Recently, several newspapers featured a report from a health advocacy group, Trust for America’s Health, claiming communities can save $16 billion annually by investing $10 per person in community health programs. This translates roughly to about a five to one return on investment. As a strong proponent of preventive medicine and the need for local communities to regain ownership of their health systems, it first appeared to me to be the perfect proposal. Every community should be clamoring to get a copy of the report to be able to find out how to redirect its resources to realize the promised gains in population health status and cost savings.
However, the reader soon realizes that the authors do not propose such community empowerment but, actually, another centralized, categorical initiative imposed from above with newly appropriated resources. Why? In the current economic environment, these resources are getting harder to obtain. If the report’s conclusions are indeed valid, surely there are resources currently spent on ineffective, less effective, or lower priority initiatives within each community that the community would gladly redirect to realize these amazing gains. Some communities are spending over $7,000 per enrollee per year on Medicaid, Medicare or private insurance; a $10 diversion (as little as one tenth of one percent) would be a pittance. Likewise, each community operates 100s of categorical health promotion programs. It is difficult to believe that any community could not redirect a few dollars from the least effective/ lowest priority programs to raise the funds. Even forgetting about health status gains, a promised five to one return makes such action a “no-brainer”.
History has clearly demonstrated that community public health and preventive medicine initiatives result in individuals living longer and more productive lives, free of major disabilities. Control – or protection from – tobacco, infectious disease agents, saturated fats, and environmental/industrial pollutants and toxins are a few examples from the last 50-100 years. If today’s health status is to be maintained or enhanced, our major challenges include substance abuse, violence, obesity/inactivity, high-risk pregnancies, mental illness/dementia, and ineffective/futile health care. Community public health efforts could play a major role in addressing these challenges.
Will such efforts save money? Maybe. It largely depends on the methodology one employs to measure savings, the length of time of the analysis and the assumptions made. Personally, I remain skeptical of projections of long-term savings since the longer we live the more body parts we need to maintain or replace. My support centers on maintaining the quality of life. That alone is worth the $10 per person investment.
Regardless of one’s analysis or justification, most individuals would at least support listening to the proponents of the proposal present their evidence for the tremendous projected improvements and cost savings. If convinced, they would support redirecting $10 per person to such an effort. But, wait! The community has no collective mechanism to listen to the proposal, reach a consensus, or redirect the funds. Each community is at the bottom of a hierarchal pyramid; individuals at the top decide how each community and each citizen spends nearly every dollar. A valuable lesson of the media reports of the proposal should center not upon whether its projections are valid but whether – if they are – communities can do anything about it. Unless we invert the pyramid, I doubt most can.
James D. Felsen (July 2008)
