This article first appeared in the St. Louis Beacon, July 11, 2013: An ounce of prevention may be worth a pound of cure, but finding money for prevention can be elusive when it comes to health care. Case in point is what is happening with the federal health reform law. Unprecedented spending to prevent illness and improve public health is one key promise of the Affordable Care Act.
That’s why $18 billion had been set aside for a newly created Prevention and Public Health Fund under Title IV of the law. Its goals include relying on innovative public health policies to address problems such as obesity and tobacco use.
But typical of the roller-coaster history of ACA, some of the money for this part of the program is being shifted, raising concerns that public health spending will be undermined in future years.
On the one hand, the administration continues to press ahead on key medical provisions of ACA, a move that is welcome by many. On Wednesday, for example, it announced $150 million in grants to health centers nationwide for outreach activities to help the uninsured get coverage through insurance exchanges. Funding includes $2.9 million for Missouri to assist an estimated 62,000 residents; Illinois is getting $6.1 million to help roughly 195,000.
On the other hand, the news is not all good for the new public health fund even though prevention is regarded as one key to reducing both medical cost and avoidable illness. Examples of prevention programs financed by the fund in 2011 included:
- $222 million for preventing heart disease, some forms of cancer and other conditions by reducing tobacco use, obesity and health disparities.
- $180 million for expanding immunization services, strengthening employer wellness programs and helping communities coordinate and integrate primary care services into community mental health programs.
The first chunk of money taken from the fund for non-prevention purposes occurred late last year when the Obama administration and Congress agreed to use $6.2 billion from the fund for other purposes over a nine-year period. The reduction was used to offset pending cuts in Medicare payments to physicians. This year, HHS is taking another $500 million from the fund, partly to underwrite insurance exchange activities.
Developments like these are raising concerns that most of this money might never get used for its intended focus on public health issues, says the American Public Health Association. That view is shared by Thomas McAuliffe, policy analyst at the Missouri Foundation for Health. He remains a champion of ACA, even though he and others note that the administration has delayed for a year the provision that companies with 50 or more full-time workers offer their workers medical coverage costing no more than 9.5 percent of a worker’s wages.
"The exchanges are moving along,” McAuliffe says. “Think about it (ACA) as a puzzle coming together. I think that’s where the feeling that it’s haphazard comes in. But it’s all moving in the right direction.”
He then says, “The most troubling part of this (ACA) law is in the latter pages where there are social media campaigns, outreach for better health literacy, better health education for people to reduce diabetes and those kinds of things.”
When reading further, he says, some of those provisions are listed as “authorized not appropriated,” meaning Congress has to authorize the money to be spent on the programs.
“And many of those programs may never be realized because, given the fiscal constraints we’re already under, money may not be there for these programs.”
The shifting of funds from one worthy program to another, as the administration and Congress did last year, seems to underscore his concern.
“One of the big challenges is how much of this law gets fully implemented. I’m not talking about the kind of marquee things like the exchange or the insurance subsidies.”
Instead, he’s thinking about items beyond medical care, such as wellness programs and workforce development, that might get lost or remain unfunded. “They may be very good public health components, but they may not get actualized.”
He says public attention is focused mainly on the first 200 to 300 pages of the law that focus on “the subsidies and exchanges, the sexy things we talk about. No one talks about the prevention trust fund.”
