This is the second of a three-part series analyzing public health infrastructure in the United States. Part one can be found here. This midsection analyzes how the public health system is incapable of keeping people healthy even outside the pandemic.
Public health is a federal responsibility. The acronymed agencies of the United States, the NIH, CDC, PHS, FDA, and others are tasked with ensuring the health and safety of the population were tested by the Covid-19 pandemic. With more than seven million infections and two hundred thousand deaths from Covid-19, the public health infrastructure of the US failed to maintain the people’s well-being.
The current administration underestimated the scale and swiftness of Covid-19, but the US public health infrastructure would likely struggle under any party or administration. Public health is consistently underfunded and often viewed as less important than clinical medicine in the United States. The result is a population with a higher prevalence of chronic illnesses and shorter lives, especially among those in lower-income brackets.
Under both Democratic and Republican leadership, the federal government took less responsibility for funding public health in the US. From the late 1960s to the 2010s, the federal share of total health expenditure for public health dropped from 45 percent to 15 percent. As a result, states were required to cover the gap in funding mostly on their own. However, states vary in economic strength and some fund public health more effectively than others.
According to the Trust for America’s Health, almost $300 million was cut from the Public Health Emergency Preparedness Program between its inception in 2002 and 2017. The fund, which is the only federal program to support state and local health departments in health emergencies, was established by the CDC with a starting budget of $940 million, but was reduced to $667 million over the following fifteen years. When the program does receive an influx of funding, it is to respond to specific threats such as Ebola and Zika, and the money cannot be used to strengthen other aspects of the program. Recent research found that US public health departments are left about $4.5 billion short of what they need, according to public health expert Nason Maani and dean of Boston University’s public health school Sandro Galea.
Reduced federal funding for public health has direct consequences for everyday citizens. As baby boomers age, there is a greater need for well-funded health services for the elderly. High opioid addiction levels require well-funded rehabilitation and assistance programs, which the US lacks. Our country has suicide rates ranking in the top ten of OECD countries, but there is not enough suicide prevention funding to lower them.
The US has the highest chronic disease burden and an obesity rate at twice the OECD average. The US death rate from heart disease is the second highest amongst 17 similarly developed nations. The prevalence of lung disease, arthritis, diabetes, HIV, and more are higher than the OECD averages of these diseases.
The US has an infant mortality rate of 5.9 deaths per one thousand live births and a maternal mortality rate of 14 deaths for every one hundred thousand live births, trailing nearly fifty countries. Kazakhstan, Bosnia and Herzegovina, and Bulgaria all have lower maternal mortality rates than the US. Among Black women, the maternal mortality rate in the US is over three times higher than it is among white women.
Access to primary healthcare and public health services can improve the health of the population and decrease the risk of health threats such as epidemics. However, US residents go to the doctor less than residents of any other OECD country. A March 2020 survey of twenty-five hundred people found that nearly one in three families had not sought medical care within the previous twelve months due to prohibitively high out-of-pocket costs. Healthcare in this country is simply not as accessible as in other countries. According to the CDC, over fifty million American adults did not see a healthcare professional in 2018. This has serious implications in a pandemic where Americans may avoid seeking health services when in need of them due to high cost and, as a result, spread the infection to others.
Our per capita health spending is the highest in the world. Considering the health outcomes we have, where is that spending going? Researchers from Johns Hopkins School of Public Health came to a simple conclusion. It’s the prices. Higher healthcare spending is due to higher drug costs, higher doctor salaries, higher administrative costs, and higher-priced medical services, some of which could be avoided if we invested in a stronger public health system.
The federal government must use its authority to address inflated costs and poor, unequitable health outcomes. There are examples of the federal government implementing public health programs to improve the health of the population. In 1998, the FDA required all enriched grains to be fortified with folic acid, which supports the neural tube development in utero, resulting in a 25% reduction in spina bifida and anencephaly, two major birth defects of a baby’s brain. However, our current public health infrastructure enables the declining health of our population. Other countries are paying less for better health outcomes. Throughout the Covid-19 response, the federal government has relied on the underfunded state and local health departments to implement testing and economic reopening with widely ranging levels of success, a practice that will likely continue during the eventual distribution of a vaccine.
In anticipation of a possible Covid vaccine, the Centers for Disease Control and Prevention recently released what it described as a playbook that outlines how a vaccine should be distributed across the country. The CDC’s guidance, however, seems certain to be inefficient and likely to be ineffective. The playbook outlines a series of suggestions for what states and localities should do, rather than a full accounting of what they must do to ensure a vaccine is distributed equitably and efficiently. None of it is binding.
The playbook parallels the damaging structural flaw of decisions generally being left to local authorities, even though the expertise often resides at the federal level, with the CDC. In the playbook, the federal government takes no responsibility in distributing eventual vaccines to US residents and suggests it will issue no federal mandates on how jurisdictions must handle distribution either. The decentralization of an effort so massive almost guarantees differences in vaccine access, storage standards, and racial or economic disparities.
The United States has the economic power to end health disparities but refuses to reinvent its public health capabilities. Investment in the current system is inadequate, akin to a new coat of paint on a broken-down car. There must be a revitalized, national public health system that effectively ensures the health of every resident of the United States.