With more than 113,000 lives already lost in the COVID-19 pandemic, it's clear America has significantly underprioritized and underinvested in prevention and public health. Indeed, many of these deaths could have been prevented if the U.S. had set up a coordinated, nationwide testing system in January and February or initiated community mitigation earlier in March.
Unfortunately, preventable deaths are not a new phenomenon for the nation. The Centers for Disease Control and Prevention previously estimated that nearly 250,000 Americans suffer potentially preventable deaths annually from the five leading causes of death—heart disease, cancer, stroke, chronic lower respiratory disease and unintentional injury. Compounding this are stark health disparities in our country due to income, race, and geography as well as an underemphasis by policymakers on the social determinants of health such as housing, nutrition and transportation.
The result of this is that U.S. life expectancy in 2018 was no different than it was in 2010. This nation continues to lag behind its peers throughout the world on this metric and on additional measures of population health. That is notwithstanding the fact that dozens of effective disease prevention interventions exist, some based in clinical settings such as immunizations and cancer screenings and substance use screening and counseling, with others based in community settings such as smoke-free policies and motor vehicle injury prevention and diabetes prevention.
That policymakers have not prioritized these issues speaks to government's default mode of being largely reactive; disease prevention, on the other hand, demands being proactive and is thus often easily cast aside to deal with more "urgent" policy issues. In addition, measurable results in the prevention area often require time and even then, are often "invisible" in the sense they they're averting disease.
Beyond this, some policymakers find it difficult to appropriate additional resources for prevention in this fiscal climate. However, the reality is that of the nearly $3.6 trillion spent on health in this country, only 5% goes to preventive services in the clinical setting; only 3% goes to public health; and only 6% to 7% goes to primary care (about half of what our peer countries spend)—and all these numbers, incidentally, are not mutually exclusive. Ultimately how we spend our resources reflects our priorities, and our priorities reflect our values.
Fortunately, there are concrete steps that the current and future administrations and Congress could take to champion prevention policy. First, HHS must make prevention its No. 1 health priority as manifested in its legislatively mandated quadrennial Strategic Plan and annual budget submissions to Congress.
Second, consistent with value-based healthcare transformation, Medicare, Medicaid and private payers should ensure that healthcare professionals are given incentives and made financially accountable for preventing, not just managing, chronic diseases through appropriate quality metrics.
Third, a new regulatory pathway, akin to pathways that exist for drugs and devices, should be created within HHS to assess the effectiveness of and determine coverage for community-based prevention programs such as those that focus on preventing falls, promoting physical activity, and supporting self-management of chronic disease.
Fourth, Congress should target investments supporting community prevention efforts for tobacco use, obesity, emotional well-being and mental health; this effort should align with the findings of the recent bipartisan Commission on Evidence-Based Policymaking. Specific investments are also needed to bolster all aspects of the nation's public health infrastructure, including emergency preparedness and response capabilities not limited to surveillance, laboratory capacity, hospital preparedness, and stockpiling of critical medical supplies and equipment.
Fifth, federal scientific agencies and Congress must address the significant underinvestment in prevention within our nation's health research institutions and expand prevention research focused on biology, behavioral change and policy implementation. Additional research will also help the Congressional Budget Office accurately score prevention initiatives within its budget windows.
While these recommendations may be aspirational, they are achievable. Prevention requires shared responsibility, and elected officials and policymakers have a critical role. It's time to seize the moment. The best path to better health is through prevention.
