At last count, the stimulus package will inject $775 billion into America’s ailing economy. That’s staggering. Yet even $775 billion isn’t enough to fix every damaged road, bridge, and school, balance every rickety state budget, or fix our multi-trillion-dollar health care system.
There is one area in which stimulus could prove transformative. Pathetic as it sounds, a few billion dollars represents a huge increase in our public health system. To see what might be done, I opened my Rolodex and asked some smart activists, practitioners, and researchers what they would advise President-elect Obama to do.
Most of these ideas are conspicuously different from traditional medical care and the expansion of traditional health coverage. Billions of dollars will--and should--be spent for health care and health insurance coverage. Yet medical care is only one tool--generally a surprisingly weak tool--to improve population health. The financial crisis provides an opportunity to do more. Each of the below proposals would put people to work. Each would make America a healthier place. Each has real research behind it suggesting its effectiveness. After years of fighting over the rounding error in our nation’s $2.4 trillion medical economy, targeted stimulus could address many public health problems.
400,000 Americans die every year from tobacco, my wife’s parents among this number. Many strategies have been shown to effectively reduce youth smoking and to help smokers quit. Anti-tobacco experts Stanton Glantz and Meg Riordan suggest (among other things) two related ideas: Expand well-implemented telephone “quit lines,” along with a hard-hitting media cessation and prevention campaign modeled on the American Legacy Foundation’s “Truth” advertisements.
Riordan reports that spending $500 million--a mere third of what CDC recommends--would create roughly 10,000 jobs staffing quit lines and also finance accompanying media promotions and cessation medications. She estimates that $500 million could bring 1.1 million additional smokers quit line counseling and medication. Clinical practice guidelines suggest that roughly 300,000 of these callers can be expected to quit, most of whom would not have quit on their own, preventing tens of thousands of avoidable deaths from cancer and heart disease.
Michael Flaherty and Debra Langer of the Institute for Research, Education and Training in Addictions note that federal block grants for drug treatment have shrunk since fiscal year 2002, seriously burdening states and localities. Another $1 billion could provide decent treatment for more than 100,000 drug users and could upgrade the quality and professionalism of treatment services. Truckloads of studies establish that such investments would bring large benefits that outweigh their costs. Problems are especially severe among injection drug users (IDUs). In Chicago, 600 IDUs fill waiting lists for methadone treatment, while heroin overdoses rivals auto accidents as a leading cause of death among working-age African-American men. Yale epidemiologist Robert Heimer recommends an aggressive vaccination campaign for hepatitis B (HBV) among street users--few programs serve active drug users, even though the Public Health Service strongly recommends vaccinating IDUs.
Public health and crime
Criminal offenders play a large role in public health concerns. UCLA crime scholar Mark Kleiman says, “Improving our ability to manage offenders on probation and parole would have a huge payoff per dollar spent. A sensible health system would use prisons, and especially jails, as places to conduct health education, screening for disease (especially infectious disease and mental-health disorders), and treatment.” As it is, Kleiman explains, “Inmates come in sick and go out sicker, spreading disease back to the general population.”
Stanford drug policy expert Keith Humphreys recommends doubling the number of Oxford Houses for ex-offenders. In these recovery-house arrangements, a group of residents receive a loan for the security deposit and first month’s rent. Every resident must work, pay some of the rent, obey house rules, and stay clean and sober. The house pays back the loan for the use of others who want to start a house. A randomized trial found that after two years, Oxford House residents achieved twice the rate of abstinence and one-third the incarceration rate of peers assigned to outpatient treatment or to self-help groups.
An estimated 56,000 Americans become HIV-infected every year. HIV incidence has been rising, particularly among gay and bisexual men. Yet inflation-adjusted federal spending on HIV prevention has markedly declined under President Bush. David Holtgrave, who led the Division of HIV/AIDS Prevention at the Center for Disease Control (CDC) under President Clinton, recently before Congress and proposed to increase annual HIV prevention spending by about $550 million. Holtgrave argues that such an investment would reduce the rate of new infections by half and would raise the proportion of infected individuals who know their HIV status from 75 percent to 90 percent. If we achieved anything close, that would be a bargain.
What else? In 2006, CDC recommended broad HIV screening in many medical care settings. Experts generally agree that this is prudent and cost-effective: Simplifying a bit, a $15 oral test can determine your HIV status in 20 minutes. Still, progress is slow, partly because CDC provided no accompanying resources. Virtually no public or private insurer reimburses the population screening CDC recommends. $500 million could provide testing for roughly 5 million Americans. HIV prevalence differs across settings, but in urban emergency departments (EDs), it would be reasonable to expect roughly one new infected person for every hundred tested. So this effort could reasonably be expected to identify 50,000 previously undiagnosed infected persons while providing resources to overstretched and under-funded components of the American safety net.
Speaking of EDs, Tom Fisher, an up-and-coming leader in this field, notes that EDs are required to spend large sums providing uncompensated care to uninsured or under-insured patients. A federal law called EMTALA rightly forbids hospitals from turning away emergent patients and pregnant women in active labor. Unfortunately, the feds don’t provide the funds to finance this (and other) care. One predictable result: increasing numbers of EDs are closing, despite--or rather because of--rising demand for their services. These facilities play a vital role in protecting us against mass casualty events, in addressing youth violence, child abuse, flu, and pretty much every other public health problem. Especially given painful layoffs now underway at many places, channeling some stimulus here would be powerful.
Public health workforce
Across the street from my office at the University of Chicago is a gleaming billion-dollar hospital. If I walk the other way, I pass crowded and understaffed primary health care facilities with out-of-date computer systems, old facilities, and other great resource needs. Merrill Goozner of the Center for Science in the Public Interest has written extensively about these issues. So has Mickey Eder, director of research programs at ACCESS Community Health Network, one of America’s largest safety-net providers. Both suggest variants of a new Health Corps.
Goozner notes that the current National Health Service Corps of primary care doctors could be expanded to include nurses, dietitians, and a variety of vital lay health workers and paraprofessionals. One can create many more jobs by hiring these men and women than by hiring more doctors. The public health benefit would be greater, too. Health Corps workers could provide home visits to help patients manage blood pressure, cholesterol, and glucose. They could help pregnant women manage the logistics of prenatal care. They could organize community walking circles, visits to local groceries to buy healthy foods. Rather than using costly space at hospitals and medical facilities, Health Corps groups could rent local storefronts and partner with local churches and civic groups. They could serve as useful ambassadors within communities mutually estranged from medical and public health systems.
Duke University’s Philip Cook writes, “Part of the public works budget should go to an expansion of off-road bicycle paths. This would be a two-fer: It would provide the public with a safe and enjoyable exercise option, and it could also provide a new ‘green’ commuting option.”
Carnegie-Mellon operations researcher Jonathan Caulkins suggests a WPA-style service corps that creates infrastructure for diverse exercise and outdoor activities. He notes that such programs could reach beyond construction workers and similar traditional constituencies to recruit underemployed software designers who would create appealing web sites and electronic games that promote healthy living, particularly for youth.
Nutrition and obesity
Between 1974 and 2004, the prevalence of child obesity has , with accompanying marked increases among adults. The Omnivore’s Dilemma author Michael Pollan’s writings on food policy have proved extremely influential: Barack Obama himself has name-checked Pollan’s work. When I asked Pollan for stimulus ideas, he delivered quite a list. Perhaps his most interesting ideas concern “food deserts”--low-income communities that lack access to reasonably-priced groceries with nutritious foods. Many of these communities struggle to support farmers’ markets. Pollan argues that such facilities are often itinerant and physically constrained, in part because they are outdoors. He suggests investing in rather basic structures on the model of Seattle’s Pike Place or Philadelphia’s Reading Terminal to build four-season farmers’ markets. “These could give a tremendous boost to the local economy, creating beautiful structures while improving nutrition.”
Pollan also notes ways to modify food assistance to encourage purchases of healthy foods. He cites efforts such as the Wholesome Wave Foundation’s that augments the purchasing power of food stamps used by low-income mothers and seniors buying fresh fruits and vegetables at farmers markets.
Even with $775 billion, we can’t do it all. We can lay a foundation, and we can experiment. Whatever we do, it is essential to proceed in a way that allows careful and rigorous evaluation so we can actually learn what works.
Adding some gravy
Two colleagues of mine introduced a sad note of caution. Roseanna Ander noted the perennial political challenge: There is nothing more compelling than the elaborate rescue of a cute toddler, Baby Jessica, who falls down a well. And there is nothing more boring than debating whether to put a $500 fence around wells before any identified toddler falls in.
McCormick Foundation Professor Jens Ludwig adds a dollop of Chicago bluntness:
The public health constituency includes every thoughtful person who understands the value of prevention. Yet to paraphrase Adlai Stevenson, that isn’t enough. I recommend making these interventions much less efficient, to broaden and intensify their political support. President-elect Obama should figure out what a sensible public health investment would be--and then triple it. For example, authorizing legislation should outsource HIV testing to Halliburton, and require that every time someone is tested, a farmer, a corrections officer, a hunter, a teacher, a firefighter, an autoworker, a former hedge fund trader, a TV evangelist, and a diversity counselor must be present, at public expense.
This seems a tad cynical, but hey, it might work.
Harold Pollack is a public health policy researcher at The University of Chicago's School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies.
By Harold Pollack