Taxes – that’s right, new taxes! – for public health

A report published last week by the distinguished Institute of Medicine of the National Academies calls attention to the poor public health infrastructure and ineffective population health strategies plaguing health care in the United States. For the Public’s Health: Investing in a Healthier Future is the third in a series of reports spurred by the Robert Wood Johnson Foundation’s request to the institute to examine the state of U.S. public health. The first two reports, released previously, reviewed how public health data can best serve public health policies and practices and how current public health laws and regulations “prevent injury and disease, save lives, and optimize health outcomes.”

Flagging the “large proportions of the U.S. disease burden [that] are preventable,” the report recommends doubling federal funding on public health from $11.6 billion to $24 billion per year. Of the $2.5 trillion in annual medical spending in the United States, only 3 percent goes to government public health activities. That’s $8,086 in total health expenditures per person, compared to $251 “spent on public health by federal, state, and local governments.” Public health remains woefully underfunded, and disease prevention efforts, funded primarily by federal, state, and local governments, continue to suffer.


This third report is sure to generate controversy - or perhaps fall on deaf ears - given its core recommendation: to finance the needs of public health in the 21st century, the federal government should enact a national tax on all medical care transactions. Also sure to be controversial is the report’s recommended shift in current public health funding. It recommends that state and local public health funding currently used to pay for clinical care should be used instead to pay for prevention and health promotion activities by public health departments. This shift, however, will not result in a net loss of funding for clinical care because under the Affordable Care Act clinical care in a public health setting will be reimbursable by Medicaid or state health insurance exchanges.

The urgency of the report’s recommendations is driven by the nation’s continued poor performance on several key health measures. According to Central Intelligence Agency estimates, the United States ranks 50th out of 221 nations in life expectancy, 48th out of 222 in infant mortality, and 51st of 172 in maternal mortality. We have a national “fixation on clinical care and its delivery,” the report notes, yet these statistics speak poorly to our ongoing struggles with basic public health challenges.

As the report says, “a growing body of evidence indicates that effective prevention strategies can substantially improve health with little or no additional lifetime spending.” It all seems so obvious. Tobacco control reduces deaths from a wide range of diseases including cancers, stroke, and heart disease. Immunizations reduce deaths from formerly deadly infectious diseases like polio, pertussis, and diptheria, and seat-belt laws reduce injuries and deaths from motor vehicle accidents.

The Affordable Care Act created a $15 billion “Prevention and Public Health Fund” that has already been cut by $5 billion by Congress. So given the general clinical care-over-public health mood of our health system, given the extreme difficulties of creating a new tax in our polarized and anti-tax political environment, and given the limited media attention the proposal has so far received, these recommendations are likely, for the moment, to sit quietly in the shadow of the current political season.

Whoever is elected in the fall would do the nation’s health well by taking a closer look at these recommendations. They make financial sense because they save us money over time in overall health care costs. They make health sense because of the improvements in health they would bring. And, they make political sense, given the creation of public health jobs, quality of life improvements, and overall health improvements that would follow in their wake.

Based on past experience, both Barack Obama, in his shaping of the Affordable Care Act, and Mitt Romney, in his support for the Massachusetts law on which it was based, understand the importance of these issues. Whether they or any other politicians are courageous enough to take up the cause of public health in the near future is another question. Sadly, at this moment, I am not at all hopeful.

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