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This article is from the In-Depth Report Stimulating Science: Following the Recovery Money

Shot in the Arm: Has the U.S. Invested Enough Health Stimulus Money in Prevention?

To help boost the physical--and financial--health of Americans, the stimulus bill sent more than $122 billion to Health and Human Services. How much of that is helping to minimize visits to--and dollars spent on--the doctor?
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As lawmakers divvied up billions of dollars last year to address the nation's fiscal crisis via the 2009 American Recovery and Reinvestment Act (ARRA), they did not skimp on funding health. About one of every six and a half ARRA dollars went to programs at the U.S. Department of Health and Human Services (HHS)—the single largest allocation for any federal agency. Less than 1 percent of those monies, however, are going toward keeping people from getting sick in the first place.

The HHS's $122-billion allotment has been spread among the U.S. Centers for Disease Control (CDC), the National Institutes of Health (NIH) and the Administration for Children and Families (ACF) as well as other groups that fund everything from cancer research to Head Start programs for children.

But not every cause was funded equally: The lion's share ($87.3 billion) went to established health care, which includes money for pricey programs such as Medicaid reimbursement and physician education. More than $25 billion was allocated for improving health care information technology, much of which is aimed at encouraging the national adoption of electronic medical records. At the bottom of the HHS's stimulus funding list, receiving less than 1 percent of the agency's ARRA funds, is the category of prevention and wellness—a bracket that includes programs for providing vaccinations, promoting healthful diets, and countless other government efforts to keep the doctor away.

The small fraction still amounts to about $1 billion, a number that is not trivial in the field. "We are delighted that Congress recognized the importance of prevention," says Donna Brown, government affairs counsel for the National Association of County and City Health Officials. "Since the government health agencies are chronically underfunded, we were delighted to get what we got and believe it is being put to good use."

Many involved in public health and health care economics, however, think that $1 billion is hardly a meaningful boost for prevention, the root of the nation's physical and fiscal health.

Nearly half of all Americans (about 133 million) have one or more so-called chronic conditions, which can include obesity, diabetes and other ailments. As noted in a House bill introduced in July 2009 (and currently in committee), to increase overall federal funding for prevention some 75 percent of U.S. health care spending goes toward "treating patients with chronic disease." And as the authors of the bill hasten to point out, "The vast majority of these diseases are preventable." These conditions also account for about 70 percent of deaths in the U.S., yet prevention commands only about 0.01 percent of the overall health care costs, notes Wayne Giles, director of the CDC's Division of Adult and Community Health.

Investing wisely
Given the small budget this field has traditionally had, "these are historic levels of funding," Giles says of the stimulus funds aimed at preventive health. And as societal investment strategies go, putting money into preventive health causes, such as public health campaigns to encourage exercise or childhood immunizations, has been shown to pay off big in the long run, with both dollars and lives saved. Giles calls prevention "one of the best buys."

From an economics perspective, the value holds true, too. "The return on investment is potentially enormous if you use the money appropriately," says Dana Goldman, director of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.

In fact, an extra $10 annual investment in prevention per person in the U.S. ($3 billion a year) would amount to a savings of about $16 billion each year in health care costs, according to a 2008 report sponsored by the Trust for America's Health, a nonprofit public health advocacy group. And if that calculation is extended to benefits outside of the medical realm, such as increased working days and productivity, the payoff is likely to be greater, the report authors note.

Goldman, whose research has highlighted the per-person savings of avoiding preventable diseases such as hypertension, explains that increased prevention means that "people will have longer, more productive lives," he says, which translates into a more productive economy, as well.

Many of the dividends of prevention—both in health and economics—however, will not be seen during the life spans of ARRA-sponsored projects. And that aspect has made it difficult for those in charge of building budgets—either private or public—to justify expenditures in the short term, especially when money is tight. "Because the benefits of prevention often accrue decades later—long after someone has switched employers or health plans—private plans will skimp on prevention coverage," Goldman wrote in an op-ed in The New York Times last June.

The government need not simply step into the prevention arena out of beneficence, he noted. "Medicare could save itself money, for example, by paying for anti-hypertensive medication before people turn 65," he wrote.

The CDC's Giles understands that expectations of government investors are little different than those of private ones: "People want to see an immediate return on investment," he says. But from his work on community health campaigns, he knows that "changing behavior takes time. People need to be patient in terms of when they are going to see" results.

Not every preventive project is guaranteed to reap rewards down the road. "You have to identify interventions that work," Goldman says. "We need to invest in research to find out what works," he adds, noting that finding a way to prevent obesity would go a long way in lowering health care costs and improving health in the future. But researchers should cast a wide net, he says: "It could be a pill; it could be a government policy."

Another $1.1 billion from HHS's ARRA purse is funding research on comparative efficacies, some of which will be geared toward finding what types of intervention strategies work best, says Giles. So, although both allocations are comparatively small in the scheme of stimulus health care spending, "there should be some synergy between the two pots of resources," he notes.

Immunizing against higher costs
Some preventive measures already have well-proved track records for keeping most recipients healthy and eventually saving more money than they cost.

"As a therapeutic class, vaccines are generally considered to be the health care intervention that provides the best value," Edward Armstrong, a professor at the College of Pharmacy at the University of Arizona in Tucson, wrote in a 2007 supplement to the Journal of Managed Care Pharmacy. Yet, each year more than 42,000 people in the U.S. still die—and countless others fall ill—from diseases that can be prevented by existing vaccines, according to the CDC.

The Recovery Act earmarked $300 million to boost nationwide immunization through the CDC's established Section 317 Immunization Grants Program. "Its use in defraying the cost of vaccine purchase is something that's important," Brown says. "The cost of vaccine has gone up and the number of immunizations recommended has escalated."

For many childhood vaccines, such as measles, rubella and tetanus, demand has been steady enough to ensure supply, but the flu vaccine—both seasonal and, more recently, pandemic—has proved difficult to pin down.

The seasonal flu alone, for which a vaccine is widely available, still kills some 36,000 people annually. As demand fluctuates and strains vary or develop resistance, manufacturing new iterations to keep up proves to be a financially risky endeavor for the few companies that attempt it. And many individuals who die from influenza already have had their health compromised by chronic diseases, notes Giles, so increasing other preventive measures would be a boost to efforts to lower pandemic death tolls, as well.

The Recovery Act was passed just a little more than two months before the government declared a public health emergency to address H1N1 in the U.S. Original drafts of the stimulus had included hundreds of millions of dollars for pandemic preparation, which was trimmed during negotiations—an action that later drew criticism from some political commentators.

"We live in a state of denial up until we get sick," says Marc Siegel, a clinical associate professor of internal medicine at the New York University Langone Medical Center and author of multiple books about pandemic flu. After the outbreak had begun to take hold, the government signed off on additional funds for vaccine research and distribution, which "had a larger impact on research and the development of the influenza vaccine" than official stimulus funding did, says Michael Ochs, a government relations associate at the Infectious Diseases Society of America.

Paying for an apple a day
With posited payoffs years away, prevention has often proved to be a hard sell—especially with programs like ARRA, where money is aimed at short-term economic goals, such as job creation, and when millions of Americans are already sick.

"The traditional focus has been on getting sick people better rather than preventing them from getting sick in the first place," Ochs explains. He calls the current health care system  "more of a sickness-treatment rather than a prevention" approach. And trying to shift the focus—not to mention the funding—he says, is "rough" going.

If everyone stuck to a proverbial apple-a-day prevention plan, the U.S. might have a healthier and more productive citizenry. But where would that leave the nation's health care workers, hospitals and insurers who depend on treatment income to pay their own bills?

"If you do a really good job on prevention, the health care system goes out of business," Goldman says. "Prevention done right would make all that superfluous." That might not sound good for the health care industry as it is presently structured. And as current reimbursement systems are designed, as a doctor "if you take your patient for a walk, you don't get money," he says.

Previous versions of the stimulus bill had included more funding for preventive health projects, but a lot of it was cut in the negotiation process. And much of what did remain in the books, especially the $650 million earmarked for chronic disease prevention, is still finding its way out to programs. (Funds for state chronic disease programs were awarded earlier this month, and local communities will be getting much of their prevention money in coming weeks.)

The upcoming drop in program budgets after stimulus funds expire is "worrisome," Ochs says. Although the end of stimulus money is no surprise, many still dread its impact. Like many preventive measures, "immunization in particular is an activity in which the need never goes away," Brown notes. "One worries that gains that will be made might just as easily be lost."

Even if more money is spent on prevention in the future, says N.Y.U.'s Siegel, economic and health benefits would not be automatic. "We need to not just throw money at something," he says. "We need to educate society."

"Prevention is an extremely hard concept," Siegel says. It requires a broader kind of accounting, one that can take into account the bottom line not just of the health care field but also in the overall GDP. "This has to be a society-wide change in perspective," he continues.

The stimulus funds granted for prevention and wellness, Brown says, show "evidence of a growing recognition" among policymakers that prevention is worth funding. Such acknowledgement, she says, "is cause for optimism going forward."

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