The COVID-19 pandemic has shone a harsh light on the consequences of chronic underinvestment in public health, and the limited recognition of its role. Unless there is a crisis, it is not always obvious that public health is “always on,” working quietly in the background on chronic disease prevention, vital statistics, sanitation, safe water, safe food, occupational diseases and injury, and infection control.

Health experts have long sounded the alarm that the U.S. needs to invest more — and more consistently — in public health systems. A 2012 National Academies report, For the Public’s Health: Investing in a Healthier Future, warned that excessive spending on medical treatments and expensive care often makes spending on disease prevention and other public health measures an afterthought.

Eight years after its release, the 2012 report is still having an impact. The American Journal of Public Health (AJPH) recently published a special issue on the report’s key recommendation: that the U.S. should set a national target for per capita health spending, to be achieved by 2030, to ensure a better balance of investments in public health. In addition, the National Academies recently launched the Health Care Expenditures Collaborative, which is advancing the report’s recommendations to bring the U.S. in line with peer nations in terms of life expectancy and spending on medical care.

The chair and vice chair of the report — Marthe Gold, senior scholar-in-residence at the New York Academy of Medicine and Arthur C. Logan Professor Emerita at the CUNY Medical School, and Steven Teutsch, adjunct professor of health policy and management at UCLA and senior scholar at University of Southern California — sat down for a Q&A to discuss why their report has remained so timely in today’s health care environment.

As the U.S. thinks about how to build a post-COVID-19 public health system, what should decision-makers take away from the 2012 report?

Teutsch: Along with increases in medical care spending, there has been a decrease in public health spending, particularly at the state and local level. Our governmental public health [system] has been extraordinarily challenged. As many as 56,000 positions have been lost at the state and local levels, primarily due to lack of funding — and we are clearly paying the price now.

The impact of COVID-19 is not really a failure to invest in medical care, but a failure to maintain a strong, functional public health system that would be able to address the pandemic in a more aggressive, effective way. We need strong emergency preparedness, a cadre of contact tracers, adequate laboratory capacity, and most importantly, political will. We can look at many countries that have done a much better job than the U.S., such as New Zealand, which is essentially free of COVID.

In 2012, your report recommended that by 2030, the secretary of health and human services set a national target for health system performance on two key measures: longevity and per capita health spending. What is the relationship between these two?

Teutsch: The common notion is that if we spend more on medical care, life expectancy will increase. That is simply not the case. Life expectancy peaked at 78.9 years in 2014. Since then, either it has fallen or it has been flat on a year-by-year basis, so we’re not making progress.

At the same time, medical expenditures continue to rise, placing us further behind other nations — especially when we use money from other sectors that would actually enhance life expectancy and quality of life. We spend more money, only to have lower life expectancy than most of our competitor nations. It’s pretty clear we need to make significant changes if we’re going to reach the targets that the committee set in 2012 to have comparable life expectancy and medical expenditures.

Gold: We weren’t asking for much in that report. We simply wanted to be on the par with other wealthy nations; we weren’t looking for American exceptionalism. We need to take instruction from other nations, because it’s clear more medical spending is not what makes a populous healthy.

Often, we hear, “more health care is better, more spending is better.” We also know access to medical care is crucial for everyone. But how is overspending — or paying for the wrong things in medical care — actually detrimental to public health and other sectors like housing and education?

Gold: In our 2012 report, we cite literature that says OECD (Organisation for Economic Co-operation and Development) nations that are outperforming us in life expectancy are spending a greater proportion on well-being versus medical care.

In the U.S., the reverse is true. That means there isn’t money available for things that have shown to be more important than medical care. A key example of this is education. As our medical spending has gone up — particularly at the state level - there have been disinvestments in education. Research tells us that the difference in life expectancy between someone who finished high school versus someone who finished college can be as much as 10 to 15 years. Ironically, we’re robbing Patricia to pay Paul when we don’t give the kind of support we need to the social determinants of health — which will make us a healthier nation.

How do we cut waste in medical care, without eliminating important and underused services — especially for populations that have historically had difficulty accessing medical care?

Gold: Studies have shown as much as a third of what goes on in medical care is wasteful, unnecessary, and inappropriate. The “haves” often get care they don’t need, and the “have nots” lack that care. What we need is universal access to a medical care system. If we began to take a more rational look at what services are available and how to provide them to everyone, we could cut waste and reduce spending, while ensuring everybody in this nation has the medical care that they need. I also want to emphasize medical rather than health care. Medicine is what really drives spending. It’s not the things we do to create health.

Teutsch: Many of the expenses in our medical care system don’t add value. We have among the highest administrative costs in the world — as much as 18 percent in the private sector. We have higher prices for individual services. Prices, administrative costs, and fraud and abuse are among the things that can be eliminated and make a big difference.

Where can we continue to follow your work?

Gold: The collaborative will be continuing, and we’re eager to make progress on this recommendation and others so we can improve the health of the nation and control medical expenditures. We are also grateful to the AJPH to give us a platform to raise the visibility of these issues. It’s important for us to see eight years later.

Resources

• American Journal of Public Health December 2020 articles featuring Collaborative members:

  • Healthier People: Setting Targets for Life Expectancy and Health Care Expenditures

  • Reduction in U.S. Health Care Spending Required to Meet the Institute of Medicine’s 2030 Target

  • Podcast: Reducing Wasteful Medical Spending Key to Reinventing Public Health?

• Health Care Expenditure Collaborative: Furthering Recommendation #1 from “For the Public’s Health: Investing in a Healthier Future”