The Prevention Dilemma

May 20, 2010

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If given the choice to spread prevention money around or to concentrate it to make a profound, historic and measurable impact, what would you do?  That’s the question raised by the new health law.  Secretary of Health and Human Services Kathleen Sebelius must soon respond to a congressional mandate to spend millions of dollars on a potentially endless array of worthy projects, ranging from bike trails and community gardens to local public health departments and obesity prevention. 

There will never be enough federal money to address every prevention need.  What the secretary needs to decide is whether there is sufficient political courage to concentrate early prevention funding to deliver a knockout blow to the leading cause of premature death in the country: tobacco.   

The health reform law includes a first-of-its-kind public health fund.  This year’s first payment is $500 million.  Next year, the annual payment increases to $750 million, and by 2015 will rise to $2 billion.

Congress considers this fund to be an investment toward the goal of transforming our “sick care” system into a true health system. It has provided minimal guidance to the Secretary - instructing her to spend the funds “to improve health and help restrain the rate of growth in private and public health care costs.”

The catch is that Sebelius must spend the fiscal year 2010 funds--$500 million--as quickly as possible.  This rush will create a powerful temptation to distribute the money through another round of stimulus bill-like “prevention grants” or to backfill shortfalls in core public health programs.  

The secretary could follow bureaucratic tradition and spread the funding broadly among numerous initiatives that would satisfy many interests. Unfortunately, that would achieve little in the way of measurable public health impact.  A bolder, but less traditional, approach would be to use the funding to target a single public health threat and attack it on a national scale, utilizing programs that have been proven to improve public health and reduce the cost of health care. 

The criteria for prioritizing this specific funding should be simple: what are the evidence-based programs that are primed and ready to go, that are proven to work, that we know will move us toward a healthier society and that we can be sure will deliver a large, measurable return on investment?

By these criteria, the top priority for prevention spending should be tobacco control.

Tobacco control programs are ready to go. Decades of rigorous study have proven that tobacco control programs can reduce smoking and improve public health. 

The need is great. Despite our success in cutting the smoking rate roughly in half over the last 50 years, tobacco use remains our leading preventable cause of premature death. It kills over 400,000 Americans a year, drives huge increases in chronic disease rates and $96 billion in health care costs.  And the Centers for Disease Control and Prevention estimates that states are currently spending only a fraction of what is needed to reap the maximum value in public health benefit.

A bold effort to meet the mission of this new public health fund would include three main components: 

1) Nationwide public education campaign modeled on the highly successful Truth® campaign that dissuades thousands of young people from initiating tobacco use and encourages smoking cessation;

2) Fully funding quit lines that provide direct cessation services and significantly improve quit rates efficiently and effectively, especially among  disadvantaged  populations served by Medicaid; and

3) Support for existing state and community-based tobacco control programs that reach people where they live, work, play and worship.

The American public wants and deserves a health system that sets a priority on keeping people healthy, not just treating them once they are ill. If community-based tobacco control programs could be brought to scale nationally, we have a genuine opportunity to drive smoking rates into single digits.  The rapid and enduring payoff, in lives and money saved, is there for the taking.  It’s a rare opportunity.  I urge Secretary Sebelius to seize it.