Restoring health to health reform: integrating medicine and public health to advance the population's well-being.

AuthorGostin, Lawrence O.

INTRODUCTION I. THE CONCEPTUAL AND FUNCTIONAL IMPORTANCE OF AN INTEGRATED HEALTH SYSTEM A. Historical Interconnections B. The Rationale for Integration C. Moving Toward Integration 1. Obesity 2. Injury Prevention 3. Health Care-Associated Infections 4. Community Health Needs Assessments II. THE IMPORTANCE OF PUBLIC HEALTH IN IMPROVING THE HEALTH OF INDIVIDUALS AND POPULATIONS A. Health Promotion and Disease Prevention: A Core Element of Population Health B. The Social Determinants of Health C. The Role of Chronic Disease D. The Lack of Economic and Political Support for Public Health III. NORMATIVE CRITERIA FOR HEALTH SYSTEM REFORM A. Criterion 1: Prevention and Wellness B. Criterion 2: Human Resources--An Adequate, Equitably Distributed, and Well-Trained Workforce C. Criterion 3: A Strong and Sustainable Public Health Infrastructure D. Criterion 4: Performance Measurement--Continuous Quality Improvement Based on Scientific Evidence E. Criterion 5: Reducing Disparities in Health IV. HOW DOES PPACA MEASURE UP AGAINST THE KEY NORMATIVE CRITERIA OF HEALTH SYSTEM REFORM? A. Criterion 1: Prevention and Wellness B. Criterion 2: Human Resources--An Adequate, Equitably Distributed, and Well-Trained Workforce C. Criterion 3: A Strong and Sustainable Public Health Infrastructure D. Criterion 4: Performance Measurement--Continuous Quality Improvement Based on Scientific Evidence E. Criterion 5: Reducing Disparities in Health V. TOWARD A ROBUST HEALTH REFORM TO SIGNIFICANTLY IMPROVE THE PUBLIC'S HEALTH A. Changing the Environment B. Strengthening the Public Health Infrastructure C. Adopting a Health-in-All-Policies Approach CONCLUSION: THE BUILDING BLOCKS OF HEALTH INTRODUCTION

It is hard to overstate the intense political and media attention given to health care. New medical discoveries and technologies are front-page news stories. In many communities, health care is either the largest or a substantial employer, and rising employee health care costs are a major concern for individual families and employers alike. That we, a wealthy society, invest more in health care than in subsistence goods signifies the value we place on high technology and spe- health services. The United States spends nearly 17% of its gross domestic product (GDP) on health care (a combination of public and private financing), or over $7000 on each American annually. (1) This amount of health care financing is nearly double the investment made in any other highly developed country. (2) As such, economic and political factors explain the salience of health care in American society.

Given the expansion of the health care enterprise, it is not surprising that the American political community is deeply focused on it. For a generation, health reform has been a dominant domestic political issue. The nation recently went through the politically grueling passage of the first comprehensive health care reform since the 1960s, with cavernous political divides on the role of government in financing and delivery of care. Critics portrayed modest proposals for cost-effectiveness comparisons--routinely accepted in other advanced democracies--as "death panels," and the final law inhibits the use of quality cost-effectiveness analysis in coverage, reimbursement, and incentive structures. (3) Within weeks of the law's passage, twenty states filed lawsuits challenging the constitutionality of the individual mandate--a fundamental component of the reform. (4)

Despite its limitations, the Patient Protection and Affordable Care Act (PPACA) (5) is a major achievement in meeting the nation's goal of improving access to health care. (6) Without a doubt, it will reduce the number of uninsured Americans, a number that rose in 2009 to a record 50.7 million people, or 16.7% of the population. (7) The Congressional Budget Office projects increased coverage through a variety of measures: imposing a tax penalty on most individuals who fail to purchase insurance, increasing Medicaid eligibility, subsidizing insurance premiums for low-income individuals, providing incentives for businesses to provide employee health insurance, establishing health insurance exchanges, and eliminating coverage barriers such as health status underwriting (i.e., excluding or charging higher rates to applicants with preexisting health conditions). (8) By 2019, PPACA is expected to extend health insurance coverage to an additional 32 million people, covering approximately 94% of the legal, nonelderly population. (9) Among the remaining uninsured will be illegal immigrants, low-income people who fail to enroll in Medicaid, and individuals who are exempt from the mandate or choose to pay the tax penalty in lieu of purchasing coverage. (10)

It would be reasonable to assume that the economic and political capital expended on health care would yield significant health benefits. However, evidence does not support this conclusion. Americans' health status is poor compared with that of citizens of countries with similar levels of economic development. Among the thirty member countries of the Organisation for Economic Co-operation and Development (OECD), the United States ranks twenty-eighth in infant mortality (6.7 deaths per 1000 live births)" and twenty-third in life expectancy at birth (78.1 years for both sexes)--behind countries with half the income and half the health care expenditures per capita. (12) The World Health Organization (WHO) ranks the United States thirty-seventh among global health systems, reflecting concerns about relatively poor health indicators and sizable racial and socioeconomic disparities (13)--although PPACA will likely improve the United States' standing.

The United States' relatively poor health outcomes raise vital questions that, although self-evidently important, rarely feature in public and political discourse. Is health care reform's core purpose to improve the health of the American population? If not, should it be? Moreover, is expanded access to health care a reliable and cost-effective way to improve health?

In response to these questions, we set forth and defend three propositions. First, although there is powerful intrinsic value in making health care services accessible, the nation could achieve better health outcomes, at a lower cost, by shifting priorities toward health promotion and disease prevention, mediated principally through primary care and population-based services. Accordingly, our second proposition is that PPACA's focus on improved access through insurance reform is insufficient to improve health outcomes. PPACA includes promising public health provisions but does not make population health a focus of the reform. Third, we argue that improvements in health status will be most effectively and efficiently achieved through the integration of health care and public health. These two spheres should be organized as parts of a single health system. In short, our thesis is that health care reform's core purpose should be to improve the public's health, which is best achieved through cost-effective interventions at the population level--an idea we frame as "restoring health to health reform." (14)

Part I of this Article demonstrates the conceptual importance of integrating public health and health care into a unified health system. (15) Our premise is that public health and personal health care are interactive fields that can and should be examined across traditional disciplinary boundaries.

Part II describes the value of public health in achieving major improvements in the population's health. Health promotion and disease prevention, which act on the major determinants of health--behavior and the environment--are mediated through primary care and public health services. We demonstrate that investing in public health is likely to achieve better results than investing an overwhelming portion of our resources in health care services and technologies. Unfortunately, as we will explain, policymakers have chronically starved population-based services of adequate and sustainable funding and political support, to the detriment of the health of communities and the nation.

In Part III, we present normative criteria against which we measure health system reform. The five criteria are prevention and wellness, human resources, a strong and sustainable health infrastructure, robust performance measurement, and reduction of health disparities. We define each criterion and describe its importance. We then illustrate why integration of the public health and health care systems will better achieve these criteria. In Part IV, we systematically assess PPACA against these criteria to determine what Congress did well and where the Act is deficient.

To inform and guide policy recommendations for future legislation and implementation (i.e., state and federal regulatory decisions), Part V shows what health reform would look like if policymakers adopted the criteria articulated in Part III. We applaud the increased access to health insurance and emphasis on prevention, but our approach would substantially alter PPACA's funding allocation, its focus on health insurance markets, and its emphasis on individual health care. To illustrate how our approach to health reform differs from PPACA, we propose three major policy reforms: (1) changing the environment to make healthy behaviors the more likely choice; (2) strengthening the public health infrastructure at the state and local levels; and (3) developing a Health-in-All-Policies strategy that would engage all government agencies in improving health outcomes. We argue that adopting these reforms would facilitate integration and dramatically improve the population's health, particularly when compared to the health gains likely to be realized from a continued focus on health care services. These reforms involve shifting the financial and political focus away from high-cost, high-technology interventions, thereby transforming the...

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