and cheapest components of health reform.

The measure has equally wide-ranging support from organizations that work in public health. Last week, 704 of them signed a letter expressing their dismay at the prospect of the fund being cut. Supportive organizations range from advocacy organizations long-involved in the health reform fight, to major medical associations, such as the American Academy of Pediatrics and the American College of Cardiology, to more surprising entries such as the National Council of Jewish Women and the YMCA.

Unfortunately, the second verity of American politics is that such generalized support is less valuable than you might think. Although citizens and politicians profess to value public health, these same services are among the first that lawmakers scrutinize when they have to start cutting budgets.

Ironically, exploding general health care costs make public health’s funding problems more acute. Medicare-funded cancer care and Medicaid-funded HIV care are provided by entitlement. It’s great that these services are politically secure. Yet there is a certain irony that preventive measures, which can be far more cost-effective, are part of the discretionary activities of American government – which means elected officials often cut these efforts when budgets are tight. So even as government expenditures for medical care grow, assistance for public health agencies shrink.

I recently got a first-hand perspective on this by speaking with Dr. Terry Mason, CEO of Cook County’s Health and Hospitals System, and Dr. Stephen Martin, Chief Operating Officer of that same system. (Stroger Hospital, the centerpiece of that system, provided the obvious model for St Elsewhere and ER.) Mason notes that Stroger provides $500 million in free care—more than every other comparable Illinois hospital combined. More people need these services, too. As Martin puts things, Cook County has always served "a certain profile" of severely disadvantaged patients at the bottom of the social and economic ladder. As the crisis has deepened, "We are seeing people who are not at the bottom. They lost a job. They lost their COBRA. Maybe they are starting a small business and can't afford the premiums.”

These are huge burdens—hitting at precisely the moment government at all levels faces serious fiscal stress. Since 2008, local health departments alone have shed more than 30,000 positions, and face further budget cuts. There have been many more cuts at the state level.

Many of these departments have also assumed major clinical responsibilities. As medical care inflation continues, and as the number of individuals requiring safety-net services continues to grow, these agencies face genuine tradeoffs between (say) mental health services for the uninsured and (say) restaurant safety inspections or HIV prevention activities that won’t otherwise get done.

So in some key efforts, we are investing less than we used to do. (See, e.g., here, here, here, and here.) Ironically, tobacco taxes have been one area of progress, because governments need the revenue. Such taxes are important to discourage smoking. Unfortunately, states rarely use these funds to specifically help smokers who pay these taxes, or to serve other key public health goals.

Spending on public health infrastructure—infectious disease outbreaks, water and food safety, epidemiological surveillance systems, vaccination outreach, and more—faces the same political obstacles that bridge maintenance and other infrastructure spending do. These routine activities are boring. They are basically invisible until there is a serious problem. Responsibilities for these tasks are divided across different levels of government. There’s no particular payoff for a particular elected official to spend money on these important matters rather than to spend this money on more exciting things.

That’s why the architects of the ACA came up with the Prevention and Public Health Fund.  Its $15 billion allocation is very small, less than two percent of new spending initiated under health reform.  Yet for various reasons, the Fund has become a target for cuts. (Fortunately, some other ACA public health provisions are more politically robust.)

Partisan matters provide one motivation to cut this Fund. Republicans can nick yet another prominent initiative of ObamaCare. Jurisdiction matters, too. Some in Congress aren’t thrilled that the Fund provides greater discretionary authority to Secretary Sebelius.

Some social conservatives also view public health—especially sensitive issues regarding sexuality and substance use--through the lens of a 1990s-style culture war. Other critics bristle at efforts such as restaurant food labeling that impose regulatory burdens and that may stimulate an instinctive, sometimes-valuable libertarian resistance to perceived nanny-state measures. One major goal of the Fund is to address high rates of avoidable death, injury, and illness in low-income minority urban communities. These are not, obviously, strong Republican constituencies.

The real political problem, though, is simpler. Few powerful constituencies are strongly invested in the Fund’s success. No powerful and organized economic interest group is particularly focused on it. Medical providers, equipment suppliers, and organized patient constituencies might think such public health activities are important. Yet virtually all of these constituencies are intensively focused on bugger-ticket items. States and localities would benefit from these funds. Yet this is too small an item to excite much attention, particularly from Republican governors who publicly oppose ACA.

Every year, more than 400,000 Americans die prematurely from smoking. Similar numbers die from obesity-related causes. HIV death rates have declined. Yet the number of AIDS-related deaths still matches the number of U.S. combat deaths in the toughest years in Vietnam. These problems must be addressed through methodically-funded public health interventions. Citizens and policymakers understand this basic reality. As seems true of climate change and other chronic problems, our political system seems unable to properly respond.

Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago.