Why Public Health Is Necessary to Improve Healthcare (click for PDF)
As the United States seeks ways to regain our
economic footing and rebuild prosperity, all should be reminded of the simple
but immensely important fact that the nation’s collective health bears both an economic
and human cost. Poor health of a
population can exert tremendous force on employment rates, interest costs and
other tangible factors that ultimately affect the ability to maintain a strong
global economic position.
Chronic Diseases – Human and Economic Costs
Chronic disease affects health and quality of
life, but it is also a major driver of health care costs and has a related
impact on business such as absenteeism and presenteeism. According to the
Centers for Disease Control and Prevention (CDC), chronic disease accounts for
approximately 75 percent of the nation's aggregate health care spending - or an
estimated $5,300 per person in the U.S. each year. In terms of public
insurance, treatment of chronic disease
constitutes an even larger proportion of spending - 96 cents per dollar for
Medicare and 83 cents per dollar for Medicaid. 2
Behavioral choices that result in an
increased incidence of chronic disease are also extremely costly in terms of the
affordability of health care coverage. According to the Partnership to Fight
Chronic Disease, since 2000, health insurance premiums for employer-sponsored
family coverage have increased by 87 percent. Health care costs for people with
a chronic condition average $6,032 annually - five times higher than for those
without such a condition.
Nearly half (45 percent) of all Americans
suffer from at least one chronic disease. More than two-thirds of all deaths
are caused by one or more of five chronic diseases: heart disease, cancer,
stroke, chronic obstructive pulmonary disease, and diabetes. More than one in
four Americans have multiple chronic conditions (MCC), and evidence is growing
that the presence of one chronic condition has a negative impact on the risk of
developing others, particularly as people age. The nation’s aging population, coupled
to existing risk factors (tobacco use, poor nutrition, lack of physical
activity), along with medical advances, lead to the conclusion that these
problems are only going to grow if they are not effectively addressed now.1
A recent Milken Institute analysis determined
that treatment of the seven most common chronic diseases, coupled with
productivity losses, will cost the U.S. economy more than $1 trillion dollars
annually. The same analysis estimates that modest reductions in unhealthy
behaviors could prevent or delay 40 million cases of chronic illness per year.
Much of Chronic Disease; Complications of Chronic Disease; and Related
Cost are Preventable
As the American population ages, and more people
are categorized as "high risk” for multiple chronic diseases, it is important
to recognize that an individual’s choices have an impact – as well as where
they live, attend school, and work. Risky behaviors such as poor diet, lack of
physical activity, use of tobacco, and ignoring known risks like family
history, result in a dramatic increase in chronic conditions. While most people
do not ignore their automobile’s "check engine light”– many routinely skip their
own body’s preventive maintenance warnings thus making poor choices about their
health. The result is a poor collective health quality in the country that
spends much more on healthcare that anywhere else in the world.
We also know there are strategies and
interventions that can make a difference. The following are some examples of
what has been proven to work:
- Healthcare costs for a person with
diabetes are over $13,000/year; for a person without diabetes, $2,500. For
every one point reduction in HbA1c (a measure of blood sugar over time), a
40% reduction in microvascular complications is reported (blindness, kidney
disease, nerve damage) and up to $4,100 can be saved in annual healthcare
- More than two thirds of persons with
diabetes have high blood pressure- the risk for stroke is two to four
times higher among persons with diabetes.
- DPP (Diabetes Prevention Program)
efforts and education for improved diabetes management have now been
proven to both improve wellbeing and reduce costs. State Public Health
Diabetes Prevention and Control Programs are essential elements in the
implementation and dissemination of these strategies.
Heart Disease and Stroke4
- In over 70% of Americans with
hypertension, blood pressure is poorly controlled. A 12- 13 point
reduction in systolic blood pressure can reduce heart attack risk by 21%
and stroke risk by 37%. In addition to the individual and family
devastation, a heart attack costs $78,221 in the first 90 days.
- State Public Health Heart Disease and
Stroke Prevention Programs provide a critical link between population-based
efforts to reduce risk; community prevention efforts; and clinical care.
- Public Health early detection programs
for breast and cervical cancer have been responsible for identifying
thousands of cancers in early stages when treatment is more effective and
- For example, treatment of early stage
breast cancer costs $11,000, diagnosis at a late stage means more intense
treatment that may not be as effective and costs $140,000.
- Treatment of early stage cervical
cancer costs $2,000, diagnosis at a late stage means more intense
treatment that may not be as effective and costs $30,000.
- State Public Health Breast and
Cervical Cancer Screening and Education efforts have been proven to
increase screening rates for at-risk populations, and often the population
as a whole.
· Early detection, advance planning and comprehensive
caregiver support has been shown to delay institutional placement for people
with Alzheimer’s disease for 1.5 years – while maintaining dignity, safety, and
· The cost differential for families and systems of
home and community-based care vs. nursing home placement varies from state to
state – but is substantial everywhere.
· The National Action Plan to Address Alzheimer’s
Disease and accompanying recommendations calls for a state lead agency to
assure coordination of evidenced-based high quality services for people with
dementia and their caregivers. This is consistent with recommendations of the National
Association of Chronic Disease Directors’ (NACDD) Healthy Aging Council. There
are clear examples of strategies that improve quality of life and reduce system
cost. Resources should back up the recommendation for state coordination of
these efforts to implement and disseminate proven strategies.
Multiple Chronic Conditions1
The confluence of MCC and functional
limitations, especially the need for assistance with activities of daily
living, produces high levels of spending. Functional limitations can often
complicate access to health care, interfere with self‐management, and necessitate reliance on
A report by the Institute of
Medicine highlighted the complexities of and the need for care coordination for
individuals with multiple conditions. This coordination is often at the link
between clinical medicine and public health/ community resources.
State Public Health Chronic
Disease Prevention and Control Programs, especially those that focus on
critical, common risk factors such as nutrition and physical activity; tobacco
use; and related behaviors are a key link to improving our nation’s health.
Programs focused on age groups (childhood obesity prevention, youth tobacco
prevention, senior physical activity programs) are all needed to serve as an
adjunct to clinical medicine. These programs provide the venues and
opportunities to help make the healthy choice the natural choice and provide
reinforcement for healthy messages provided in the course of clinical care
where people live, go to school, and work. These programs are the difference
between hearing "you should eat better and get more exercise” from one’s doctor
once a year and being in communities where healthy foods and opportunities for
physical activity are the norm and part of one’s daily life.
Mays and Smith noted in Health Affairs that a
10% increase in public health spending would yield a reduced mortality rate
across all causes, and a higher reduction in heart disease, diabetes, and
Keys to Progress
The keys to making progress in prevention and chronic disease control
are comprehensive and have been addressed in significant detail in a number of
recent publications. The magnitude of our national health crisis requires more
than occasional, individual visits to a primary care physician; it requires
population-based public health strategies to reach people at work, school and
in their communities.
Key #1 – Health in All Policies
We must assure that all public policy and responsible
corporate/institutional policies consider health implications.
Key #2 – Health Promotion
Everyone needs good information, and the opportunity to make good
choices. Health promotion happens in homes and communities. Decision makers
need to help every community focus on making the healthy choice the easy
Key #3 – Across the Age Spectrum
Promoting health isn’t for a select group. Children, working adults,
parents, seniors, professionals, and policymakers all have a role in improving the
nation’s collective health status.
Key #4 – Proceed Based on Science
Many examples of the evidence base are available; one recent article
documents the evidence published in Health Affairs in May 2011. Milstein ET all
offer a dynamic simulation model of three approaches: increased coverage;
better preventive and chronic care; and enabling healthier behavior and
environments (referred to as "protection”).7 All three are shown to
result in projected savings of hundreds of thousands, if not millions, of
preventable deaths while offering good economic value.
The article states, "The baseline simulation shows that when added to
coverage and care, protection would save 90 percent more lives and reduce costs
by 30 percent in year ten. Those benefits would be even larger in year 25, when
adding protection would save about 140 percent more lives and reduce costs by
62 percent. Key factors of time and scale would impact the outcome of the
simulation, but using both optimistic and pessimistic scenarios the authors
found the general pattern is stable. "
Key #5 – Address Disparities
It is known that many health disparities currently exist, and that in
some cases these disparities can be reduced by implementing strategies that are
already known to work. Areas without
known solutions should be addressed without delay.
Key #6 – Adjust the scale of resources to be proportional to the issues
at CDC, State Health Departments, and other HHS agencies responsible for
assuring an adequate workforce and expanding the availability of prevention and
Bringing Resources Up to Scale
Today, only a small fraction of the United States’
governmental healthcare investment supports prevention and health promotion. States are implementing diverse, cost-effective strategies that work for early
detection of cancer, prevention and control of diabetes, reduction of heart
disease and stroke, reduction of the disability associated with all of these
conditions and arthritis as well (http://www.chronicdisease.org/?page=Arthritis). The state success stories on NACDD’s
website are just the beginning. A
substantial investment in the CDC, State Health Departments, and other HHS
agencies must be made for a real impact. The investment needs to be such that
every state in America has a full complement of evidenced-based programs to promote
health and fight chronic disease, as well as the necessary resources to
coordinate these programs with related activities (Medicaid, CHIP, Exchanges).
These programs must include resources for every state to address:
· Early Detection of Cancer and Cancer
· Diabetes Prevention and Control
(including prevention of kidney disease)
· Heart Disease and Stroke Prevention
· Healthy Community Programs (ACHIEVE,
· Tobacco Prevention and Control
· Arthritis Prevention and Control
· School Health and Oral Health Programs
· Healthy Aging - including Alzheimer's
· Improving Physical Activity and
Public health programs work to improve care, prevent disease, and
prevent complications of disease. An investment in chronic disease prevention
and control programs saves lives, improves quality of life and saves healthcare
Questions to: David Hoffman, firstname.lastname@example.org; Amy Souders, email@example.com.
U.S. Department of Health and Human Services. Multiple Chronic Conditions—A
Strategic Framework: Optimum Health and Quality of Life for Individuals with
Multiple Chronic Conditions. Washington, DC. December 2010.
2. http://www.fightchronicdisease.org/media-center/facing-issues, accessed 7/6/2012.
JR. Economic Considerations in Treating Type 2 Diabetes. Am J Health Syst
Pharm. 2002;59 Suppl 9:S14-7.
D, McClellan M, Newhouse J. The Costs and Benefits of Intensive Treatment for
Cardiovascular Disease. NBER Working Paper 6514; Hewitt Assoc. 2005. Available
at http://www.nber.org/papers/w6514.pdf. Accessed February 2011.
5. American Cancer Society. Cancer Facts and
Figures 2010. Available at http://www.cancer.org/Research/CancerFactsFigures/index; Accessed 7/6/2012.
6. Mittelman M, Haley W,Clay O, Roth D
Improving caregiver well-being delays nursing home placement of patients with
Alzheimers disease, Neurology 2006;67;1592-1599
7. Milstein, B,
Homer, J, Briss, P, Burton, D, Pechacek, T. Why Behavioral and Environmental
Factors Are Needed to Improve Health At Lower Cost. Health Affairs, 30, no.5
Smith,S., Evidence Links Increases In Public Health Spending To Declines In
Preventive Deaths. Health Affairs,30,no.8,(2011):1585-1593.
The National Association of Chronic Disease Directors (NACDD) is a
non-profit Public Health organization committed to serve the chronic disease
program directors of each state and U.S. jurisdiction. Founded in 1988, NACDD
connects more than 3,000 chronic disease practitioners to advocate for
preventive policies and programs, encourage knowledge sharing and develop
partnerships for health promotion. Since its founding, NACDD has been a
national leader in mobilizing efforts to reduce chronic diseases and their
associated risk factors through state and community-based prevention
NACDD activities help
to support state efforts by:
educational and training opportunities for our members
legislative analyses, materials, policy statements and other resources
policymakers about the importance of funding for state chronic disease
prevention and control efforts
technical assistance and mentoring to state public health practitioners
partnerships and collaboration with public health and scientific
communities, health care providers, federal agencies, universities and
the private sector to pursue common goals
for the use of epidemiological approaches in chronic disease services
planning and chronic disease data
NACDD has numerous Councils across all state health departments that address
the unique prevention and control efforts of specific chronic diseases while
advancing the professional development of chronic disease staff with common
program interests. For more
information on chronic disease prevention please visit: www.chronicdisease.org