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Back to The Milbank Quarterly Opinion
The imbalance in US health spending between public health and medical care is no secret. For example, of the more than $3.8 trillion in US health spending in 2019, less than 3% went to public health. As if we needed another reminder of that funding disparity, the COVID-19 pandemic exposed the consequences of neglecting the governmental public health infrastructure.
Throughout the pandemic, many states saw the criticality of public health’s mitigation strategies. But the disproportional way we finance health, especially long-standing federal, state, and local underfunding of governmental public health, undermined (and continues to undermine) these efforts. To be clear, minimally adequate funds were appropriated specifically for public health at the height of the pandemic. But states were compelled to use medical care funding through Medicaid, Medicare, and private insurance to support sustainable programs for the long term rather than being able to rely on robust public health funding.
Equally important, because of the reliance on medical care funding, primary care emerged as central to public health’s pandemic mitigation strategies. Under very difficult circumstances, primary care physicians did an exemplary job in treating COVID patients and participating in vaccination campaigns. Even so, relying on disease-oriented medical care insurance as a funding approach is not an optimal strategy for mitigating future pandemics.
Perhaps inadvertently, the COVID-19 experience demonstrates the feasibility of a divergent model: utilizing primary care in ways that would strengthen core public health services and enhance the community’s health. It is now time to go beyond using medical care funding to fill in the gaps for public health. In fact, a key lesson from COVID-19 is that expanding the scope of primary care to include population health better aligns medical care and public health to improve health outcomes.
Despite the vast literature on primary care, until recently there has been scant attention to opportunities that would expand primary care beyond its clinical origins. Primary care can become an integral part of improving the population’s health without sacrificing its traditional role as care coordinator for individual patients. Recent state-level innovations demonstrate the feasibility of this approach. In short, reconsidering the role of primary care would begin to address the funding disparity that hobbles our public health system.
Throughout the COVID-19 pandemic, many states implemented innovations designed to better connect medical care and public health. In each of these models, primary care physicians play a central role in coordinating care and working together with public health departments and other community-based organizations to improve the community’s health. These models provide more resources for primary care practices to have an expanded role and enable more connections to community-based structures.
Because the vast majority of US health funding is spent on personal medical care, the most readily available tool that states had during the COVID-19 pandemic to address public health gaps was using Medicaid funding to support the work of public health. The Affordable Care Act (ACA) greatly expanded Medicaid in most states, and the Center for Medicare and Medicaid Innovation (CMMI) demonstration projects have enabled new approaches to help address social needs. In fact, the Centers for Medicare and Medicaid Services (CMS) has established priorities and incentives for primary care physicians to “move care upstream” through partnerships with community organizations to address social needs.
Medicaid is a creative and powerful tool for states. But Medicaid, like all health insurance programs, is designed to pay for personal medical care; it was never intended as a vehicle to fund core public health functions or be responsive to broader population health concerns.
Although funding from Medicaid must fit into some form of “reimbursable” category, CMMI has encouraged broad flexibility in meeting this requirement. As a result, many states have successfully expanded the concept of “reimbursable” services to support more community-based programs. For example, CMMI funding for State Innovation Models and Accountable Health Communities has enabled many states to address gaps between medical care and social needs, including support of non-medical interventions and community health workers.
Patient-Centered Medical Home efforts have also encouraged greater investment in primary care practices. Like public health, primary care has long been underfunded and some of these initiatives have been designed to provide more financial support for primary care practices. With the focus of newer CMMI and state initiatives on advancing health equity and reducing disparities, primary care practices can partner with public health to address social determinants of health. Doing so could include both social needs screening as a routine part of the primary care encounter and follow-up coordination of care with community-based organizations.
The lesson from these models is that primary care and public health can and must work together to address the complex challenges of public health. However, primary care practices alone cannot be the leader in addressing community health. Primary care practices must have community partners, especially local public health, for population health goals to be fully realized. While perhaps falling short of proof of concept, future success will require additional funds to expand these approaches and train primary care physicians in public and population health methods. Overburdened primary care practices must receive additional funding to incentivize this work and build capacity.
Building on state experiments to connect public health and primary care is a fruitful and important approach to strengthening public health. Fortunately, a vehicle exists to exploit these strategies and provide the additional funding needed to replicate and scale the state experiments: the ACA’s Prevention and Public Health Fund (PPHF). Section 4002 of the ACA established the PPHF with the express intent “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health care costs”. The PPHF had the potential to make a substantive impact on the nation’s public health preparedness. Over the years, unfortunately, the funds were cut and redirected away from public health so that at the start of the pandemic, less than $1 billion had been appropriated, compared to the original ACA intent of a $2 billion annual appropriation.
In the fund’s early years, the Obama administration transferred dollars from the fund to support the primary care workforce. At the time, this action was seen as counter to the fund’s specific purposes. But as the state experiments have demonstrated, use of this fund to support the connection between primary care and public health may have furthered the fund’s original goals.
In 2018, the funding to the PPHF was partially restored such that FY2022 and FY2023 funding were $937 million and $1 billion, respectively. Scheduled FY2024 funding is $1.3 billion with planned increases each year until 2030, when the fund is expected to reach an annual appropriation of $2 billion, the original intended amount. Still, there remain proposals in Congress to redirect funds from the PPHF to other purposes. In September 2023, Senators Sanders and Cassidy introduced S. 2840 which would reduce the PPHF by another $980 million to partially pay for funding for community health centers, the National Health Service Corps, and the Teaching Health Centers Graduate Medical Education program. While these are worthy programs, they are not core to the PPHF’s mission. Rather than redirecting the funds once again, the lessons from COVID-19 and the states show that a more valuable approach would be to use the fund to build stronger ties between primary care and public health.
Physicians already play an important public health role as messengers in addressing issues such as childhood vaccinations and effective disease mitigation strategies. Using the PPHF to support primary care physicians to screen and refer patients with social needs as well as to focus on preventive services would be enormously beneficial. Newer CMMI models encourage primary care physicians to address social drivers of health, including through screening and referrals for social needs. However, primary care practices often don’t have the resources, capacity, or training to work with community-based organizations and local public health to support patients with complex needs. PPHF funds can formalize the relationships among primary care, community organizations, and public health to move care upstream in line with CMS priorities.
State innovations necessitated by COVID-19 were laboratories for learning. Funding to enable information sharing and communication between public health and primary care will allow providers to engage in joint campaigns and data sharing. Building on the lessons learned is essential to meet the ever-increasing public health challenges facing us all. It’s time to stop raiding the PPHF and to use it as intended – to improve the nation’s health.
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