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Prevention Politics—Congress Reduces Funding for Health Prevention Fund

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On Feb. 17th, in an extremely shortsighted move, Congress voted to cut $5 billion from the Affordable Care Act’s health prevention fund to offset the cost of delaying (by 10-months) scheduled cuts to Medicare physician payments, known colloquially as the “doc fix.”  This represents a one-third reduction in the fund’s current budget.  The prevention fund, which has been lauded as one of the most important contributions to the advancement of public health, began with $500 million in 2010 and was scheduled to reach $2 billion by 2014.  Now, the prevention fund will not reach $2 billion until 2022, at the earliest.  The Secretary of Health and Human Services may transfer money from the fund to any program authorized by the Public Health Service Act for “prevention, wellness, and public health activities including prevention research and health screenings, such as the Community Transformation grant program, the Education and Outreach Campaign for Preventive Benefits, and immunization programs.”

This decision was penny wise and pound foolish.  Chronic diseases, which many of the fund’s programs target, cause approximately 80% of deaths in the United States and account for 75% of the nation’s health spending.  If we have any hope of bending the cost curve, we must take prevention seriously and spend accordingly.  Annual spending related to type 2 diabetes, a mostly preventable disease, is expected to reach $336 billion by 2034 up from $113 billion in 2009.  At the same time, a mere 3 percent of national health expenditures in 2009 went to “government public health activities.”

According to Rep. Henry Waxman (D-Calif.), “It certainly is not right to reduce our commitment to prevention by robbing the prevention fund of critical dollars that could help us keep people healthy instead of paying for them when they are sick.”  Indeed, studies are beginning to demonstrate the effectiveness of prevention programs.  For example, according to one study, Massachusetts saved over $3 for every $1 it spent on smoking cessation programs for Medicaid enrollees. The Cleveland Clinic was also recently able to halt the growth its employees’ health care costs through wellness and prevention programs at a time when the rest of the nation’s health care costs rose at 6 percent annually.  The chair of the Senate Health, Education, Labor and Pensions Committee, Sen. Tom Harkin (D-Iowa) said in a statement that the cuts to the prevention fund were “an extremely short-sighted and fiscally irresponsible decision.  If we continue down this path, we will never get the cost of health care in this country under control.”

In today’s political climate it is not surprising that the prevention fund was put on the chopping block, despite the fact that Republicans and Democrats alike tout the importance of prevention in reducing health care costs.  A recent article in the Journal of Health Politics, Policy and Law identifies four factors that make investments in prevention politically hard:

  • The benefits of prevention programs are usually dispersed and delayed. The programs themselves are aimed at keeping something bad from happening in the first place and often target future populations of individuals that can be measured only statistically.  In this case, the cuts to Medicare payments were immediate. while most of the prevention fund’s effects will be in the distant future.
  • The benefactors of prevention programs are generally unknown and taken for granted.  According to the authors, Rick Mayes and Thomas Oliver, “When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary.” 
  • Public health costs are often concentrated and offend powerful interests.  Mays and Oliver describe New York’s failed attempt to impose a penny-per-ounce state-wide tax on sugar sweetened beverage as an example of “how scientifically supported public health campaigns can be easily thwarted by powerful corporate or political interests.”  Despite strong support from a variety of sectors, including public health advocates, good-government organizations, hospital associations and medical groups the American Beverage Association and Pepsico, which outspent the tax’s proponents by a measure of two to one, were able to convince the New York State legislature that the tax was unfairly regressive because it would disproportionately affect poorer individuals.  The prevention fund was similarly a target of conservative scorn, with Sen. Mike Enzi (R-Wyo.) derisively calling it a “slush fund” for jungle gyms.
  • Public health programs often clash with moral values or social norms.  This can be readily seen in the current debate over contraceptive coverage.  From a public health perspective, contraception empowers women to time their pregnancies better, benefiting the health of both mothers and infants.  But, the Catholic bishops and some evangelical Christian organizations oppose contraception and have objected to the requirement that employer health plans cover it, even after President Obama created a compromise that required health insurers to cover contraception without charging an additional premium to religious employers or their employees. 

At a press conference last Thursday, Senate Majority Leader Harry Reid (D-Nev.) stated that the prevention fund “is going to grow at the rate of about $2 billion a year in the next few years.  This is not a loss, overall, for the program.  We feel confident this program will be able to go forward.  It accumulates money every year.”  Hopefully, he is correct.  But, given the lack of political will to make wise public health investments, it won’t be surprising if Congress turns to the prevention fund again the next time it needs to find money to pay for some other more politically immediate problem.

Related Articles

Disappointing Cuts to the ACA Prevention Fund (The Boston Globe)
Chronic Disease and the Shifting Focus of Public Health:  Is Prevention Still a Political Lightweight
(Journal of Health Politics, Policy and Law)
Why Congress Cuts Prevention Funds
(The Washington Post)
The Return on Investment of a Medicaid Tobacco Cessation Program in Massachusetts
Health Care’s Brave New World of Compulsory Wellness
Reid Vows Health Prevention Fund will be Replenished, Eventually
(Capsules: the KHN Blog)
For Health Reform’s Prevention Fund, an Uncertain Future
(The Washington Post)
Obama Shifts Course on Birth Control Rule to Calm Catholic Leaders’ Outrage
(The Washington Post)

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